ChloroquineV1, Istex, Corpus, bibRecord, 002792

Nocardia infection of a joint prosthesis complicating systemic lupus erythematosus

Identifieur interne : 002792 ( Istex/Corpus ); précédent : 002791; suivant : 002793

Nocardia infection of a joint prosthesis complicating systemic lupus erythematosus

Auteurs : C. Arnal ; H. Man ; F. Delisle ; P. M'Bappe ; J-J Cocheton

Source :

Lupus [ 0961-2033 ] ; 2000-05.

RBID : ISTEX:60BDBC727CAF2BC04E271985E14516081D3A8CBD

English descriptors

Teeft :
- Actinomycete, Antibiotic, Antibiotic therapy, Autoimmune haemolytic anaemia, Clin, Clin microbiol, Corticosteroid, Cotrimoxazole, December, Erythematosus, Haematogenous, Haematogenous spread, Hopital tenon, Imipenem, Institut pasteur, Internal medicine department, January, Joint prosthesis, Lupus, Lupus erythematosus, Lupus nephritis, Lupus patients, Membranous glomerulonephritis, Mgad, Nocardia, Nocardia infection, Nocardia infections, Nocardia nova, Nocardiosis, Nova, November, Opportunistic, Opportunistic behaviour, Poor prognosis, Prosthesis, Prosthesis infection, Pulmonary nocardiosis, Rare infection, Recurrence, Renal, Renal biopsy, Renal function, Systemic lupus erythematosus, Trimethoprim sulfamethoxazole.

Abstract

The authors report the case of a 43-year-old woman suffering from severe systemic lupus erythematosus treated with long-term prednisone, who developed Nocardia nova infection on a hip prosthesis. Sepsis occurred about two years after an episode of pulmonary nocardiosis with the same Nocardia species, that was successfully treated by 12 months of antibiotics. A good outcome of the joint infection was observed in response to antibiotics and removal of the prosthesis. Nocardiosis is a rare infection, acting as an opportunisticinfection, facilitated in the present case by systemic lupus erythematosus and chronic corticosteroid therapy. Nocardia infections mainly affect the lungs, skin and central nervous system; these last two sites are mostly due to haematogenous spread, a frequent event. Treatment is based on antibiotics, usually continued for 3 ‐ 12 months, especially because of the risk of relapse. The imipenem ‐ amikacin combination appears to be more effective than trimethoprim ‐ sulfamethoxazole. To our knowledge, this is the first case report of Nocardia nova joint prosthesis infection also presenting as late septic spread of pulmonary nocardiosis, complicating corticosteroid-treated systemic lupus erythematosus.

Url:

