Michael Riste1, Pretin Davda2, E Grace Smith2, David H Wyllie2, Martin Dedicoat1, Simantini Jog3, Steven Laird3, Gerald Langman4, Neil Jenkins1, Jonathan Stevenson5, Matthew K O'Shea6,7. 1. Department of Infectious Diseases, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. 2. National Mycobacterial Reference Service, Public Health England, Heartlands Hospital, Birmingham, UK. 3. Department of Microbiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. 4. Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. 5. Bone Infection Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK. 6. Department of Infectious Diseases, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. m.k.oshea@bham.ac.uk. 7. Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK. m.k.oshea@bham.ac.uk.
Abstract
BACKGROUND: Joint replacement is an effective intervention and prosthetic joint infection (PJI) is one of the most serious complications of such surgery. Diagnosis of PJI is often complex and requires multiple modalities of investigation. We describe a rare cause of PJI which highlights these challenges and the role of whole-genome sequencing to achieve a rapid microbiological diagnosis to facilitate prompt and appropriate management. CASE PRESENTATION: A 79-year-old man developed chronic hip pain associated with a soft-tissue mass, fluid collection and sinus adjacent to his eight-year-old hip prosthesis. His symptoms started after intravesical Bacillus Calmette-Guerin (BCG) therapy for bladder cancer. Synovasure™ and 16S polymerase chain reaction (PCR) tests were negative, but culture of the periarticular mass and genome sequencing diagnosed BCG infection. He underwent a two-stage joint revision and a prolonged duration of antibiotic therapy which was curative. CONCLUSIONS: BCG PJI after therapeutic exposure can have serious consequences, and awareness of this potential complication, identified from patient history, is essential. In addition, requesting appropriate testing is required, together with recognition that traditional diagnostics may be negative in non-pyogenic PJI. Advanced molecular techniques have a role to enhance the timely management of these infections.
BACKGROUND: Joint replacement is an effective intervention and prosthetic joint infection (PJI) is one of the most serious complications of such surgery. Diagnosis of PJI is often complex and requires multiple modalities of investigation. We describe a rare cause of PJI which highlights these challenges and the role of whole-genome sequencing to achieve a rapid microbiological diagnosis to facilitate prompt and appropriate management. CASE PRESENTATION: A 79-year-old man developed chronic hip pain associated with a soft-tissue mass, fluid collection and sinus adjacent to his eight-year-old hip prosthesis. His symptoms started after intravesical Bacillus Calmette-Guerin (BCG) therapy for bladder cancer. Synovasure™ and 16S polymerase chain reaction (PCR) tests were negative, but culture of the periarticular mass and genome sequencing diagnosed BCGinfection. He underwent a two-stage joint revision and a prolonged duration of antibiotic therapy which was curative. CONCLUSIONS:BCG PJI after therapeutic exposure can have serious consequences, and awareness of this potential complication, identified from patient history, is essential. In addition, requesting appropriate testing is required, together with recognition that traditional diagnostics may be negative in non-pyogenic PJI. Advanced molecular techniques have a role to enhance the timely management of these infections.
Authors: T Phuong Quan; Zharain Bawa; Dona Foster; Tim Walker; Carlos Del Ojo Elias; Priti Rathod; Zamin Iqbal; Phelim Bradley; Janet Mowbray; A Sarah Walker; Derrick W Crook; David H Wyllie; Timothy E A Peto; E Grace Smith Journal: J Clin Microbiol Date: 2018-01-24 Impact factor: 5.948