Cutibacterium acnes Septic Arthritis of the Nonoperated Knee: A Case Report

Abstract

Intra-articular injections are a common practice in conservative management of knee osteoarthritis.1 Septic arthritis following these injections is a rare but potentially devastating complication. 2 The culpable microorganisms in the majority of cases are from the Staphylococcus or Streptococcus sp. 3 Septic arthritis of the nonoperated knee joint caused by Cutibacterium (Propionibacterium) acnes is not often expected or encountered. The more common presentation of this pathogen in orthopaedics is an indolent prosthetic joint or spinal infection. We present a rare case of C. acnes septic arthritis of the nonoperated knee, following multiple intra-articular injections. This case demonstrates the subtle presentation of C. acnes septic arthritis and suggests careful consideration of the implications of intraarticular injections in management of knee osteoarthritis. Case ReportA 56-year-old male patient with a medical history of diabetes (HgA1c, 7.5) and obesity (body mass index [BMI], 39.15) presented to a sports medicine clinic complaining of right knee pain and mechanical symptoms. Radiographic and clinical evaluation was consistent with primary osteoarthritis. His symptoms were treated conservatively with physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), sodium hyaluronate injections, and multiple corticosteroid injections. The patient returned a year later with acute exacerbation of chronic knee pain. An aspiration was performed under sterile technique and the analysis demonstrated 68,000 white blood cells (WBCs), 88% polymorphonuclear (PMN) leukocytes, positive uric acid crystals, and negative cultures. Indomethacin and colchicine were initiated to treat gout with transient symptomatic improvement. At 1-week follow-up, the patient presented with recurrent pain accompanied by erythema and swelling. Due to concern for septic arthritis, the patient was admitted to the hospital. Aspiration was attempted and he was initiated on IV vancomycin for cellulitis. Gout treatment was continued and he was discharged on oral antibiotics following significant symptomatic improvement. Keywords► Propionibacterium acnes ► Cutibacterium acnes ► septic arthritis ► intra-articular injection ► steroid injection ► septic knee ► corticosteroid Abstract Cutibacterium (Propionibacterium) acnes, a gram-positive bacillus with low pathogenicity, is an uncommon but known cause of prosthetic joint infections, particularly related to shoulder surgery. C. acnes, however, is an extremely rare pathogen in the nonoperated knee joint. This report details an uncommon case of C. acnes septic knee arthritis after multiple intra-articular steroid injections in a 56-year-old male patient. After an indolent presentation and late diagnosis, the patient underwent surgical debridement with IV antibiotic management. This case illustrates that intra-articular corticosteroid injections for the management of osteoarthritis are not without risk. Literature supporting their use remains limited and clinicians should use proficient clinical judgm...

Microbial colonization of sacral nerve stimulators pseudo-capsule: A single institution experience

“…Generally, Coryneform bacillus and Cutibacterium acnes are low-virulence organisms that are unlikely to cause life-threatening infections; however, some fatal infections were reported [ 25 26 27 ]. Conversely, pseudomonas aeruginosa is not uncommon cause of serious infections [ 28 ].…”

Bilateral native knee septic arthritis due to Propionibacterium acnes; a case report and review of literature

“…Most studies suggest clindamycin and vancomycin as the first‐line treatment for deep‐seated P. acnes infections. In the presence of clindamycin‐resistant strains, intravenous penicillins and cephalosporins can be considered as viable alternatives while awaiting culture sensitivities . Furthermore, combination antibiotic therapy with rifampin and daptomycin has shown promising results in eradicating up to 67% of P. acnes biofilms …”

“…In the presence of clindamycin-resistant strains, intravenous penicillins and cephalosporins can be considered as viable alternatives while awaiting culture sensitivities. 4,5 Furthermore, combination antibiotic therapy with rifampin and daptomycin has shown promising results in eradicating up to 67% of P. acnes biofilms. 10 presenting mild, vague symptoms with mildly elevated clinical and inflammatory markers.…”

“…Recently, it has been shown to be a common pathogen associated with prosthetic joint infections (PJI) of shoulder arthroplasties with a reported incidence ranging from 12% to 51.3% of all PJI . However, it is rarely implicated in native joint infections and is usually associated with an inciting event such as surgery, arthrocentesis, or therapeutic steroid injection . Propionibacterium acnes normally inhabits hair follicles and sebaceous glands of the skin.…”

“…1,2 However, it is rarely implicated in native joint infections and is usually associated with an inciting event such as surgery, arthrocentesis, or therapeutic steroid injection. [3][4][5] Propionibacterium acnes normally inhabits hair follicles and sebaceous glands of the skin. Therefore, regions of the body devoid of hair follicles such as the knee are unexpected sites of infection and add to its unique diagnostic challenge.…”