Infectious Diseases in Clinical Practice:
Prosthetic Septic Arthritis Secondary to Prevotella bivia Bacteremia in a Patient With Polymyalgia Rheumatica
Nseir, Bacel MD*; Cutrona, Anthony F. MD, FACP, FIDSA†
*Department of Internal Medicine/Pediatrics, and †Infecftious Disease Division, Northeastern Ohio Universities College of Medicine/Western Reserve Care System, Youngstown, OH.
Address correspondence and reprint requests to Bacel Nseir, MD, Department of Internal Medicine, Northside Medical Center, 500 Gypsy Lane, Youngstown, OH 44505. E-mail: email@example.com.
Prevotella bivia is gram-negative anaerobic bacteria previously classified in the genus Bacteroides and usually reported in obstetric and gynecologic infections. To our knowledge, there has been only 2 descriptions of infectious arthritis secondary to this bacterium. We report the first case of a spontaneous prosthetic septic arthritis caused by Prevotella bivia in a patient with long-lasting polymyalgia rheumatica.
A 77-year-old man with a history of osteoarthritis involving both hips and knees and a right total hip replacement 5 years ago was admitted with excruciating pain in the right hip in addition to fever and chills of 2 days' duration. Three weeks prior, he complained of increasing right hip pain instability of the right hip prosthesis. Medical history included aortic valve replacement 4 years ago and a dual-chamber pacemaker which was revised 4 weeks before admission because of an accidental break in the right ventricle pacemaker wire. His medications included prednisone 10 mg daily for a polymyalgia rheumatica. Physical examination showed fever of 38.4°C, pulse of 110 beats/min, respiratory rate of 25 breaths/min, and blood pressure of 104/41 mm Hg. He was tachycardic with III/VI systolic ejection murmur radiating to the left axilla which was not previously documented, in addition to erythematous tender right hip. Because of evolving sepsis, the patient was transferred to the intensive care unit; a right hip arthrocentesis revealed a dark purulent fluid. The white blood cell count was 20.6 × 103 cells/μL, with 50% bands. Erythrocyte sedimentation rate was 44 mm/h at the end of the first hour. Empiric antibiotic started using intravenous vancomycin 1.5 g every 12 hours and cefepime 2 g every 12 hours. Transthoracic echocardiogram showed no changes in the ventricular or valvular function. Transesophageal echocardiograph revealed no valvular vegetations. Anaerobic β-lactamase-producing Prevotella bivia was the only identified pathogen in the blood and the arthrocentesis fluid cultures. The β-lactamase activity was tested by the chromogenic cephalosporin (Cefinase) disk method. Antimicrobials were changed to intravenous ampicillin/sulbactam 3 g every 6 hours and metronidazole 500 mg every 12 hours according to the pathogen antibiogram profile identified by the MicroScan antimicrobial susceptibility system. Three days later, the patient underwent total hip arthrotomy, extensive joint irrigation, removal of prosthesis, and placement of tobramycin-impregnated spacer. The bone biopsy was consistent with osteomyelitis, and tissue culture grew the P. bivia.
Prevotella bivia, previously classified as Bacteroides bivius, has been identified as a normal flora in the female genital tract but has also been implicated in osteomyelitis,1 osteitis,2 endocarditis,3 necrobacillosis,4 sinusitis,5 animal bites wound infections,6,7 intracranial abscesses,8 and periodontal9 and tubo-ovarian abscesses.2 Two cases of septic arthritis caused by P. bivia have been documented: an elderly man with rheumatoid arthritis10 and a young female with seronegative juvenile rheumatoid arthritis after intra-articular joint injection.11 Except for trauma or postoperative wound infection or injections, the precise mechanism of septic arthritis is not clear. In cases not associated with interruption of anatomical integrity, transient bacteremia and occluded vasa vasorum in bone may lead to anaerobic conditions and hence the proliferation of bacteria.12 This case is consistent with earlier data on septic hip joint infections with P. bivia; the patient had chronic inflammatory joint disease, was on immunosuppressive medication, and had prosthetic joint as risk factors. However, our patient had documented bacteremia, unlike previously reported cases. The response was favorable to prompt diagnosis and antimicrobials (ampicillin/sulbactam and metronidazole), as well as surgical debridement and removal of prosthesis. The hip arthroplasty demonstrated significant destruction as evinced clinically by increased pain on exertion and progression of the joint loosening before presentation. The severe septic syndrome that developed in part may be attributed to the location of the infection; however, anaerobes such as P. bivia were reported to produce elastase as a virulence factor13 which may account for this patient's severe toxicity. This case provides further evidence of the role of P. bivia as a causative agent in septic arthritis and bacteremia in immunocompromised patients.14 The growth of P. bivia in blood cultures from immunocompromised patients always warrants careful clinical consideration for unusual presentation of septic arthritis,12,14 osteomyelitis,1 or endocarditis.3
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