Rare case of primary meningococcal arthritis in an adult male
A 64-year-old man felt pain in his swollen right knee joint that progressed for a few more days rendering him unable to walk or even bend the knee joint. He had not eaten anything for a few days, so he was undernourished and dehydrated. He was taken to the emergency clinic and immediately hospitalized. The patient presented with erythematous, warmth, tenderness, and severe pain upon extension and flexion of the joint, but no edema of the other limbs. Synovial fluid from the right knee was aspirated on the day of admission, and the cell count appeared 166,000 cells/mm3 dominated by polymorphonuclear cells and macrophages (P/M ratio, 76:24). Microscopic examination of the centrifuged and Gram stained synovial fluid revealed Gram-negative diplococci.
The most likely diagnosis of this patient is
- Meningococcal Arthritis
- Lupus Erythematosus
Invasive meningococcal infection is caused by the Gram negative diplococcus, Neisseria meningitides. They occur in the blood stream and spinal cord and causes septicemia and meningitis, respectively. The bacterium disseminates to other parts of the body and potentially to other individuals.1,2 Meningococcal arthritis has been seen as a complication of N. meningitidis infection mainly in large joints (e.g., the knee and elbow) and it is very rare in children. The most common type is arthritis caused by local acute meningococcal infection, and the less common type is sterile arthritis caused by immune complex or an allergic reaction. Menigococcal arthritis is recognized in 2–10% of meningococcal infections and these cases are mostly the result of direct invasion to the synovium during the acute infection phase or course of chronic meningococcal infection. 3–6 We report here a very rare case of primary arthritis of the knee joint in an adult male caused by N. meningitidis without the clinical features associated with meningococcemia, meningitis, or any detectable commensal meningococcus in the nasal-pharyngeal tract.
The patient presented to a local ophthalmology clinic because of blurred vision and was diagnosed with retinitis due to type II diabetes. One week later, he visited for laser treatment for retinitis and diabetes management. A blood test revealed the fasting blood sugar of 179 mg/100 mL and the HbA1c was 9.9%. According to patient’s own recollection, 10 years ago, he was found to have high blood sugar approximately 200 mg/100 mL and positive urine sugar. He did not consult a doctor. He had a history of joint trauma including bruising both knees at the age of 35 years and a right knee sprain at the age of 45 years. In addition, the patient had hypertension and hyperlipidaemia.
Examination and Laboratory Investigation
MRI examination: Magnetic resonance imaging (MRI) of the right knee joint revealed effusion of the synovial fluid, thickening of the inflamed synovium, and mild degenerative bone changes.
Physical examination: Body weight, 61 kg; height, 163 cm; body mass index (BMI), 32.6 kg/m2; ideal body weight (IBW), 58.5 kg; body temperature, 37.3°C; blood pressure, 140/95 mmHg; pulse, 120 bpm; and respiration, 20 per minute.
The total blood count showed elevated leukocytes (14,500/mm3) dominating neutrophil and gradually decreasing to 7,000/mm3 on day 15. Fasting blood sugar was 403 mg/100 mL on day 1 and dropped to 104 mg/100 mL on day 11. C-reactive protein (CRP) was 34.1 mg/100 mL at admission which dropped to 1.22 mg/ 100 mL on day 15. Hemoglobin A1c (HbA1C) and glycoalbumin were 11.0% and 28.4%, respectively. The level of sodium 147 mEq/L appeared high, perhaps due to dehydration. The level of albumin and urine protein appeared, 3.3 mg/100 mL and ++, respectively, which may be a sign of diabetic nephropathy.
The patient was first suspected having purulent arthritis, so we immediately administered ampicillin/ sulbactam (2:1, w/w ratio) intravenously at a dose of 1.5 g, 9 4 times per day, for 18 consecutive days. For the diabetes, insulin detemir was administered according to the regimen shown in Fig. 1. An intravenous infusion electrolyte supplement was given for dehydration.
On the second day of admission, the body temperature dropped to a normal level, and he was a febrile thereafter. Dehydration improved, and the level of ketone bodies dropped to an undetectable level. As an analgesic, loxoprofen, a non-steroidal anti-inflammatory drug, was administered. Insulin was started on day 2 and continued as shown in Figure 1. For diabetes management, a calorie-limited dietary program (26kcal/kg) was started on day 2 and was continued for 26 consecutive days. Bacteria found in the synovial fluid on the first day were eventually identified as N. meningitidis on day 5; therefore, the condition was diagnosed as meningococcal arthritis. The sputum culture on day 6 was meningococcus negative. The edematous right knee, local pain, and warmth and tenderness of the erythema phased out gradually from days 7 to 14 and the patient was able to stretch and flex both knees. Because there was no sign of headache, subconsciousness, meningeal stiffness or irritation, or of any other neurological assessments, examination of the cerebrospinal fluid was not performed. There was no sign of pain upon urination, urethritis, or inflammation of the respiratory tract. The sputum fluid culture and the synovial culture on days 6 and 12, respectively, were negative for meningococcus. Rehabilitation was given intermittently from day 19 through day 25. Because clinical symptoms abated and the synovial fluid was sterile, the patient was discharged on day 27. The patient convalesced satisfactorily from the right knee arthritis, and there are no symptoms of recurrence to date.
