Septic arthritis is the most serious form of arthritis and can lead to significant joint destruction. Usually, gonococcal septic arthritis occurs in young adults with polyarticular presentation.
Nongonococcal arthritis targets elderly patients and patients with underlying malignancy, rheumatoid arthritis, or immunocompromised state. The most common cause of nongonococcal septic monoarthritis is Staphylococcus aureus. Staphylococcus aureus can disseminate hematogenously and present as polyarticular septic arthritis. Gram-negative septic arthritis accounts for approximately 26% of nongonococcal septic arthritis and has a higher mortality and morbidity rate.1 Most gram-negative septic arthritis is due to Enterobacteriaceae, mostly Escherichia coli. Other gram negatives less frequently encountered include Pseudomonas aeruginosa among intravenous drug users, Haemophilus influenzae among nonvaccinated children, and Pasteurella multocida and Capnocytophaga sp. in the setting of cat and dog bites, respectively. Among gram-negative organisms, Moraxella species are an infrequent cause of septic arthritis.2-12 Moraxella lacunata is classically associated with conjunctivitis.13 We report a 78-year-old man with M. lacunata symmetric polyarticular arthritis and present a literature review on Moraxella sp. septic arthritis.
A 78-year-old man with a history of esophageal cancer status post distal esophageal resection 20 years ago, human immunodeficiency virus (HIV) infection, chronic hepatitis C, cardiac pacemaker insertion for heart block, and aortic graft surgery for repair of abdominal aortic aneurysm presented with multiple symmetric joint pain. He was diagnosed with HIV infection 10 years ago and was on highly active antiretroviral therapy until 1 year before presentation. He denied intravenous drug use and past opportunistic infections. He was well until 2 days before admission when he developed left elbow pain. He denied trauma or prior history of arthritis. He was evaluated in the emergency department and discharged home with the diagnosis of bursitis. Two days later, he was stopped by a policeman on the highway for driving aggressively. He was found to be disoriented and was brought to the hospital by ambulance. On admission, the patient was disoriented to time and complained of diffuse joint pain. He denied morning stiffness, fever, and chills. His temperature was 36°C, heart rate was 63/min, respiratory rate was 18/min, and blood pressure was 94/52 mm Hg. On physical examination, his neck was supple without nuchal rigidity. No heart murmur was noted; lung examination was unremarkable. Musculoskeletal exam revealed erythema, edema, and extreme tenderness in bilateral knees, ankles, elbows, wrists, and proximal, middle, and distal phalangeal joints with limited range of motion due to pain. Neurological examination showed normal cranial nerve function and sensory exam, but motor examination and deep tendon reflexes were limited by extreme joint pain. Laboratory findings revealed a leukocytosis of 13,200/μL with 65% neutrophils and a CD4 cell count of 129/μL. A computerized tomography of the head without contrast was unremarkable. Further data revealed an elevated rheumatoid factor of 1:1250 and a negative antinuclear antibody titer. Knee fluid showed a white blood cell count of 51,120/mm3, with 93% polymorphonuclear cells and glucose of 41 mg/dL. Wrist joint was also aspirated and yielded similar results. The patient was empirically treated with vancomycin and imipenem. Three days later, blood cultures and joint fluid cultures grew gram-negative rods that later were identified as M. lacunata, and vancomycin was discontinued. On the sixth day of hospitalization, bilateral knee incision and drainage were performed. To attempt to locate the source of infection, a computed tomography of the abdomen was performed, revealing a normal aortic graft without surrounding fluid collection. In addition, a transthoracic echocardiogram did not show valve vegetation. There was no sign of infection at the pacemaker site. Because of a possible risk for esophageal complication from his history of distal esophageal resection, a transesophageal echocardiogram was not performed. After 3 weeks, his joint swelling and pain were significantly improved, and he started rehabilitation. At the end of 6 weeks of therapy, all of his joint symptoms resolved without complications.
Septic arthritis usually presents in a single joint, but polyarticular involvement can be seen in approximately 19% of cases.14 Polyarticular disease is more frequently bacteremic (80% vs 50%-61% for monoarticular disease) and has a higher mortality rate (22% vs. 4% for monoarticular disease). Concurrent rheumatoid arthritis and chronic steroid use are more common in polyarticular disease, and the average number of joint involvement is four. Staphylococcus aureus accounts for 70% to 80% of the cases of polyarticular septic arthritis; other gram-positive bacteria such as Streptococcus pneumoniae, group G Streptococcus, and gram-negative organisms such as H. influenza, E. coli, and P. multocida have also been identified.14,15 We report M. lacunata as the causative organism of polyarticular septic arthritis with more than 10 involved joints, which is extremely rare, in a patient with underlying immunocompromised condition of HIV infection.
Moraxella lacunata is an aerobic, oxidase-positive, gram-negative coccobacillus found on mucous membranes of warm-blooded animals. It is usually considered nonpathogenic. The classic infection caused by M. lacunata is chronic angular blepharoconjunctivitis.13 Moraxella lacunata has been described as the causative organism of infective endocarditis in 4 patients.16 In all of them, the diagnosis was based on the presence of bacteremia, but only 1 of 4 cases had vegetations on heart valves noted on transesophageal echocardiogram. The other 3 cases were diagnosed based on predisposing factors such as prosthetic valves or bicuspid aortic valves. One patient had an infected aortic graft detected by positron emission tomography scan. Interestingly, our patient also had abdominal aortic graft, but the computed tomography of the abdomen did not reveal infection involving the graft.
From our literature search, there has been only 1 case report on M. lacunata septic arthritis8: a 73-year-old man with gout and osteoarthritis who underwent bilateral curettage and articular washout procedure of bilateral shoulders and presented 1 year later with bilateral M. lacunata shoulder infection. Both this patient and our patient had symmetric presentation of joint complaints. Our patient's predisposing factor for disseminated M. lacunata infection could have been his immunocompromised status from HIV infection.
Only 11 cases of Moraxella septic arthritis have been previously reported in the literature (Table 1). Moraxella catarrhalis was the etiologic agent for 4 cases, Moraxella nonliquefaciens for 2 cases, and Moraxella osloensis and M. lacunata for 1 case each; no further identification of Moraxella sp. was performed in 3 cases.2-12 The knee was the most common site of infection, and usually, a single joint was involved in most cases (Table 1). Of the 11 reported patients with Moraxella sp. septic arthritis, 8 had associated medical conditions. Five patients had a history of arthritis, including gout, osteoarthritis, juvenile rheumatoid arthritis, and undifferentiated spondarthritis. Five patients had conditions that affect the immune system, including diabetes, malignancy, nephritic syndrome, and immunosuppressive therapy. Two patients had a history of recurrent infections but no other apparent predisposing condition. Regarding treatment and outcome, approximately one third of the patients underwent surgical intervention. All the patients were treated with antibiotics. Treatment period varied from 6 days to 6 weeks. All the patients recovered without any joint problems.
In summary, we report a case of symmetric polyarticular arthritis with involvement of more than 10 joints due to M. lacunata in an HIV-infected patient and provide the first systematic review of previous case reports of Moraxella septic arthritis. Moraxella septic arthritis is unusual and most frequently occurs in patients with underlying medical conditions such as arthritis or immunocompromising diseases. No deaths were reported associated with Moraxella septic arthritis. In conclusion, although Moraxella species rarely causes invasive disease, there are now at least 12 cases of septic arthritis associated with Moraxella.
The authors thank Drs. Sreedevi Gondi and Shahriar Tavakoli-Tabasi for their help on the preparation of the article.
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