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• W1940397776 abstract "Infection after a total hip replacement is a serious complication, often requiring removal of the prosthesis for healing [1.Brause BD Infections with prostheses in bones and joints.in: Mandell GL Douglas Jr, RG Bennett JE Principles and practice of infectious diseases. 4th edn. Churchill Livingstone, New York1995: 1051-1055Google Scholar]. The commonest etiologic agents are Staphylococcus aureus and Staphylococcus epidermidis, which account for more than 50% of the pathogens isolated, according to recent series. Other organisms may be involved, especially in hematogenous infections, including Gram-negative bacteria, Streptococcus, anaerobic bacteria, diphtheroids, or mycobacteria [1.Brause BD Infections with prostheses in bones and joints.in: Mandell GL Douglas Jr, RG Bennett JE Principles and practice of infectious diseases. 4th edn. Churchill Livingstone, New York1995: 1051-1055Google Scholar, 2.Inman RD Gallegos KV Brause BD Redecha PB Christian CL Clinical and microbial features of prosthetic joint infection.Am J Med. 1984; 77: 47-53Abstract Full Text PDF PubMed Scopus (120) Google Scholar]. We report the first case of typhoid salmonella infection of a total hip prosthesis. A 51-year-old black African man was admitted because of fever, pain of the right hip and a fistula from the joint to the thigh surface. His past medical history was remarkable for several episodes of malaria, and type 2 diabetes mellitus. Eleven years before this admission, he suffered post-traumatic necrosis of the right femoral head, and underwent total hip arthroplasty with a satisfactory postsurgical functional result. Thirty months before admission, the patient suddenly developed a fever, and swelling of the upper lateral part of the right thigh. A hip puncture, performed in Brazzaville, Congo, withdrew 1.5 L of a purulent fluid. He subsequently developed a chronic fistula with a purulent discharge at the puncture site. Many prolonged anti-infectious regimens were prescribed there, including co-trimoxazole, amoxicillin, and chloramphenicol, but the patient's general status and local symptoms progressively deteriorated. He was transferred to our department. On admission, his body temperature was 38.5°C. Movement of the right hip was painful, limited to 20° of flexion, and 10° of abduction. The discharge from the fistula was yellowish-green, and the surrounding skin was erythematous. Laboratory values were as follows: white blood cell (WBC) count 4800/mm3 with a normal differential; hemoglobin 12 g/dL with a mean corpuscular volume of 74 μ3. Hemoglobin electrophoresis revealed a heterozygous state for sickle cell disease. Serology was positive for HIV-1 by ELISA, and confirmed by Western blot. CD4 T-cell count was 1000 cells/mm3. Glycemia was 16.7 mmol/L. Hip X-ray revealed migration of the acetabulum and lysis of the femoral metaphysis. Bacteriologic culture of the fistula discharge yielded Salmonella hirschfeldii (formerly paratyphi C). Blood culture remained sterile. Stool cultures were negative. The hip prosthesis was removed, associated with a complete cement extraction, a thorough debridement, and drainage of the voluminous purulent abscess of the vastus externus through which the fistula joined the hip joint. Intraoperative samples of bone, cement, prosthesis and pus also yielded Salmonella hirschfeldii. Traction of the hip was maintained for 6 weeks. Ofloxacin (200 mg b.i.d. per os) was prescribed for 3 months. The pathogen isolated was highly sensitive to this antibiotic, with MIC and MBC at 0.125 and 0.25 mg/L respectively. The patient became afebrile and has remained so during the 12 months of follow-up. Hip mobility improved and is now 50° of flexion, and 30° of abduction. Salmonellae are non-spore-forming Gram-negative rods of the family Enterobacteriaceae. Although non-typhoid salmonellae are primary pathogens of lower animals, typhoid salmonellae have reservoirs primarily in humans. Thus, direct or indirect contact with a person with typhoid fever or with a chronic carrier is necessary for infection. There has been an impressive decline in the number of cases of typhoid fever in developed countries since 1900 in conjunction with improved sanitation [3.Miller SI Hohmann EL Pegues DA Salmonella (including Salmonella typhi).in: Mandell GL Douglas Jr, RG Bennett JE Principles and practice of infectious diseases. 4th edn. Churchill Livingstone, New York1995: 2013-2033Google Scholar]; and as total hip replacements are mostly performed in these countries, there is little chance of observing typhoid salmonella infection of a hip prosthesis. However, typhoid salmonellae have not disappeared in developed countries, and primary septic arthritis of the hip due to Salmonella paratyphi B in a diabetic Caucasian woman has been reported in the UK [4.Stranks GJ McLaren MI Salmonella paratyphi - an unusual cause of primary septic arthritis of the hip.Scand J Infect Dis. 1994; 26: 489-490Crossref PubMed Scopus (1) Google Scholar]. Many studies have demonstrated a high percentage of underlying disease in patients with salmonella infections. Patients with sickle cell diseases have an increased incidence of