Abstract
Legionella spp. are an important cause of pulmonary and rarely extrapulmonary infections. L. cincinnatiensis has only been implicated in five cases to date. We herein report the first case of L. cincinnatiensis septic arthritis in a 90-year old lady with a past medical history of chronic kidney disease. She developed septic arthritis of her left wrist after having received intraarticular corticosteroid injections and oral corticosteroids administered for presumed chondrocalcinosis. Appropriate antimicrobial treatment of L. cincinnatiensis septic arthritis was delayed until identification of this organism in joint biopsies by broad-range bacterial PCR targeting the 16S rRNA gene with subsequent rDNA sequence analysis and by culture on special media. Reviewing all reported cases of septic arthritis caused by Legionella spp. other than L. cincinnatiensis it is notable that diagnosis was established by PCR in the majority of cases and only subsequently confirmed by special culture. Although most patients were immunosuppressed, outcome was favourable. Treatment consisted of a fluoroquinolone alone or in combination with rifampicin or a macrolide. Our case highlights the need for a high index of suspicion for infections with unusual/fastidious organisms when symptoms are suggestive of septic arthritis but conventional methods fail to identify a causative organism.
References
Gaia V, Casati S, Tonolla M. Rapid identification of Legionella spp. by MALDI-TOF MS based protein mass fingerprinting. Syst Appl Microbiol. 2011;34:40–4. doi:10.1016/j.syapm.2010.11.007.
Ratcliff RM, Lanser JA, Manning PA, Heuzenroeder MW. Sequence-based classification scheme for the genus Legionella targeting the mip gene. J Clin Microbiol. 1998;36:1560–7.
Lowry PW, Tompkins LS. Nosocomial legionellosis: a review of pulmonary and extrapulmonary syndromes. Am J Infect Control. 1993;21:21–7.
Thacker WL, Benson RF, Staneck JL, Vincent SR, Mayberry WR, Brenner DJ, et al. Legionella cincinnatiensis sp. nov. isolated from a patient with pneumonia. J Clin Microbiol. 1988;26(3):418–20.
Jernigan DB, Sanders LI, Waites KB, Brookings ES, Benson RF, Pappas PG. Pulmonary infection due to Legionella cincinnatiensis in renal transplant recipients: two cases and implications for laboratory diagnosis. Clin Infect Dis. 1994;18:385–9.
Spieker S, Petersen D, Rolfs A, Fehrenbach F, Kuntz R, Seuffer RH, et al. Acute disseminated encephalomyelitis following Pontiac fever. Eur Neurol. 1998;40:169–72.
Gubler JG, Schorr M, Gaia V, Zbinden R, Altwegg M. Recurrent soft tissue abscesses caused by Legionella cincinnatiensis. J Clin Microbiol. 2001;39:4568–70. doi:10.1128/JCM.39.12.4568-4570.2001.
Casati S, Conza L, Bruin J, Gaia V. Compost facilities as a reservoir of Legionella pneumophila and other Legionella species. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2010;16:945–7. doi:10.1111/j.1469-0691.2009.03009.x.
Casati S, Gioria-Martinoni A, Gaia V. Commercial potting soils as an alternative infection source of Legionella pneumophila and other Legionella species in Switzerland. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2009;15:571–5. doi:10.1111/j.1469-0691.2009.02742.x.
Bemer P, Leautez S, Ninin E, Jarraud S, Raffi F, Drugeon H. Legionella pneumophila arthritis: use of medium specific for Mycobacteria for isolation of L. pneumophila in culture of articular fluid specimens. Clin Infect Dis. 2002;35:E6–7. doi:10.1086/340713.
Linscott AJ, Poulter MD, Ward K, Bruckner DA. Legionella pneumophila serogroup 4 isolated from joint tissue. J Clin Microbiol. 2004;42:1365–6.
Just SA, Knudsen JB, Uldum SA, Holt HM. Detection of Legionella bozemanae, a new cause of septic arthritis, by PCR followed by specific culture. J Clin Microbiol. 2012;50:4180–2. doi:10.1128/JCM.01899-12.
Flendrie M, Jeurissen M, Franssen M, Kwa D, Klaassen C, Vos F. Septic arthritis caused by Legionella dumoffii in a patient with systemic lupus erythematosus-like disease. J Clin Microbiol. 2011;49:746–9. doi:10.1128/JCM.00606-10.
Fernandez-Cruz A, Marin M, Castelo L, Usubillaga R, Martin-Rabadan P, Bouza E. Legionella micdadei, a new cause of prosthetic joint infection. J Clin Microbiol. 2011;49:3409–10. doi:10.1128/JCM.00770-11.
Dugar M, Rankin WA, Rowe E, Smith MD. “My foot hurts”: a flare of rheumatoid arthritis? Med J Aust. 2009;190:392–3.
Thurneysen C, Boggian K. Legionella pneumophila serogroup 1 septic arthritis with probable endocarditis in an immunodeficient patient. J Clin Rheumatol. 2014;20:297–8. doi:10.1097/RHU.0000000000000128.
Naito T, Suda T, Saga K, Horii T, Chida K. Reactive Legionella pneumophila arthritis diagnosed by polymerase chain reaction. Rheumatol Int. 2007;27:415–6. doi:10.1007/s00296-006-0223-3.
Andereya S, Schneider U, Siebert CH, Wirtz DC. Reactive knee and ankle joint arthritis: abnormal manifestation of Legionella pneumophila. Rheumatol Int. 2004;24:182–4. doi:10.1007/s00296-003-0382-4.
Muder RR, Yu VL. Infection due to Legionella species other than L. pneumophila. Clin Infect Dis. 2002;35:990–8. doi:10.1086/342884.
Lowry PW, Blankenship RJ, Gridley W, Troup NJ, Tompkins LS. A cluster of Legionella sternal-wound infections due to postoperative topical exposure to contaminated tap water. N Engl J Med. 1991;324:109–13. doi:10.1056/NEJM199101103240207.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Funding
No funding was received for the current project.
Rights and permissions
About this article
Cite this article
Banderet, F., Blaich, A., Soleman, E. et al. Septic arthritis due to Legionella cincinnatiensis: case report and review of the literature. Infection 45, 551–555 (2017). https://doi.org/10.1007/s15010-016-0964-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s15010-016-0964-1