Letters to the Editor 1197

Rheumatology 2005;44:1197–1198 Mortality during the initial hospitalization was 3 of 15 patients

doi:10.1093/rheumatology/kei035 (20%) in the MRSA group vs 3 of 44 patients (7%) in the non-
Advance Access publication 27 July 2005 MRSA group (P ¼ 0.13). Six of the 12 MRSA patients who
survived developed osteomyelitis in the bone adjacent to the
Methicillin-resistant Staphylococcus aureus septic joint. Five of the 15 patients had extra-articular foci of MRSA
arthritis: an emerging clinical syndrome infection: two patients had central line sepsis, one patient had
endocarditis, one patient had an epidural abscess, and one patient
SIR, Despite the increasing importance of methicillin-resistant had infection of an abdominal aortic graft. All 12 survivors were
Staphylococcus aureus (MRSA) as a nosocomial and community clinically cured of septic arthritis after an average of 6 weeks of
pathogen, little is known about the clinical characteristics of antibiotic therapy. Eleven patients received vancomycin and one
MRSA septic arthritis. Prior descriptions of native joint MRSA patient received linezolid. Limited information was available
septic arthritis in adults are confined to case reports [1–4]. In recent regarding functional outcome.
European studies, 6–8% cases of septic arthritis were due to Colonization or infection with MRSA during hospitalization
MRSA [5, 6], although these patients were not described in detail. establishes a durable risk of subsequent MRSA infection. In one

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We reviewed cases of native joint septic arthritis from the past 5 yr study, 29% of hospitalized patients who acquired MRSA devel-
from our institutions to assess the prevalence and characteristics of oped new or recurrent MRSA infection in the 18 months after
MRSA septic arthritis, and the relative contributions of the health- discharge [7]. Of the 12 patients with a history of hospitalization
care setting and the community to its epidemiology. Dichotomous in the preceding 6 months, seven developed symptoms of septic
variables were analysed using Fisher’s exact test and continuous arthritis in patients (58%) while out in the community. Although
variables were analysed using Student’s t-test. these patients all received empirical treatment with vancomycin,
Demographic and clinical information are summarized in failure to take into account the history of hospitalization could
Table 1. Fifteen of 59 septic arthritis cases (25%) involved have resulted in inappropriately narrow empirical antibiotic
MRSA. Patients with MRSA septic arthritis were significantly coverage.
older than patients with non-MRSA septic arthritis (69 vs 54 yr; MRSA may be more virulent than methicillin-sensitive
P ¼ 0.003). MRSA septic arthritis patients also had a significantly Staphylococcus aureus (MSSA). Approximately 1.6% of episodes
greater mean number of comorbid medical conditions compared of MRSA bacteraemia result in septic arthritis, a rate higher
with non-MRSA septic arthritis patients (5.8 vs 2.6; P<0.0001). than observed for MSSA bacteraemia [8]. One meta-analysis
All 15 patients with MRSA septic arthritis had significant exposure showed a higher mortality for MRSA bacteraemia than MSSA
to the health-care system. Hospitalization within the preceding bacteraemia, a finding that might be explained by bacterial
6 months was observed in 80% (12 of 15 patients) of the MRSA virulence, patient factors, or the lack of rapidly bactericidal
group compared with 34% (15 of 44 patients) of the non- antibiotics for MRSA treatment [9]. Our experience is inadequate
MRSA septic arthritis group (P ¼ 0.002). Of the other three to determine whether MRSA septic arthritis is more aggressive
MRSA patients, one had a history of MRSA bacteraemia 3 yr than MSSA septic arthritis, particularly as the affected older
previously and the other two were HIV-positive intravenous population with chronic illness would be expected to have worse
drug users. clinical outcomes.
Joint involvement was similar between the two groups, Ten of 12 (83%) MRSA isolates were resistant to clindamycin.
except that shoulder involvement was significantly more com- As 79% of health-care-associated MRSA strains in the USA
mon in MRSA cases: 6 of 15 MRSA cases (40%) vs 6 of 44 are resistant to clindamycin, compared with only 17% of
non-MRSA cases (14%), P ¼ 0.03. This probably relates to the community isolates of MRSA, this suggests a predominance of
predisposing role of recent falls, upper extremity trauma and MRSA septic arthritis from strains originating in the health-care
orthopaedic procedures among the older patient population with system [10].
MRSA infection, rather than a particular tropism for the Recommendations for the treatment of septic arthritis place
shoulder joint. insufficient emphasis on the possibility of MRSA infection
in individuals with health-care system exposure. As septic
TABLE 1. Characteristics of patients with septic arthritis due to MRSA vs arthritis may cause rapid joint destruction, and delayed
those with non-MRSA septic arthritis initiation of appropriate therapy is associated with poor
outcomes, the correct choice of empirical antibiotic therapy
MRSA septic Non-MRSA is crucial. Patients with suspected septic arthritis who have
arthritis septic arthritis a history of recent hospitalization, previous MRSA infection
Characteristic (n ¼ 15) (n ¼ 44) P or colonization, multiple comorbid medical conditions, other
Demographics and risk factors risk factors for MRSA infection, such as intravenous drug use,
Male 9/15 (60) 31/44 (70) 0.13 or who live in locales with a high prevalence of community-
Age (yr), mean 69 54 0.003 acquired MRSA, should receive an antibiotic regimen containing
Hospitalization in 12/15 (80) 15/44 (34) 0.002 vancomycin.
past 6 months
No. of comorbid medical 5.8 2.6 <0.0001
conditions, mean The authors have declared no conflict of interest.
Pre-existing rheumatic disease 3/15 (20) 11/44 (25) >0.2
Previously healthy 0/15 (0) 7/44 (16) 0.11
Clinical presentation and outcome J. J. ROSS, L. DAVIDSON1
Fever 7/15 (47) 16/39 (41) >0.2 Division of Infectious Diseases, Caritas Saint Elizabeth’s
Leucocytosis 10/15 (67) 14/37 (38) 0.04
Medical Center and 1Division of Geographic Medicine and
Bacteraemia 9/15 (60) 16/44 (36) 0.07
Polyarticular involvement 4/15 (27) 4/44 (9) 0.08 Infectious Diseases, New England Medical Center, Boston,
Arthroscopic or open 9/15 (60) 26/44 (59) >0.2 MA, USA
surgical drainage Accepted 24 June 2005
Mortality 3/15 (20) 3/44 (7) 0.13 Correspondence to: J. J. Ross, Division of Infectious Diseases,
Caritas Saint Elizabeth’s Medical Center, 736 Cambridge Street,
Data are n/N (%) of patients unless otherwise indicated. Boston, MA 02135, USA. E-mail: [email protected]
1198 Letters to the Editor

