Neisseria meningitidis Serogroup C Causing [605557]

Neisseria meningitidis Serogroup C Causing
Primary Arthritis in a Child
Case Report
Sergiu Straticiuc, MD, PhD, Ancuta Ignat, MD, PhD-student: [anonimizat], MD, PhD,
Vasile Valeriu Lupu, MD, PhD, Alexandru Bogdan Ciubara, MD, PhD, and Roxana Cretu, MD
Abstract: Introduction: Neisseria meningitidis (N. meningitidis) is
associated with severe invasive infections such as meningitis andfulminant septicemia. Septic arthritis due to N. meningitidis is rare
and bone infections have been reported exceptionally. We report the
case of a 1-year old girl who presented with a painful, swollen rightknee, accompanied by fever and agitation. Arthrocentesis of the rightknee, while patient was under anesthesia, yielded grossly purulent fluid,
so we made arthrotomy and drainage. The culture from synovial fluid
revealed N. meningitidis , sensitive to Ceftriaxone. The patient received
intravenous antibiotherapy with Ceftriaxone. The status of the patient
improved after surgical drainage and intravenous antibiotic therapy. She
recovered completely after 1 month.
Conclusion: This observation illustrates an unusual presentation of
invasive meningococcal infection and the early identification of the
bacteria, combined with the correct treatment, prevent the compli-
cations and even death.
(Medicine 95(5):e2745)
Abbreviations : CRP = C-reactive protein, ESR = erythrocyte
sedimentation rate, PCR = polymerase chain reaction, PMA =
primary meningococcal arthritis.
INTRODUCTION
Neisseria meningitidis is associated with severe invasive
infections such as meningitis and fulminant septicemia.
Septic arthritis due to N. meningitidis is uncommon and bone
infections have been reported exceptionally.1
There is a concomitant septic arthritis in 11% of cases of
meningococcemia. We describe below a rare clinical case of a
1-year-old girl with primary meningococcal arthritis (PMA)without meningococcemia.CASE REPORT
A Caucasian 1-year old girl presented to the Emergency
Department with a painful, swollen right knee accompanied byfever and agitation. She was unable to move it or bear weight on
it. There was no history of close contact with other children, no
history of respiratory or urinary tract infections. Our patient hadnever received meningococcal vaccination. Her body tempera-ture was 38.6 8C. There was no skin rash. There was no neck
rigidity or photophobia. The knee examination revealed an
erythematous, warm, swollen right knee that was diffuselytender to palpation. Active and passive range of motion wasseverely limited secondary to pain. The peripheral blood
white cells count was 22.74 /C210
3, Neutrophils ¼75.0%,
Lymphocytes ¼16.9%, Monocytes ¼7.8%, erythrocyte sedi-
mentation rate (ESR) ¼53 mm/1 hour, C-reactive protein
(CRP) ¼49.45 mg/L. Two sets of blood cultures were per-
formed. Both blood cultures were negative for any bacteriaafter incubation for 5 days. X-ray of the right lower limb did notreveal any bone lesions (Figure 1). Arthrocentesis of the right
knee, while the patient was under anesthesia, yielded grossly
purulent fluid, so we made arthrotomy and drainage. We madealso, puncture of the right hip to exclude the diagnosis ofosteoarthritis. Microscopic examination of synovial fluid
revealed numerous polymorphonuclear neutrophils with intra-
cellular Gram-negative diplococci. The synovial fluid culturerevealed N. meningitidis serogroup C, sensitive to Ceftriaxone.
The patient received intravenous Ceftriaxone for 12 days (1 g/
day) and continued to take oral Cefuroxime for another 2 weeks.
The evolution of the patient was favorable, removing the drainon 5th day after surgery. She showed full recovery at later
follow-up.
The patient responded well to the treatment over 12 days.
The white blood cells, CRP, and ESR have fallen consistently(Figure 2).
We evaluated the patient in each month, for 6 months, with
the monitoring of blood count, ESR, and CRP, which weremaintained within normal limits.
