Prosthetic Joint Infection due to Mycobacterium avium-intracellulare in a Patient with Rheumatoid Arthritis: A Case Report and Review of the Literature

Abstract

Nontuberculous mycobacteria (NTM) are a rare cause of prosthetic joint infections (PJI). However, the prevalence of NTM infections may be increasing with the rise of newer immunosuppressive medications such as biologics. In this case report, we describe a rare complication of immunosuppressive therapies and highlight the complexity of diagnosing and treating PJI due to NTM. The patient is a 79-year-old Caucasian male with a history of severe destructive rheumatoid arthritis on several immunosuppressive agents and right hip osteoarthritis s/p total hip arthroplasty 15 years previously with several complex revisions, presenting with several weeks of worsening right hip and abdominal pain. A right hip CT scan revealed periprosthetic fluid collections. Aspiration of three fluid pockets was AFB smear-positive and grew Mycobacterium avium-intracellulare. The patient was deemed a poor surgical candidate. He underwent a limited I&D and several months of antimycobacterial therapy but clinically deteriorated and opted for hospice care. PJI caused by NTM are rare and difficult to treat. The increased use of biologics and prosthetic joint replacements over the past several decades may increase the risk of PJI due to NTM. A high index of suspicion for NTM in immunosuppressed patients with PJI is needed.

Role of Infections in the Pathogenesis of Rheumatoid Arthritis: Focus on Mycobacteria

“…In addition, there are reports of some other species of Mycobacterium associated with RA disease that make it difficult to treat the disease. There have been case reports of other Mycobacterium species in infections and arthritis and other parts of the body in RA patients around the world [ 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 ]. Furthermore, the risk of death in RA patients with mycobacterial infection was higher than that in patients without infection [ 13 ].…”

Mycobacterium Avium Prosthetic Hip Infection on Abatacept Presenting as Fever of Unknown Origin

“…At the time of writing, only a few case reports of MAC PJI were found in the literature. Most cases occurred in an immunosuppressed patient due to transplant, both renal and cardiac 2,5,6,9. One episode was reported in a patient similar to this patient, who was immunosuppressed due to chronic steroid use for rheumatoid arthritis 6.…”

Treatment of Extrapulmonary Nontuberculous Mycobacterial Diseases

“…NTM prosthetic joint infections can rarely occur. RGM are a more common cause of prosthetic joint infections than SGM [54]. A study of 8 cases of prosthetic joint infection caused by RGM over 4 decades at the Mayo Clinic required a combination of resection arthroplasty and antibiotic therapy [55].…”