Abstract
Aim
According to Tsukuyama classification, late acute hematogenous prosthesis joint infections (PJI) should be treated with debridement and implant retention (DAIR). We report here a recurrent Salmonella Dublin hip prosthesis infection. Through this case, we show how a recurrence of chronic PJI may have an acute clinical presentation leading to an inadequate surgical treatment.
Method
Case report. On May 2011, a 74-year-old woman with bilateral hip prostheses (implanted in 1998 (right) and 2001 (left)), was admitted to intensive care for sepsis and pain of her left hip. Blood cultures and a joint aspiration of the left hip yielded pure cultures of S.Dublin. The patient had a recent history of febrile diarrhea after consuming dubious meat. The patient underwent DAIR followed by a six-week antibiotherapy. Three years later, she presented to the emergency room for an acute onset febrile PJI of the right hip. The patient underwent DAIR of the right hip. Blood cultures, joint aspiration fluid, and all intraoperative periprosthetic tissue samples yielded S.Dublin. Colonoscopy and abdomen ultrasound were negative. The patient received two weeks of intravenous combined antibiotherapy followed by oral antibiotics for further 10 weeks. Six weeks post operatively, the surgical wound was healed and the patient walked normally. One year later, the patient was referred by her primary care practitioner for night fevers without local signs or dysfunction of her prostheses. Radioleucoscintigraphy showed right hip inflammation. Bilateral hip biopsies were nevertheless performed, yet S. Dublin was recovered solely from the right hip biopsy. A one-stage exchange of the right hip was performed. All intraoperative periprosthetic tissue samples yielded S.Dublin. A six-week-combined antibiotherapy was undertaken. One year later, the patient appeared free of infection and walked normally.
Results
Whole-genome sequencing was carried out on the three patient's strains (2011/2014/2015). Their genomes differed by only six SNPs, suggesting that they derived from a single “infecting” strain.
Conclusions
This is the first report of recurrent S.Dublin PJI proven by whole genome sequencing. In the absence of detectable gallbladder and/or intestinal carriage, it is most likely that S. Dublin was able to persist at the surface of prosthesis, leading to a chronic disease with recurrences occurring years after the initial episode.
These recurrences were associated with a clinical acute onset of the infection, inducing an inadequate surgical treatment at the first time. A better knowledge of possible acutisation of chronic PJI by orthopedic surgeons may improve surgical management of these infections.