DISCUSSION
PMA is an uncommon form of meningococcal disease.
PMA is defined as acute septic arthritis without meningitis or
classical syndrome of meningococcemia, defined as the com-
bination fever, rash, and hemodynamic instability.2Giamarel-
los-Bourboulis et al3reported 34 cases of PMA in literature
from 1980 to 2002.
Staphylococcus aureus is the most likely causative agent of
septic arthritis, occurring in 44% of cases.4Escherichia coli and
Pseudomonas are much less common. These gram-negative
bacteria affect newborns and patients with immunodeficiencies.
It was reported that N. gonorrhoea is a frequent cause of septicEditor: Victor Asensi.
Received: August 18, 2015; revised: January 5, 2016; accepted: January 13,2016.
From the Pediatric Orthopaedic Department, ‘‘St. Mary’’ Emergency
Children Hospital (SS, RC); Pediatrics Department (AI, VVL); Pediatric
Surgery Department (EH); and Anatomy Department, University of
Medicine and Pharmacy ‘‘Gr. T. Popa’’; Orthopaedics Clinic, ‘‘St.
Spiridon’’ Emergency Clinical Hospital, Iasi, Romania (ABC).
Correspondence: Vasile Valeriu Lupu, Pediatrics Department, University of
Medicine and Pharmacy ‘‘Gr. T. Popa’’, 16 Universitatii St., Iasi
700115, Romania (e-mail: valeriulupu@yahoo.com).
The authors have no funding and conflicts of interest to disclose.
Copyright
#2016 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative CommonsAttribution-NoDerivatives License 4.0, which allows for redistribution,
commercial and non-commercial, as long as it is passed along unchanged
and in whole, with credit to the author.
ISSN: 0025-7974
DOI: 10.1097/MD.0000000000002745Medicine®
CLINICAL CASEREPORT
Medicine /C15Volume 95, Number 5, February 2016 www.md-journal.com |1

arthritis in young people. N. meningitidis is a less common
cause of septic arthritis. Its predilection for causing oligo
articular infection makes it difficult to separate it from dis-
seminated gonococcal infection.5–8
Our child presented with only 1 joint arthritis, associated
with rash and a clinical differential diagnosis was difficile. The
presentation of PMA can be very similar to other septic arthritis
and it can be identical with arthritic disease induced by Neis-
seria gonorrhoeae . Both bacteria have an affinity to cause oligo
articular arthritis associated with rash. Direct bacterial invasion
of the synovium via blood-borne infection is the proposed
pathogenesis of PMA, with approximately 40% from patientshaving positive blood culture.9Symptoms of an upper respir-
atory infection precede the arthritis up to 50% of cases;8a
maculopapular rash is another sign, observed in 30% of cases.5,9
In our case, the infant had no history of respiratory or urinarytract infections.
The clinical spectrum of meningococcal infections ranges
from asymptomatic carriage to fulminant sepsis, with menin-gitis and septicemia. However, the ability of the organism tocause focal disease is often overlooked.
10Effort was made to
classify the various presentations according to the clinical types
and pathogenic mechanisms. Schaad postulated that 4 differentmechanisms may be involved:
(1) direct bacterial invasion of the synovium-septic arthritis.
(2) hypersensitivity reaction-allergic arthritis.
(3) intra-articular hemorrhage – hemarthrosis.
(4) iatrogenic causes9
Although arthritis has been observed in approximately 7%
of meningococcal infections, PMA is uncommon. A review of
the literature found 46 reported patients – children and adults –
with meningococcal joint infections without meningeal symp-toms. Of the 46 patients, 19 involved isolated joints. Of these,the knee was the most common – 11 patients, followed by the
ankle. Approximately 50% of patients were children younger
than 4 years old.
11,12In this review, we can add our 1-year old
girl with meningococcal infection in only 1 joint.
In our case, the synovial fluid culture revealed N. menin-
gitidis serogroup C, but in our country there were no epidemics
with this organism, and the PMA serogroup C is the only casereported in a 1-year old child.
