Native Joint Septic Arthritis Due to Rothia mucilaginosa: A Case Report and Literature Review

Alessa Fischer; Isabel Akers; Daniel Baunach; Roberto Buonomano

Native Joint Septic Arthritis Due to Rothia mucilaginosa: A Case Report and Literature Review

Alessa Fischer ¹ , Isabel Akers ^2* , Daniel Baunach ³ , Roberto Buonomano ²

¹ Division of Medicine, Spital Limmattal, 8952 Schlieren, Switzerland

² Division of Infectious Diseases, Spital Limmattal, 8952 Schlieren, Switzerland

³ Division of Orthopedic Surgery, Spital Limmattal, 8952 Schlieren, Switzerland

*Corresponding author: Isabel Akers, Divison of Infectious Diseases, Spital Limmattal, 8952 Schlieren, Switzerland.

Received Date: 9 March 2023

Accepted Date: 20 March 2023

Published Date: 24 March 2023

Citation: Fischer A, Akers I, Baunach D, Buonomano R (2023) Native Joint Septic Arthritis Due to Rothia mucilaginosa: A Case Report and Literature Review. Infect Dis Diag Treat 7: 209. DOI: https://doi.org/10.29011/2577-1515.100209

Abstract

Rothia spp. are gram-positive bacteria that are part of the normal human oral and gut microbiome. They mainly cause opportunistic infections in immunocompromised hosts and are associated with periodontal disease. Here, we present a rare case of septic arthritis of a native knee due to Rothia mucilaginosa in a 66-year-old, immunocompetent, male patient with osteoarthritis of both knees. Intra-articular corticosteroid injection was identified as most likely source of infection. We discuss the increase of iatrogenic joint infections caused by intra-articular injections or surgical procedures and identify the association of Rothia mucilaginosa joint infections with intra-articular corticosteroid injections.

Keywords: Opportunistic joint infections; Rothia mucilaginosa; Rothia spp.; Septic arthritis; Intra-articular injections

Introduction

Septic arthritis of native joints is a rare condition with high morbidity [1,2]. Without early recognition of infection and timely initiation of antibiotic therapy, septic arthritis can lead to severe joint destruction. Septic arthritis of native, non-prosthetic, joints occurs with an incidence of approximately 2 to 19 cases per 100000 people per year with rising tendency [3-9]. It usually affects elderly people or very young children and previous joint pathology such as rheumatoid arthritis, osteoarthritis and gout predispose to septic arthritis [3-6,8]. Further risk factors are end-stage renal disease, skin disease and intake of prednisone and other immunosuppressive medications [3,4,7,8]. A rise in iatrogenic infections caused by intra-articular injections or surgical procedures has been reported [4,7,9]. The knee is affected in approximately 45% of all septic arthritis cases in adults [3]. The most frequently isolated causative organisms of septic arthritis are Staphylococcus aureus in approximately half of cases followed by other gram-positive bacteria such as streptococci [3,4,7,9,10]. The isolation of opportunistic species from joint infections is rare and occurs mostly in immunocompromised patients [5,11]. Whether the increase in iatrogenic joint infections affects the spectrum of isolated organisms is unknown.

Here, we report the rare case of septic arthritis of a native knee due to Rothia mucilaginousa isolated from synovial fluid of an immunocompetent 66-year-old male three days after intraarticular injection of corticosteroids.

Case presentation

A 66-year-old male patient with known osteoarthritis of both knees presented to our emergency room with exacerbation of pain in the left knee. Upon physical examination the left knee was warm, swollen and tender with restricted movement. The patient was afebrile and hemodynamic stable and denied having any chills, shortness of breath or other joint pain . Trauma or injury to the affected knee was denied. The patient was previously obese with a BMI of 45.8 kg/m² and received bariatric surgery in 2019. At the current presentation the patient had a BMI of 31 kg/m² and was on antihypertensive medication. Additionally, the patient reported a history polymyalgia rheumatica for which he took oral prednisone on an irregular basis. Last prednisone intake was approximately two months before the current presentation. Conventional imaging of the left knee revealed severe osteoarthritis (Figure 1). An osteoarthritis flare-up was suspected and the patient sent home with analgesics.