Figure 1. Clinical findings, treatments, and laboratory data during hospitalization
Arthritic complications of meningococcal diseases are relatively common as evidenced by 2–10% of all cases develop arthritis. 3–6 Most of the cases are the result of secondary infection from meningococcomia or meningitis. 3,7–9 Primary meningococcal arthritis is a very rare form of meningococcal disease. For the past 5 years, we found 8 reports of primary meningococcal arthritis in shoulder, pelvis, sacrolic joint, knee, elbow, ankle, and polyarticular joints, and 2 cases, among those, were sterile or allergic. 10–17
Meningococcus is a commensal inhabitant of the human body in the nasal-pharynx cavity. It may be transmitted through the air, after a cough or a sneeze, or by direct mouth-to-mouth contact. It was reported that pre-existing joint disease is a risk factor for septic arthritis with a frequency of approximately 47%. 3,18 The patient reported here had a history of joint trauma. An association between septic arthritis and joint trauma could be suspected. The patient suffers from diabetes mellitus type II, but correlation to meningococcal arthritis is not clear.
The patient reported could not walk or even move his right leg and was undernourished, dehydrated, and incontinent. It must be stressed that early antibiotic treatment is important in meningococcal arthritis before degenerative bone damage progresses. However, it is important to survey and further examine meningococcal arthritis to understand the overall level of infection and stress the importance of immediate treatment.
We report here a very rare case of primary meningococcal arthritis of the knee joint without clinical features associated with meningococcemia, meningitis, or meningococcal complications. The patient suffered from diabetes mellitus and had experienced two episodes of joint trauma. Intravenous infusion of ampicillin/ sulbactam for 18 consecutive days was successful.
- Balows, A., W. J. Hausler, Jr, K. L. Herrmann, H. D. Isenberg, and H. Shadomy, eds. 1991. Neisseria meningitidis. Pp. 269–272 in ed. Manual of Clinical Microbiology. 5th ed. American Society for Microbiology, Washington, DC.
- Kanematsu, Y., I. Hayashi, N. Satoh, T. Hayakawa, H. Mituya, Y. Hayase, et al. 2003. Acute urethritis caused by Neisseria meningitidis. Int. J. Urol. 10:346–347.
- Schaad, U. B. 1980. Arthritis in disease due to Neisseria meningitidis. Rev. Infect. Dis. 2:880–888.
- Pinals, R., and M. W. Ropes. 1964. Meningococcal arthritis. Arthritis Rheum. 7:241–258.
- Kidd, B. L., H. H. Hart, and R. R. Grigor. 1985. Clinical features of meningococcal arthritis; a report of four cases. Ann. Rheum. Dis. 44:790–792.
- Apicella, M. A. 2010. Neisseria meningitidis. Pp. 2737–2752 in G. L. Mandell, J. E. Bennett, and R. Dolin, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 7th ed. Elsevier Churchill Livingstone, Philadelphia.
- Rosenstein, N. E., B. A. Perkins, D. S. Stephens, T. Popovic, and J. M. Hughes. 2001. Meningococcal disease. N. Engl. J. Med. 344:1378–1388.
- Laurenson, I., M. Sangra, and C. Thompson. 2001. Meningococcal disease. N. Engl. J. Med. 345:699.
- Rosenstein, N. E., B. A. Perkins, D. S. Stephens, L Lefkowitz, M. L. Cartter, R. Danila, et al. 1999. The changing epidemiology of meningococcal disease in the United States, 1992–1996. J. Infect. Dis. 180:1894–1901.
- Stryhn, T., and T. Haller. 2010. Neisseria meningitidis arthritis in 4-year-old child. Ugeskr. Laeger 172:633–634.
- Rousseau, V., G. Descours, M. Chaker, A. Tristan, A. M. Freydi_ere, and Y. Gillet. 2012. Primary meningococcal B osteomyelitis and arthritis with multifocal pyomyositis in a child: a case report. Arch. Pediatr. 9:1330–1333.
- Garner, A. J., F. Sundram, and K. Harris. 2011. Group C Neisseria meningitidis as a cause of septic arthritis in a native shoulder joint: a case report. Case Rep. Orthop. 2011:862487.
- Sahu, S., I. Mohanty, M. V. Narasimham, S. Pasupalak, and B. Parida. 2013. Primary meningococcal arthritis of sacroiliac joint: a rare case report. Indian J. Med. Microbiol. 31:87–89.
- Michel, M. D., L. W. Kao, and B. K. Sloan. 2013. Primary meningococcal arthritis leading to Neisseria meningitidies purpura fulminans. West. J. Emerg. Med. 14:165–167.
- Jiang, J. J., S. Zhang, and J. Angeles. 2013. Primary meningococcal arthritis requiring surgical drainage. J. Clin. Rheumatol. 19:94–97.
- Verma, N., R. Verma, S. Sood, B. K. Das, P. Singh, A. Kumar, et al. 2011. Primary meningococcal polyarthritis in a young man. Natl Med. J. India 24:278–279.
- Gee, C., T. Tandon, A. Avasthi, S. Jerwood, B. M. Rao, and S. Cavanagh. 2014. Primary meningococcal septic arthritis of the ankle joint: a case report. J. Foot Ankle Surg. 53:216–218.
- Ross, J. J., C. L. Saltzman, P. Carling, and D. S. Shapiro.2003. Pneumococcal septic arthritis; review of 190 cases. Clin. Infect. Dis. 36:319–327.