Primary meningococcal arthritis and pseudogout in an elderly woman

Abstract

Septic arthritis caused by Neisseria meningitidis has been demonstrated in approximately 2% of patients with systemic meningococcal infection (1).Meningococcal arthritis in the absence of documented meningococcemia or meningitis, however, is extremely uncommon. In a recent review, Schaad (1) identified only 25 patients from both personal experience and the literature. The incidence of this entity, termed primary meningococcal arthritis, follows the characteristic agespecific attack rate seen in other forms of N meningifidis infection (1). Most cases have been described in children less than 2 years old: a rapid decline in incidence occurs with increasing age. To our knowledge, the disease has not been reported in patients over the age of 50. We report here an elderly patient with chronic lymphocytic leukemia who presented with primary acute meningococcal arthritis and pseudogout in the same joint.Case history. A 64-year-old white woman with a 3-year history of chronic lymphocytic leukemia (B cell type) and a history of chronic obstructive pulmonary disease presented to the Montefiore Hospital emergency room with 12 hours of progressive tenderness, swelling, and redness of the right knee. She denied rigors or recent trauma to the joint. There was no history of acute arthritis, rash, dysuria, frequency, vaginal discharge, headache, or stiff neck. She did, however, note increased sputum production and cough. Three months earlier she had had acute pneumococcal pneumonia (type 19), despite previous immunization with pneumococcal vaccine. She was allergic to penicillin.On physical examination her respiratory rate was 24/minute and temperature was 101.1"F orally. There was no rash. The pharynx was clear and the neck supple without signs of meningeal irritation. Generalized lymphadenopathy in the neck, axillary, femoral, and epitrochlear regions was present. Auscultation of the lungs revealed bilateral coarse airway sounds with occasional scattered ronchi. Heart sounds were normal and the spleen was not enlarged. Her right knee was warm, swollen. tender, and painful on passive and active motion. The suprapatellar area was boggy and a joint effusion was present. Homan's sign and calf swelling were absent.Significant laboratory data included: a peripheral leukocyte count of 64,7OO/pl (18% neutrophils, 6% band forms, 60% lymphocytes with 16% atypical lymphocytes), hemoglobin 1 1.8 gm/dl, platelet count 230,00O/pl, serum glucose 156 mg/dl, calcium 9.9 mg/dl, phosphorous 2.9 mg/dl, uric acid 4.3 mg/dl, alkaline phosphatase 142 IU/liter, serum albumin 2.8 gm/dl, and total protein 4.7 gm/dl. Serum protein electrophoresis revealed a total gamma globulin fraction of 200 mg/dl With a normal range of 600-1,800 gm/dl. After the acute illness, quantitative immunoglobulin tests were performed by immunodiffusion and showed IgG of 319 mg/dl (normal 800-1,800 mg/dl), IgA of 31 mg/dl (normal >90 mg/dl), and IgM of 0 (normal >90 mg/dl). Complement determinations showed a CH5O of I : 64 (control 1 : 64). A chest roentgenogram showed no inf...

Not Just Another Flare: Acute Polyarthritis in Rheumatoid Arthritis

“…7 Higher incidence in the setting of immunosuppressive disorders including HIV and hematologic malignancy has been reported. [7][8][9][10] In meningococcal arthritis, response to antibiotics is slow, and confidence in the diagnosis may be further compromised by immune-complex-mediated synovial inflammation during the convalescent phase. [7][8][9][10] In such cases, presumed deposition of circulating immune complexes or development of an articular reaction to antigen fixed in the tissues results in persistent arthritis accompanied by fever despite appropriate antimicrobial therapy and surgical joint irrigation.…”