https://api.istex.fr/ark:/67375/M70-3LWHMVJJ-V/fulltext.pdf

DOI: 10.1191/096120300680198917

Links to Exploration step

ISTEX:60BDBC727CAF2BC04E271985E14516081D3A8CBD

Le document en format XML

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<journal-id journal-id-type="publisher-id">LUP</journal-id>
<journal-title>Lupus</journal-title>
<issn pub-type="ppub">0961-2033</issn>
<publisher>                 
            <publisher-name>Sage Publications</publisher-name>                 
            <publisher-loc>Sage CA: Thousand Oaks, CA</publisher-loc>             
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<article-meta><article-id pub-id-type="doi">10.1191/096120300680198917</article-id>
<article-id pub-id-type="publisher-id">10.1191_096120300680198917</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Articles</subject>
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<title-group><article-title>Nocardia infection of a joint prosthesis complicating systemic lupus erythematosus</article-title>
</title-group>                 
         <contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Arnal</surname>
<given-names>C</given-names>
</name>
<aff>Service de Médecine Interne, Hôpital Tenon, 4 rue                         de la Chine, F-75970, Paris Cedex 20, France.Tel: (/33) (1) 56 01 66 14;                         Fax: (+33) (01) 70 82</aff>
</contrib>
</contrib-group>                 
         <contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Man</surname>
<given-names>H</given-names>
</name>
<aff>Service de Médecine Interne, France</aff>
</contrib>
</contrib-group>                 
         <contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Delisle</surname>
<given-names>F</given-names>
</name>
<aff>Laboratoire de Bactériologie, Hôpital Tenon,                         Paris, France</aff>
</contrib>
</contrib-group>                 
         <contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>M'Bappe</surname>
<given-names>P</given-names>
</name>
<aff>Laboratoire de Bactériologie, Hôpital Tenon,                         Paris, France</aff>
</contrib>
</contrib-group>                 
         <contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Cocheton</surname>
<given-names>J-J</given-names>
</name>
<aff>Laboratoire de Bactériologie, Hôpital Tenon,                         Paris, France</aff>
</contrib>
</contrib-group>             
         <pub-date pub-type="ppub"><month>05</month>
<year>2000</year>
</pub-date>
<volume>9</volume>
<issue>4</issue>
<fpage>304</fpage>
<lpage>306</lpage>
<abstract>             
            <p>The authors report the case of a 43-year-old woman suffering from severe systemic                 lupus erythematosus treated with long-term prednisone, who developed Nocardia nova                 infection on a hip prosthesis. Sepsis occurred about two years after an episode of                 pulmonary nocardiosis with the same Nocardia species, that was successfully treated                 by 12 months of antibiotics. A good outcome of the joint infection was observed in                 response to antibiotics and removal of the prosthesis.</p>             
            <p>Nocardiosis is a rare infection, acting as an opportunisticinfection, facilitated in                 the present case by systemic lupus erythematosus and chronic corticosteroid therapy.                 Nocardia infections mainly affect the lungs, skin and central nervous system; these                 last two sites are mostly due to haematogenous spread, a frequent event. Treatment                 is based on antibiotics, usually continued for 3 ‐ 12 months, especially                 because of the risk of relapse. The imipenem ‐ amikacin combination appears                 to be more effective than trimethoprim ‐ sulfamethoxazole. To our                 knowledge, this is the first case report of Nocardia nova joint prosthesis infection                 also presenting as late septic spread of pulmonary nocardiosis, complicating                 corticosteroid-treated systemic lupus erythematosus.</p>         
         </abstract>
<kwd-group>             
            <kwd>nocardiosis</kwd>             
            <kwd>recurrence</kwd>             
            <kwd>joint prosthesis</kwd>             
            <kwd>systemic lupus erythematosus</kwd>             
            <kwd>corticosteroid therapy</kwd>         
         </kwd-group>
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<meta-value>Journal Article</meta-value>
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<meta-value> CASE REPORT Nocardia infection of a joint prosthesis complicating systemic lupus             erythematosus C Arnal1 *, H Man1 , F Delisle2 , P M'Bappe1 and J-J Cocheton1 1 Service             de MeÂdecine Interne and 2 Laboratoire de BacteÂriologie, HoÃpital Tenon, Paris, France             The authors report the case of a 43-year-old woman suffering from severe systemic lupus             erythematosus treated with long-term prednisone, who developed Nocardia nova infection             on a hip prosthesis. Sepsis occurred about two years after an episode of pulmonary             nocardiosis with the same Nocardia species, that was successfully treated by 12 months             of antibiotics. A good outcome of the joint infection was observed in response to             antibiotics and removal of the prosthesis. Nocardiosis is a rare infection, acting as an             opportunistic infection, facilitated in the present