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• W2065396969 abstract "To the Editors: lostridium difficile commonly causes diarrhea and pseudomembranous colitis, but can also rarely lead to severe extracolonic manifestations such as osteomyelitis and empyema.1 We report the first case to our knowledge of C. difficile causing infectious arthritis in a native joint. An 11-year-old male with hemoglobin SS disease who was recently discharged from the hospital after treatment for a vaso-occlusive crises was readmitted with right shoulder pain. On presentation, he had a fever of 38.0°C and complained only of shoulder pain. White blood cells count was 15,900/mL and C-reactive protein (CRP) was 118 mg/dL (normal <5 mg/dL). The patient was empirically treated with ceftriaxone. A magnetic resonance image of the right shoulder identified a large, partially loculated joint effusion with a fluid-fluid level posteriorly suggesting debris. The humeral head had changes consistent with chronic avascular necrosis without evidence of osteomyelitis. The joint was aspirated and 20 mL of purulent fluid was obtained. Vancomycin was added to the patient's antibiotic regimen and he was taken to the operating room for irrigation and debridement of the glenohumeral joint. Turbid, congealed fluid was removed from the joint and a tissue biopsy was done. Bacterial cultures of fluid from joint aspiration and all 3 surgical samples grew Clostridium spp. not perfringens. The organism did not appear morphologically to be C. difficile. The patient's therapy was changed to intravenous clindamycin for several days and then to oral clindamycin 300 mg every 8 hours before discharge. He had no further fevers during 16 days of hospitalization and at the time of discharge the CRP had improved to 15 mg/dL. Four days after discharge, the results of DNA sequencing of the clostridial isolate revealed speciation of C. difficile. The patient was contacted and therapy was changed to oral metronidazole 375 mg every 8 hours. The patient completed 5 weeks of metronidazole therapy, at which time the CRP was 3 mg/dL and he had recovered full motion of his right shoulder. C. difficile, like other enteric pathogens, is a well-known cause of reactive arthritis.2 Two previous reports have identified C. difficile as the causal pathogen in prosthetic joint infections.3,4 In both of these cases the presumed source of infection was intraoperative contamination during placement of the prostheses. Our patient had no previous instrumentation of his shoulder, suggesting that the source of this infection was hematogenous spread, presumably originating from the intestine. Although the patient did not have any gastrointestinal symptoms of infection during his preceding or current hospitalization, and multiple blood cultures were sterile, he did have exposure to antibiotics within 3 months of presentation. Given the advanced nature of the infection, we surmise that our patient may have had bacteremia well before his most recent vaso-occlusive crisis. Sickle cell disease predisposes patients to infections with enteric organisms possibly due to intestinal ischemia and also impaired innate immune defenses,5 both of which may have contributed to this occurrence. Interestingly, this patient improved mainly with irrigation and drainage of the infected joint. He received only 48 hours of effective antibiotic therapy with vancomycin before being changed to clindamycin when the speciation of the organism was thought not to be C. difficile. His initial improvement after surgery suggests the importance of aggressive surgical intervention in addition to antimicrobial therapy for this condition. Kevin S. Gregg, MD Section of Infectious Diseases University of Chicago Medical Center Chicago, IL Kenneth A. Alexander, MD, PhD Section of Pediatric Infectious Diseases University of Chicago Medical Center Chicago, IL" @default.
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• W2065396969 date "2009-09-01" @default.
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• W2065396969 title "Native Joint Septic Arthritis Caused by Clostridium difficile in an 11-year old With Hemoglobin SS Disease" @default.
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• W2065396969 doi "https://doi.org/10.1097/inf.0b013e3181b05449" @default.
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