Figure 1: X-ray of the left knee showing severe osteoarthritis.

The next day the patient returned to our emergency department. This time, a prominent effusion of the left knee with painful range of motion was observed upon clinical examination. Laboratory workup revealed a normal blood count with normal liver and kidney function but a high elevated C-reactive protein of 129 mg/dl.

A diagnostic arthrocentesis of the left knee was performed. The synovial fluid appeared turbid with a total synovial fluid cell count of 101’220 cells/mm³ which of 90.5% were polynucleated cells. Cultures of the joint fluid and blood cultures were sent for evaluation in microbiology. While awaiting culture results, antibiotic treatment with amoxicillin clavulanic acid 2.2 grams intravenously three time a day was initiated. In the meantime, cultures of the joint fluid grew gram-positive cocci and the decision for surgery the next day was taken. Four days after the initial intraarticular glucocorticoid injection, a knee arthroscopy with lavage was performed. Several tissue probes and synovial joint fluid were sent for culturing. Further differentiation of the joint fluid culture as well tissue resected during arthroscopy revealed growth of Rothia mucilaginosa.

A thorough patient history revealed, that the patients presented to the family doctor with exacerbation of pain in both knees three days before initial presentation. The patient received intra-articular corticosteroid injections in both knees and initially reported regress of pain. However, three days after the intraarticular injections, he developed increasing pain of the left knee and presented to our emergency room. No dental pathology was detected upon examination nor reported by the patient.

Antibiotic treatment was switched to amoxicillin and continued for a total of four weeks. Due to pain resistant to intravenous analgesic therapy, the patient received two further arthroscopies with lavage of the left knee joint. No microbial growth was observed in probes resected during the second and third arthroscopy. C-reactive protein decreased and swelling and pain of the left knee diminished the following days. The patient continued to see a physiotherapist and total knee replacement surgery was planned for three to four months after stop of antibiotic therapy.

Discussion

We present a rare case of septic arthritis with Rothia mucilaginosa in a non-prosthetic knee after intra-articular injections of corticosteroids. Rothia species (R. mucilaginosa, R. dentocariosa, R. aeria, R. nasimurium, and R. amarae) are aerobic or facultative anaerobic gram-positive, coagulase-negative coccibacilli occurring as part of the normal human oral and upper respiratory tract microbiome. Rothia spp. infections rarely occur in healthy humans and are mostly reported in immunocompromised hosts [12-16]. Invasive Rothia species infections have been reported in immunocompromised patients with endocarditis [17], meningitis [18,19], pneumonia [20], endophthalmitis [21,22], peritonitis [23,24] and prosthetic device infections [25-29].

Rothia species are seldom isolated from prosthetic joint infections or native joints. In the literature, ten cases of Rothia species associated infections of prosthetic [25-30] or native joint [31-34] were identified (Table 1). Most patients were immunocompromised and several patients suffered from periodontal disease or had undergone dental procedures prior to presenting with septic arthritis (Table 1). The causative agent was Rothia mucilaginosa in four reports [27,29,31,33]. In contrast, we report a case of septic arthritis with Rothia mucilaginosa in a patient with osteoarthritis as risk factor but without a known immunosuppressing condition. However, the patient received an intra-articular injection of corticosteroids in the affected knee three days before start of symptoms due to pain related to osteoarthritis. The patient did not present with symptoms of bacteremia such as fever or chills and blood culture remained sterile. Hence, a systemic infection with Rothia mucilaginosa and secondary septic arthritis seems unlikely and the intra-articular injection three days before presentation was identified as source of infection.

