CASe repOrt

A 63-year-old female, obese, presented to our hospitalfor pain in her left knee of one-year duration. She under-went left total knee arthroplasty on november 2011 forknee osteoarthritis. After two years she developed ten-derness, swelling and redness of her left knee (fig. 1),treated by painkillers without any further investigations.

She presented in february 2015 with worsening of hersymptoms, so she became unable to bear weight. her painwas continuous in type, waking her at night and interfer-ing with her daily activities; she also reported night sweatsand chills. laboratory studies showed the following: anelevated C-reactive protein of 27.4 mg/l and normalwhite blood cell count. X-rays and leucoscan of her leftknee revealed loosening of the tibial prosthesis (fig. 1),and evidence of osteomyelitis, respectively.

the patient underwent a two-stage revision total kneearthroplasty. in the first stage her left knee prosthesiswas removed with gentamicin spacer insertion (fig.1).During this surgical procedure, synovitis with granula-tion tissue were removed, cultures were taken and re-turned to be negative after 3 days. On the 4th day, subcul-tures showed growth of Gram-negative coccobacilli onchocolate agar supplemented with polyvitex. the wrighttest was positive at a titer > 1/5120. there was a puregrowth of Brucella spp.

while reviewing her history, the patient reported eat-ing homemade cheese prepared from unpasteurizedfresh milk. After the first surgical procedure antibiotictherapy was given for four months (gentamicin 240 mgfor 15 days, rifampicin 300 mg three times daily anddoxycycline 100 mg twice daily) and was followed by asecond stage revision left total knee arthroplasty (fig. 1).During the second procedure the surgical field was ma-croscopically clean, without pus, or any other sign of in-flammation or infection. Several cultures specimen fromthe femur and the tibia were taken and returned to benegative. At two years follow-up, the patient was painfree with excellent functional result and reported a highlevel of satisfaction.

DiSCuSSiOn

Brucellosis, which is primarily an animal disease, istransmitted to humans from infected animals’ meat,milk, urine and body fluids. it is a common zoonosisseen all over the world, especially in the Mediterraneancountries, the Arabian peninsula, india, Mexico, andCentral and north America. in developed countries, theinfection has been eradicated from animals, but develop-ing countries still have significant morbidity.

the disease is generally transmitted to humans eatingcheese, made from raw milk, and milk products such ascream and butter as well as eating animals’ reticulo-endothelial organs, such as the spleen and liver, withoutproper cooking. in addition, it may be transmitted byway of infected secretions coming into contact withskin cracks, conjunctiva, or inhalation of dust in stables.it manifests as a systemic infection with nonspecificsymptoms as fever, sweats, anorexia, fatigue or weightloss. it can affect any organ or organ system of the body.

46 Lebanese Medical Journal 2018 • Volume 66 (1)

CAS CLINIQUE / CASE REPORTPERiPRoSTHETiC KnEE inFECTion WiTH Brucella SEPCiESA Case Reporthttp://www.lebanesemedicaljournal.org/articles/66-1/case1.pdf

peter MAAlOuf1*, Amer ABDAllAh

2.3, Angelique BArAKAt

4, Matta MAttA

5

Maalouf p, Abdallah A, Barakat A, Matta M. periprostheticknee infection with Brucella spp. : A case report. J Med liban2018 ; 66 (1) : 46-48.

Maalouf p, Abdallah A, Barakat A, Matta M. étude d’un casd’infection périprothétique de genou à Brucella spp. J Medliban 2018 ; 66 (1) : 46-48.

ABSTRACT • A 63-year-old female patient presented forinfected total knee prosthesis by brucella spp. several yearsafter undergoing knee replacement arthroplasty. She under-went a two-stage revision surgery and was treated wih gen-tamicin, rifampicin and doxycycline for a total duration offour months.

Keywords : total knee replacement; knee prosthesis infec-tion; brucella

RÉSUMÉ • Nous présentons le cas d’une femme âgée de63 ans, opérée d’une prothèse totale du genou gaucheinfectée par brucella spp. plusieurs années plus tard. Elle aété opérée d’une reprise de son arthroplastie totale du ge-nou en deux temps et a été traitée par antibiothérapie, pourune durée de quatre mois, à base de gentamicine, de rifam-picin et de doxycycline.

Mots-clés : prothèse totale de genou; prothèse de genouinfectée; brucella

1hôtel-Dieu de france university hospital, Saint-Joseph uni-versity (uSJ), Beirut, lebanon.

