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A 64-year-old man presented to the emergency department
complaining of severe pain in the left knee joint for the last two days, which
was also accompanied by swelling, warmth, and tenderness. The severity of the
pain and the joint stiffness was severe enough to restrict him from walking or
even bending the knee joint. He had visited the outpatient department a few
months back, complaining of mild-to-moderate pain in multiple joints. The intensity
of the pain was consistently increasing for the past two weeks, and there was
no relief even after taking various doses of over-the-counter pain relievers.
Although he was a well-built person, he seemed very weak and dehydrated; maybe
due to decreased appetite.
The most likely diagnosis
of this presentation is
Primary meningococcal arthritis (PMA) represents a rare
form of septic arthritis caused by N. meningitides that
affects as little as 1% of meningococcal infections. Meningococcal arthritis
prominently affects larger joints like knee and elbow joints. It may be often
linked to history or on-going upper respiratory infections (50–55%) or
psoriasis and usually doesn’t show other signs of meningococcal disease such as
meningitis, fever, rash, and hemodynamic instability. Septic arthritis is
caused by a variety of other microorganisms, including Staphylococcus
aureus, which accounts for almost 44% of cases, Escherichia
coli, Pseudomonas and N. gonorrhoea which is the
most common cause in adults. Studies have also indicated
the role of low socioeconomic status, drug abuse, weak immunity and history of
trauma in the development of septic arthritis. Inappropriate diagnosis and/or
management may lead to local destruction of the joint and peripheral spread of
infection. Thus, septic arthritis is considered a medical emergency and needs
prompt diagnosis and effective treatment to avoid further complications.
Patient without any significant symptoms related to meningococcal disease, was diagnosed with primary meningococcal
arthritis of the knee joint. The patient was successfully treated with intravenous
infusion of ampicillin/sulbactam.
The patient had a history of type II
diabetes but was not on any anti-diabetic medications until he diagnosed with
retinitis a few months back. He also recollected history of an accident that
had injured his both the knees and he was on bed rest for almost a week. He was
recently diagnosed with high blood pressure and elevated lipids.
A physical examination clearly showed the
signs of arthritis, including swollen, reddened, and tender knee joint. Imaging
studies showed an effusion of the synovial fluid, inflamed joint-lining, and
loss of cartilage, causing degenerative changes in the joint. Microscopic
assessment of the synovial fluid from the diseased knee revealed the presence
of gram-negative diplococci (which are further identified as N. meningitides) that indicated PMA. Blood
examinations ruled out the increased levels of white blood cells (WBCs), and
sodium (due to dehydration). Urine analysis showed an increased level of
albumin and urine protein indicating diabetic nephropathy.
Immediately after the hospitalization,
intravenous injection of ampicillin/sulbactam (2:1, w/w ratio; 5 g, four times
a day) was administered and continued for 18 days. Insulin detemir and a
special (calorie-limited) diet plan were considered as a part of the treatment
regimen to manage diabetes. Electrolyte replenishment was undertaken to
overcome the dehydration. A non-steroidal anti-inflammatory drug was given to
relieve the local pain and inflammation. The severity of symptoms decreased
gradually with the treatment for 1-2 weeks, and movement of the knee was
significantly improved. Re-examination of the synovial culture (after two weeks
of hospitalization) turned out to be negative for meningococcus.
Although PMA is uncommon, immunocompromised patients have a higher risk of developing this disease. Infection of N. meningitides affects almost 5 million cases per year across the world, among which, about 10% of cases are estimated to develop arthritis complications. In this case, the patient did not show any symptoms of meningococcemia, and blood culture/sputum analysis turned out to be negative; therefore, the possibility of having meningococcemia was eliminated. It is essential to begin an appropriate antibiotic regimen (first-line treatment) to treat meningococcal arthritis at an early stage to avoid further complications like degenerative damage. Since most of the septic arthritis cases have gram-positive organisms as an underlying cause, the most appropriate first-line antibiotic choice would be penicillin or first-generation cephalosporin. However, if Neisseria gonorrhoeae is suspected, a third-generation cephalosporin is the recommended choice.
Moreover, in the case of
methicillin-resistant S. aureus or
opportunistic infection, vancomycin is preferred. Penicillin administered as an
intravenous injection is a smart choice to treat PMA and other forms of
meningococcal infection. After antibiotics, aggressive open irrigation of the
diseased joint is the recommended therapy for septic arthritis. Further,
considering the meningococcal conjugate vaccine as a preventive measure may
play an important role in disease management.
Since PMA can be mistakenly diagnosed as a
disseminated gonococcal disease, assessment of the synovium and blood cultures
is important to rule out the cause of septic arthritis. Identification of
underlying cause helps the experts to design the most effective treatment
regimen at an early stage of the disease.
Clinical Case Reports 2015; 3(2): 76–80
A very rare case of primary meningococcal arthritis in an adult male
Shin Nihonyanagi et al.
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