1. Ash N, Salai M, Aphter S, Olchovsky D. Primary psoas

abscess due to methicillin-resistant Staphylococcus aureus
concurrent with septic arthritis of the hip joint. South Med J
1995;88:863–5.
2. Byrne PA, Hosein IK, Camilleri J. Methicillin-resistant
Staphylococcus aureus septic arthritis: urgent and emergent.
Clin Rheumatol 1998;17:407–8.
3. Kallarackal G, Lawson TM, Williams BD. Community-acquired
septic arthritis due to methicillin-resistant Staphylococcus aureus.
Rheumatology 2000;39:1304–5.
4. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of
180 cases. Medicine (Baltimore) 2004;83:139–48.
5. Gupta MN, Sturrock RD, Field M. Prospective comparative study
of patients with culture proven and high suspicion of adult onset

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septic arthritis. Ann Rheum Dis 2003;62:327–31.
6. Dubost JJ, Soubrier M, De Champs C, Ristori JM, Bussiere JL,
Sauvezie B. No changes in the distribution of organisms responsible
for septic arthritis over a 20 year period. Ann Rheum Dis 2002;
61:267–9.
7. Huang SS, Platt R. Risk of methicillin-resistant Staphylococcus
aureus infection after previous infection or colonization. Clin Infect
Dis 2003;36:281–5. FIG. 1. Fixed flexion deformities of the second, third and fourth
8. Melzer M, Eykyn SJ, Gransden WR, Chinn S. Is methicillin-resistant fingers of the left hand. This figure may be viewed in colour as
Staphylococcus aureus more virulent than methicillin-susceptible supplementary data at Rheumatology Online.
S. aureus? A comparative cohort study of British patients with
nosocomial infection and bacteremia. Clin Infect Dis 2003;37:
1453–60.
9. Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber MJ,
Karchmer AW, Carmeli Y. Comparison of mortality associated
with methicillin-resistant and methicillin-susceptible Staphylococcus
aureus bacteremia: a meta-analysis. Clin Infect Dis 2003;36:53–9.
10. Naimi TS, LeDell KH, Como-Sabetti K et al. Comparison of
community- and health care-associated methicillin-resistant
Staphylococcus aureus infection. JAMA 2003;290:2976–84.

Rheumatology 2005;44:1198
doi:10.1093/rheumatology/keh667
Advance Access publication 3 May 2005

Rheumatic fever—a vignette

SIR, A 12-yr-old boy presented with 7 weeks of arthralgia, affecting

the knees, cervical spine and small joints of both hands, and pain FIG. 2. Fixed flexion deformities of the second, third and fourth
in the palms of both hands with reduced flexion of the second, fingers of the right hand. This figure may be viewed in colour as
third and fourth fingers. supplementary data at Rheumatology Online.
He was initially apyrexial but subsequently developed a
temperature of 38
C. He was pale with cervical lymphadenopathy. prednisolone. Persistent aortic and mitral valve regurgitation
A nodule was noted over the lateral epicondyle of his left elbow. were treated with enalapril.
He had tenosynovitis affecting the palms, fixed flexion deformities There have been case reports of tenosynovitis and rheumatic
of the second, third and fourth fingers of both hands (Figs. 1 and 2) fever in adults [1] but not children.
and a reduced range of movement in the cervical spine. Pansystolic
and diastolic murmurs were noted. The authors have declared no conflicts of interest.
Investigations showed: haemoglobin 9.9 g/dl (normochromic,
normocytic picture), white blood cells (WBC) 9.5  109/l, platelets
268, erythrocyte sedimentation rate (ESR) 92 mm/h, C-reactive R. L. BOON, E. BAILDAM1
protein (CRP) 48 mg/l, ferritin normal, urea and electrolytes and
liver function tests normal. Complement levels were normal and Musgrove Park Hospital, Paediatrics, Taunton and 1Booth Hall
Children’s Hospital, Rheumatology, Manchester, UK
autoantibodies negative. The ECG was normal. Echocardiogram
Accepted 29 March 2005
revealed aortic and mitral valve regurgitation. A throat swab grew
group A beta haemolytic streptococcus: anti-DNase 360 unit/ml Correspondence to: R. L. Boon. E-mail: robboon69@
(normal <240), antistreptococcal antibody titres (ASOT) hotmail.com
>800 unit/ml (normal <200).
Rheumatic fever was diagnosed. The patient responded well 1. Peretz A, Van Laethem Y, Famaey JP. About five cases of acute
to aspirin and penicillin. Ongoing tenosynovitis improved with rheumatic fever in the adult. Clin Rheumatol 1985;4:308–11.

Published by Oxford University Press on behalf of the British Society for Rheumatology 2005.