We report the first case of prosthetic joint infection caused by Mycobacterium alvei, which was identified by PCR-restriction fragment length polymorphism and verified by analysis of nucleotide sequences of its amplified 16S ribosomal DNA. The pathogen was susceptible to linezolid, amikacin, ciprofloxacin, tigecycline, and trimethoprim-sulfamethoxazole. The clinical implications are discussed.
CASE REPORTA 75-year-old woman received hemiarthroplasty and underwent bipolar endoprosthesis replacement for osteoarthritis involving her left knee. She had received numerous intra-articular injections of steroids for pain relief over her left knee before this procedure. Pain, redness, and swelling began insidiously developing over her left knee 2 months after the arthroplastic surgery. Laboratory tests disclosed an elevated erythrocyte sedimentation rate (ESR, 125 mm/h [normal is Ͻ20 mm/ h]). Her chest radiograph was normal. During left-knee arthroscopic surgery, prosthetic implant loosening with extensive periprosthetic tissue necrosis was found. Analysis of synovial fluid revealed a leukocyte count of 10,424 cells/l with 75% polymorphonuclear cells. Synovial fluid was negative for Gram staining and for aerobic and anaerobic bacterial cultures. The histopathology of the excised synovial tissue suggested acute and chronic inflammation. Resection arthroplasty was performed, and antibiotic-loaded cement beads (vancomycin, piperacillin, and amikacin in polymethylmethacrylate [PMMA]) were implanted. The patient then received intravenous teicoplanin injection for 4 weeks, followed by oral fusidic acid and rifampin for maintenance therapy, because methicillin-resistant Staphylococcus aureus was assumed to be the most likely culprit pathogen for her prosthetic joint infection (PJI).Three months later, her PJI did not improve clinically, and her ESR was 151 mm/h, suggesting an intractable infection. A computed tomography scan revealed an edematous change in the muscular structure around the left knee and a loculated abscess located medial to the tibialis posterior. A pocket with yellowish necrotic tissue-like content in the soft tissue near the synovial membrane of the left knee was found at an exploratory surgery. The histopathology of the excised synovial membrane disclosed granulomatous inflammation with the presence of multinucleated giant cells. Both acid-fast staining and Gram staining were negative. Culture of the excised synovium by spreading it on 5% sheep blood agar for 48 h of incubation turned out to be negative. Spreading of the excised synovium on egg-based Lowenstein-Jensen slants (bioMérieux, La Balme-les-Grottes, France) incubated at 37°C with 10% CO 2 developed scanty, buff-colored, rough colonies 2 weeks later. Microscopic examinations revealed short Gram-positive bacilli and acid-fast bacilli that formed clumps. Conventional biochemical reactions revealed a negative niacin test result and a positive nitrate reductase test result, suggesting that the acidfast bacilli were nontuberculous mycobacteria. Identific...