Case Reports

Arthritis, Infectious Tenosynovitis, and Tendon Rupture in a Patient With Rheumatoid Arthritis and Psoriasis

Fed Pract. 2015 February;32(2):31-35

References

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15. Schoellnast H, Deutschmann HA, Hermann J, et al. Psoriatic arthritis and rheumatoid arthritis: Findings in contrast-enhanced MRI. AJR Am J Roentgenol. 2006;187(2):351-357.

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Septic Arthritis

The suspicion of septic arthritis and infectious tenosynovitis substantially increased on day 6 with worsening symptoms, involvement of additional joints, and spiking fevers. Group G Streptococcus was obtained from the aspirate of the left wrist and from the surgical specimens from the bilateral wrists. The clinical presentation, MRI imaging studies, and surgical and nonsurgical specimens supported a diagnosis of GGS tenosynovitis. However, there was no clear evidence (ie, positive culture with identified organism) of septic arthritis, likely secondary to early septic arthritis and initiation of antibiotics before joint aspirations. The aspirate from the left ankle was yellow and opaque, but the culture was negative.

The pathogenic organism in the patient was GGS. Group G Streptococcus is normal flora of the oral cavity, gastrointestinal (GI) tract, upper respiratory tract, genital tract, and skin, which were all possible sources of seeding.¹⁸ Streptococcal species account for about 20% of septic arthritis, and GGS arthritis accounts for 4% to 19% of streptococcal arthritis.^19-22 From a review of the literature, 2 cases of GGS tenosynovitis have been published.^23,24 However, in an ultrasound study and MRI study, 49% and 43%, respectively, of patients with RA had tenosynovitis of the tendons of the hands.^15,25

GGS Demographics

About three-quarters (71%) of patients with GGS arthritis are male.¹⁹ The analysis of the literature by Bronze and colleagues found that chronic joint disease and alcoholism are present in 34% and 14% of patients with GGS arthritis, respectively. One-quarter (23% from Dubost and colleagues) to one-third (32% from Schattner and colleagues) of patients with GGS arthritis have RA.^19,26

Fever is present in less than half (43%) of patients with GGS arthritis.¹⁹ Positive synovial fluid is expected in 90% of patients.¹⁹Leukocytosis and elevated ESR need not be present.^27,28 The arthritis is polyarticular in one-quarter of patients (24% from Bronze and colleagues and 26% from Dubost and colleagues).^19,26

Positive blood cultures can be expected in one-fourth (26%) of patients with GGS arthritis.¹⁹ The patient’s blood cultures were negative. Blood cultures drawn before initiation of antibiotics yielded no growth, so if the spread was hematogenous, the bacteremia was transient or intermittent. Before and after initiation of antibiotics, specimens from the shoulders did not grow colonies, whereas specimens from the wrists did. If the shoulders were truly infected, these findings and the notably later involvement of the shoulders suggest that the shoulders may have been seeded later in the hospital course.

Trenkner and colleagues proposed that GI abnormalities provide a portal of entry for GGS, which is under the umbrella of S. milleri.²⁹S. milleri is associated with abscess formation, usually of the GI tract.^30-32 In the study patient, the possible gastroenteritis may have provided such a portal of entry and subsequent seeding to the joints, and an abscess was found in the left wrist.

Tendon Rupture

Additionally, bilateral EPL tendon rupture likely occurred as a consequence of the inflammatory process from RA and infectious tenosynovitis in the patient. According to Zheng and colleagues, tenosynovitis is an inflammatory process of the synovial tendon sheath that may result in degeneration and rupture of the tendons and may contribute to bone erosions, development of joint deformities, and loss of functional capacity.³³ In a histologic study of a ruptured EPL tendon from a patient with RA, Harris observed a chronic inflammatory cellular reaction.³⁴ Harris also described a male with RA with unconfirmed bilateral EPL rupture.³⁴ Björkman and colleague identified previous injury, RA, and local or systemic steroids as important etiologic factors for EPL tendon rupture.³⁵

As in the case of this patient, the utilization of both medical and surgical therapy is not uncommon for treating GGS infection. Antibiotic therapy typically consists of penicillin (74%).²⁶ Surgical intervention is necessary in 16% to 37% of patients.^19,26 This patient required both penicillin and incision and drainage/debridement before significant clinical improvement was noted. Prognosis of GGS arthritis is favorable with 5% mortality.²⁶

Conclusion

Septic arthritis and infectious tenosynovitis are readily treatable with low mortality if promptly identified. Identification can be masked by other medical conditions, such as RA and psoriasis, and their associated immunosuppressive treatment. Bilateral EPL tendon rupture may be a complication of RA, particularly with an underlying septic arthritis and infectious tenosynovitis.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.