serious bacteremic infection and osteomyelitis with salmonellae for various reasons: (1) their alternative complement pathway is defective [5.Hand WL King NL Serum opsonization of Salmonella in sickle-cell anemia.Am J Med. 1978; 64: 338Google Scholar]; (2) erythrophagocytosis impairs the phagocytosis of salmonellae by monocytes [6.Gill FA Kaye D Hook EW The influence of erythrophagocytosis on the interaction of macrophages and Salmonella in vitro.J Exp Med. 1966; 124: 173Crossref PubMed Scopus (16) Google Scholar]; and (3) splenic infarctions lead to functional splenectomy. Furthermore, it has been demonstrated that hemolysis induced experimentally in mice markedly enhanced susceptibility to infection with Salmonella typhimurium [7.Hook EW Kaye D Gill FA Factors influencing host resistance to Salmonella infection. The effect of hemolysis and erythrophagocytosis.Trans Am Clin Climatol Assoc. 1966; 78: 230Google Scholar]. Our patient presented two other conditions that may have facilitated the development of salmonellosis: (1) HIV infection and (2) seriously uncontrolled diabetes mellitus. One small study performed in an endemic area estimated the incidence of typhoid salmonella infection in HIV-infected patients to be 60 times that of the general population [8.Gotuzzo E Frisancho O Liendo G et al.Association between the acquired-immunodeficieny syndrome and infection with Salmonella typhi or Salmonella paratyphi in an area endemic for typhoid fever.Arch Intern Med. 1991; 151: 381-382Crossref PubMed Scopus (58) Google Scholar]. The severity of typhoid salmonella infections in HIV-infected patients without AIDS is similar to that of infection in immunocompetent hosts [3.Miller SI Hohmann EL Pegues DA Salmonella (including Salmonella typhi).in: Mandell GL Douglas Jr, RG Bennett JE Principles and practice of infectious diseases. 4th edn. Churchill Livingstone, New York1995: 2013-2033Google Scholar]. Diabetic patients are not considered to be at risk for salmonellosis, but they have a predilection for certain infections (e.g. pseudomonas ‘malignant’ external otitis, monilial skin infections, rhinocerebral mucormycosis) [9.Nathan DM Long-term complications of diabetes mellitus.N Engl J Med. 1993; 328: 1676-1685Crossref PubMed Scopus (1067) Google Scholar], and our patient's diabetes may have contributed to the development of salmonellosis, in combination with his other risk factors. Given the known pathophysiology of typhoid salmonellae [3.Miller SI Hohmann EL Pegues DA Salmonella (including Salmonella typhi).in: Mandell GL Douglas Jr, RG Bennett JE Principles and practice of infectious diseases. 4th edn. Churchill Livingstone, New York1995: 2013-2033Google Scholar], we presume that the infection occurred via the hematogenous route. Our patient gave no history of fever or enteric symptoms preceding the onset of the symptoms, and we have no argument for a gastrointestinal pathology that could have increased susceptibility to salmonellosis. However, neither barium X-ray studies nor digestive endoscopy were performed, which might have revealed an asymptomatic lesion. He is probably not a chronic carrier, because the stool cultures performed in our department did not yield any salmonellae, and he has not relapsed since. Prognostic factors of prosthetic joint infections are not clearly established, but are probably strongly associated with early, extensive and meticulous surgical debridement, effective antimicrobial therapy, and the immune status of the patient [10.Tsukayama DT Estrada R Gustdo RB Infection after total hp arthroplasty.J Bone Joint Surg. 1996; 78A: 512-523Google Scholar]. The delayed initiation of treatment for our patient and his immune status are probably more important prognostic factors than the nature of the pathogen involved. To the best of our knowledge, there is no reported case of typhoid salmonella infection of a joint prosthesis. Samra et al reported five cases of non-typhoid salmonellosis in patients with total hip replacement, and found five more cases by reviewing the English literature [11.Samra Y Shaked Y Maier MK Nontyphoid salmonellosis in patients with total hip replacement: report of 4 cases and review of the literature.Rev Infect Dis. 1986; 8: 978-983Crossref PubMed Scopus (26) Google Scholar]. All their patients recovered, as did four of the five patients reported in the literature (the fifth was continuing therapy at the time of the report). The overall prognosis of salmonella infection does not seem to differ from that of the overall prognosis of prosthetic joint infection. In the case we describe, because the surgical intervention was extensive, the anti-infectious regimen well adapted according to in vitro studies, and no relapse has occurred after 1 year without any antimicrobial therapy, treatment may be considered successful. Reimplantation of a total hip prosthesis can be reasonably performed, as soon as the patient so desires. The authors are indebted to Janet Jacobson for editorial comments." @default.
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• W1940397776 title "First case of Salmonella hirschfeldii (paratyphi C) infection of a prosthetic hip" @default.
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