*Rothia species*	Affected Joint	Immunosuppression/ Co-morbidities	Dental/periodontal disease	Recent Intra-articular injection or joint surgery in the affected joint	First author
*Rothia mucilaginosa*	Prostethic knee	Diabetes	No	Total joint arthroplasty 3 months prior to presentation	Schermerhorn et al. [29]
*Rothia mucilaginosa*	Native knee	Severe bilateral osteoarthritis	Yes	Intra-articular injection with corticosteroids 3 days prior to presentation	Daoub et al. [31]
*Rothia mucilaginosa*	Native knee	Rheumatoid arthritis, daily prednisone therapy	Unknown	Intra-articular injections with corticosteroids 2 and 6 days and 12 weeks prior to presentation. Radiation synovectomy of the right knee 6 months prior	Kaasch et al. [33]
*Rothia mucilaginosa*	Prosthetic hip	No immunosuppression	Yes	No	Michels et al. [27]
*Rothia aeria*	Prosthetic knee	Rheumatoid arthritis, weekly methotrexate 12.5 mg, daily prednisolone 7.5 mg, chronic kidney disease, asthma, hypertension	Yes	No	Mahobia et al. [25]
*Rothia aeria*	Prosthetic shoulders	Rheumatoid arthritis, weekly methotrexate 12.5 mg. prednisone 2 mg and hydrocortisone 10 mg daily	Yes	No	Verrall et al. [34]
*Rothia dentocariosa*	Native knee	Rheumatoid arthritis, etanercept 25 mg twice weekly. oxaprozin	Yes	Meniscectomy and synovectomy 9 months prior	Favero et al. [32]
*Rothia dentocariosa*	Prosthetic knee	HIV infection	Yes (2 dental extractions 5 months prior to admission without prophylactic antibiotics)	No	Klinger et al. [28]
*Rothia dentocariosa*	Prosthetic hip	Chronic obstructive pulmonary disease, lung cancer	Tooth extraction 4 months before fracture of the right hip	Hemiarthroplasty due to right femoral neck fracture two weeks prior	Ozan et al. [30]
*Rothia spp.*	Prosthetic knee	Rheumatoid arthritis (no medical therapy)	Yes	No	Trivedi et al. [26]

Table 1: Previously reported cases of septic arthritis due to Rothia species.

Surgical procedures and intraarticular injections are increasingly recognized as iatrogenic causes of septic arthritis [4,7,9,35]. Two studies in Iceland between 1990 and 2017 showed a significant increase in incidence of iatrogenic joint infections following arthroscopic procedures in adults from 9/100000 per year in 1990–2002 to 25/100000 per year in 2003–2017 [7,9]. Kennedy et al. (2015) identified in 42 of 248 (16.9%) patients with confirmed septic arthritis an iatrogenic cause of infection. In both studies, the most frequently identified bacterial species was Staphylococcus aureus [4,7]. However, the causative specimens of iatrogenic infections was not further specified in these studies.

Interestingly, two other case reports describe septic arthritis of native knee joints with Rothia mucilaginosa after intraarticular injections with corticosteroids and local anesthetics [31,33]. Kaaschet al. (2011) reports septic arthritis with Rothia mucilaginosa in a native knee of a female patient with rheumatoid arthritis on daily prednisone therapy and intra-articular injections with corticosteroids and local anesthetics into the affected knee at two and six days and 12 weeks prior to admission for septic arthritis of the knee [33]. Daoub et al. report the case of a 58-yearold woman with serial corticosteroid and local anesthetic intraarticular injections due to osteoarthritis, who was subsequently diagnosed with Rothia mucilaginosa septic arthritis of the right knee [31].

Conclusion

In addition to hematogenous spread of Rothia species after dental procedures or periodontal disease, we identified direct inoculation of joints as relevant cause of septic arthritis due to Rothia mucilaginosa.

Our case report highlights the importance of proper aseptic technique during intra-articular injections.

Acknowledgements

Funding

No funding or sponsorship was received for this study or publication of this article.

Conflicts of interest

Alessa Fischer, Isabel Akers, Roberto Buonomano and Daniel Baunach declare they have no conflicts of interest that might be relevant to the contents of this manuscript.

Compliance with Ethics Guidelines

The patient described in this case report provided consent for publication.