Searching PubMed database about Neisseria meningitidis
serogroup C causing primary arthritis, we found a few results
(Table 1).
The polymerase chain reaction (PCR) technique is some-
times used to identify various strains of meningococci from the
blood, cerebrospinal fluid, or other normally sterile sites withvalidity comparable to that of culture-based diagnosis. It pro-vides a complementary tool of classic culture and often
enhances confirmatory results. The distinction between gono-
coccal arthritis ( N. gonorrhoeae ) and meningococcal arthritis
(N. meningitidis ) may be difficult. On microscopic examination
of knee aspirate N. meningitidis and N. gonorrhoeae are
morphologically indistinguishable and cultures may be nega-
tive, especially if antimicrobial agents have been given.
20PCR
can provide a specific diagnosis in such cases. Also, PCR does
not require organisms to be viable.21In our case, the result of the
FIGURE 2. Serum analysis of WBC, CRP, and ESR levels during
treatment. CRP ¼C reactive protein, ESR ¼erythrocyte sedimen-
tation rate, WBC ¼white blood count.
FIGURE 1. X-ray of the right lower limb.
TABLE 1. Reported Cases of Primary Arthritis With Neisseria meningitidis Serogroup C
First Author Name Year of Publication Age Gender Joint Involved Treatment Received Out-Come
Joice et al131995 19 Female Hip IV Penicillin G Healed
Christiansen142001 19 Female Knee IV Ceftriaxone,
IV Amoxicillin,
PO OfloxacinHealed
Cartolano et al152002 16 Female Knee IV Penicillin G Healed
Giamarellos-Bourboulis et al162003 19 Female Knee IV Benzylpenicillin Healed
Joyce et al172008 29 Female Knee IV Ceftriaxone Healed
Harwood et al182011 76 Female Shoulder IV Ceftriaxone Healed
Garner et al192015 19 Female Knee IV Ceftriaxone HealedStraticiuc et al Medicine /C15Volume 95, Number 5, February 2016
2|www.md-journal.com Copyright #2016 Wolters Kluwer Health, Inc. All rights reserved.

culture was positive, so it was not necessary to perform the
PCR technique.
Vaccination remains the best control strategy to prevent
invasive meningococcal disease, but our infant did not receivedmeningococcal vaccination. He had no risk factors in history
and in our country this vaccine is optional and it is not covered
by the national health system.
Septic arthritis is a medical emergency that needs prompt
recognition and treatment to prevent local disruption of the joint
and peripheral circulation of infection. Initial diagnosis of septic
arthritis is obvious. The patient presents with fever and a warm,swollen, and tenderness joint. The knee is the most frequent
involved.
20Further evaluation of septic arthritis includes arthro-
centesis of affected joint, complete blood cell count, andperipheral blood cultures. The synovial fluid should be cultured,gram-stained, and analyzed for cell count to help with initial
management.
22,23The synovium is positive for meningococcus
in 90 % of PMA cases, the blood cultures are positive only in40% of PMA cases.22
CONCLUSIONS
Our case confirms the data from the literature that N.
meningitidis does not appear to be aggressive toward hyaline
cartilage. Complete recovery does usually occur, provided
appropriate intravenous antibiotic therapy, joint aspiration,and/or washout are performed early.
This observation illustrates an unusual presentation of
invasive meningococcal infection and the early identification
of the bacteria, combined with the correct treatment, preventedthe complications and even death.
CONSENT
Written informed consent was obtained from the parents of
the child for publication of this case report. A copy of the written
consent is available for review by the Editor of this journal.
ACKNOWLEDGMENTS
The authors thank Dr Anca Gabriela Savu, Intensive Care,
Dr Letitia Doina Duceac, Epidemiology, and Dr Elena Petraru,Microbiology, from the ‘‘St. Mary’’ Children Emergency Hos-
pital, Iasi, for their help in managing this patient.
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