2Orthopedic Surgery, Bellevue Medical Center (BMC), uSJ. 3Orthopedic Surgery Department, faculty of Medical Sciences,lebanese university.

4Clinical laboratory, BMC. 5infectious Diseases, BMC, uSJ.

*Corresponding author : Peter Maalouf, MD.e-mail: petermaalouf@hotmail.com

On physical examination, the most notable findings arefever, lymphadenopathy, and hepato-splenomegaly. Osteo-articular complications of brucellosis include: arthritis,spondylitis, osteomyelitis, tenosynovitis, and bursitis, themost commonly reported complication is the sacroiliacjoint infection as described in many studies [1-3].

the incidences of infection of primary total hip andknee arthroplasty sites lie between 1% and 5.6%. Aero-bic Gram-positive cocci (S. aureus, coagulase negativestaphylococci and enterococci) account for 65% ofthese infections [4]. less frequent causes of infection(6%) are aerobic Gram-negative bacilli (Escherichiacoli, Proteus mirabilis and Pseudomonas aeruginosa).fungal or mycobacterial infections are extremely un-usual [5].

first described in 1991 [6], Brucella infection of totalknee prosthesis was then reported in many cases [7-12].in 2011 in Germany, wünschel et al. described a case ofa 64-year-old female who presented with loosening ofher knee prosthesis following total knee replacement,five years earlier. About two weeks after replacement ofthe prosthesis, bacterial growth was detected by chancein the preoperative culture and Brucella melitensis wasdiagnosed. the authors focused on the considerable riskfor laboratory-acquired infections [13]. tassinari et al.reported a case of Brucella infection in a total knee arthro-plasty without radiological signs of prosthetic loosening.they were able to manage the infection only with anti-biotic therapy using rifampicin and doxycycline for eightweeks [14]. Sazegari et al. described a 78-year-old man

whose total knee arthroplasty showed the symptoms ofinfection with Brucella with radiographic signs of loos-ening five years after the surgery. the patient was treat-ed successfully with a two-stage revision arthroplastysurgery along with rifampicin and doxycycline for eightweeks [15].

infection caused by Brucella following total hiparthroplasty was also reported in the literature by otherauthors [10,16]. ruiz-iban et al. and rozado et al.reported two cases of total hip arthroplasty infected byBrucella pathogens; one had evidence of componentloosening and was managed with a two-stage reimplan-tation along with oral antibiotics, and the other caseshowed no evidence of component loosening and wastherefore treated with a course of oral antibiotics alone[10].

treatment strategy depends on the implants fixationstatus. when component loosening is present, thetreatment of choice is a two-stage management com-prising removal of the implants in the first stage fol-lowed by 3 to 4 months of antibiotic treatment with orwithout gentamicin cement spacer [10,9,15]. in thesecond stage, the spacer is removed and the final revi-sion prosthesis is implanted. Conservation of the im-plants and the use of suppressive antibiotic therapy arerarely indicated and are reserved for patients withwell-fixed implants or those who are unfit for surgery[12,14]. in all cases, revision surgery was performedonly when evidence of loosening was seen on imagingstudies.

P. MAALOUF et al. – Periprosthetic knee infection with brucella spp. Lebanese Medical Journal 2018 • Volume 66 (1) 47

Figure 1. Left: AP and lateral X-rays of the left knee showing the loosened prosthesis (postero-lateral tibial plateau)Center: AP and lateral X-rays of the left knee after replacement with a spacer.Right: AP and lateral X-rays of the left knee after the second stage revision surgery.

COnCluSiOn

Our patient suffered from chronic brucellosis, which wasmisdiagnosed and was not appropriately managed foralmost three years. She presented with evidence of com-ponent loosening and was therefore treated with a two-stage procedure as described in the literature. Brucellosisshould be considered in endemic areas and should belisted in the differential diagnosis in the management ofloosened or painful knee prosthesis, especially in en-demic regions.

COnfliCt Of intereSt

the authors have no conflict of interest in this study.

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14. tassinari e, Di Motta D, Giardina f, traina f, De fine M,toni A. Brucella infection in total knee arthroplasty. Casereport and revision.Chir Organi Mov 2008 May; 92 (1):55-9.

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48 Lebanese Medical Journal 2018 • Volume 66 (1) P. MAALOUF et al. – Periprosthetic knee infection with brucella spp.