Native Joint Propionibacterium Septic Arthritis

Abstract

Propionibacterium species are associated with normal skin flora and cultures may be dismissed as contaminants. They are increasingly recognized as a cause of septic arthritis following shoulder arthroplasty and arthrotomy. We identified three cases of Propionibacterium septic arthritis in native joints mimicking atypical osteoarthritis and review the literature, clinical course, and treatment of 18 cases. Two cases of Propionibacterium acne in native knee joints and one in a sternoclavicular joint are described. A literature search for Propionibacterium septic arthritis was performed. Clinical course, treatment, and outcome are reviewed for all cases. Our three cases were combined with 15 cases from the literature. Fourteen cases showed few signs of acute infection, slow culture growth, and delayed diagnosis. In 3 cases an early culture was dismissed as a contaminant. Six cases were reported as caused by recent arthrocentesis. Fifteen cases were cured with antibiotics, although 5 of these 15 also required surgical intervention. Two patients were diagnosed while undergoing surgery for osteoarthritis. Four patients required arthroplasty and two of our patients will require arthroplasty for good functional results. Propionibacterium as a cause of septic arthritis in native joints demonstrates few signs of acute infection, presents with prolonged course, and is often misdiagnosed or unsuspected. Anaerobic growth may be delayed or missed altogether, and outcomes are consequently poor. Consider Propionibacterium septic arthritis in atypical osteoarthritis prior to arthroplasty.

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 …”

“…To our knowledge, there are a total of six reported cases of native knee P. acnes septic arthritis, only two of which are absent of any predisposing events. In both of these cases, the patients had an underlying diagnosis of rheumatoid arthritis and were successfully treated with long‐term parenteral antibiotics . We report on the first documented case of P. acnes bilateral septic arthritis in native knees in a patient with no known precipitating event.…”

“…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.…”

“…Constitutional symptoms include fevers, chills, and malaise. Thus, the indolent clinical course which is often absent with P. acnes , as well as the delayed anaerobic growth, may contribute to under‐diagnosis of native joint infections by this microbe …”

“…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.…”