case by systemic lupus erythematosus             and chronic corticosteroid therapy. Nocardia infections mainly affect the lungs, skin             and central nervous system; these last two sites are mostly due to haematogenous spread,             a frequent event. Treatment is based on antibiotics, usually continued for 3 ± 12             months, especially because of the risk of relapse. The imipenem ± amikacin combination             appears to be more effective than trimethoprim ± sulfamethoxazole. To our knowledge,             this is the ®rst case report of Nocardia nova joint prosthesis infection also presenting             as late septic spread of pulmonary nocardiosis, complicating corticosteroid-treated             systemic lupus erythematosus. Lupus (2000) 9, 304±306 Keywords: nocardiosis; recurrence;             joint prosthesis; systemic lupus erythematosus; corticosteroid therapy Introduction             Nocardiosis is a rare infection caused by strict aerobic actinomycetes of the Nocardia             genus present in the soil, that are not commensal organisms for animals or man. In man,             they are responsible for acute, subacute or chronic suppurative infections, essentially             pulmon- ary and disseminated infections.1 It occurs with predilection in debilitated or             immunodepressed sub- jects and has been described, in particular, in the course of             systemic lupus erythematosus (SLE)2 and corticosteroid treatments.3 We report a case of             Nocardia infection of a hip prosthesis, two years after prolonged treatment of pulmonary             nocardiosis in a patient with SLE. Case report Mrs B, 43 y old, was admitted to the             Internal Medicine Department in January 1999 for investigation of hip pain. She had been             followed since December 1987 for SLE with various combinations of manifestations:             cutaneous (alopecia, vespertilio, discoid lupus, distal vasculitis), articular,             pericardial (two episodes of pericarditis, with one constrictive episode in Novem- ber             1998 requiring surgical drainage), gastrointestinal (steroid-sensitive exudative             enteropathy) and haema- tological (autoimmune haemolytic anaemia, leuko- penia and             lymphopenia). She also suffered from renal disease. A renal biopsy performed in January             1993 because of persistent, isolated proteinuria up to 2.2 gad, revealed class V lupus             nephritis according to the WHO classi®cation (membranous glomerulone- phritis). In             September 1996, she developed neph- rotic syndrome (proteinuria of up to 4 gad, serum             albumin: 21 gal, microscopic haematuria, renal failure with serum creatinine of 150             mmolal) and hyperten- sion; renal biopsy showed class Vc lupus nephritis             *Correspondence: Dr C Arnal, Service de MeÂdecine Interne, HoÃpital Tenon, 4 rue de la             Chine, F-75970, Paris Cedex 20, France. Tel: ( 33) (1) 56 01 66 14; Fax: (+33) (01) 70             82 Received 7 August 1999; accepted in revised form 6 December 1999 Lupus (2000) 9,             304±306 ß 2000 Macmillan Publishers Ltd All rights reserved 0961-2033/00 $15.00             www.nature.com/lup (membranous glomerulonephritis with segmental sclerosis).             Immunological assessment revealed anti- nuclear, anti-DNA, anti-RNP and anti-SSA             antibodies associated with low serum complement C3 and C4. Treatment of systemic lupus             erythematosus consisted of prednisone at dosages adapted to the course of the disease,             continuous from December 1987 to July 1997, then restarted in November 1998, in combina-             tion with hydroxychloroquine. Intravenous boluses of methylprednisolone (10 mgakgad for             2 ± 3 consecu- tive days) were also administered during severe acute episodes of the             disease. The clinical course was complicated by numerous infections (Salmonella sp             septicaemia in November 1988, Streptococcus pneumoniae and Staphylococcus aureus             cavitating pneumonia in November 1996, Pseudomonas aeruginosa laryngitis and pneumonia             in December 1998) and aseptic necrosis of the femoral heads in December 1990, requiring             total arthroplasty in June and September 1991. Left breast cancer was treated by             mastectomy and axillary lymph node dissection in January 1993. In February 1997, she was             admitted to our Internal Medicine Department with bilateral cavitating Nocar- dia nova             pneumonia. Initial treatment by cotrimox- azole was discontinued due to deterioration of             her renal function and was replaced by a combination of amoxicillin (3 gad, per os) and             doxycycline (200 mgad, per os) for one month. The clinical and radiological course was             favourable, allowing subse- quent treatment with oral amoxicillin 3 gad for 11 months.             In November 1998, the patient complained of pain of the left hip and proximal extremity             of the left thigh, with a mechanical chronology. She was afebrile and presented no             laboratory signs of infection (no modi®cation of white blood cell count and no elevation             of CRP). X-rays allowed the pain to be attributed to loosening of the prosthesis,             secondary to probable granulomas (titanium prosthesis). It was decided to wait and see,             especially as corticosteroids were reintroduced because of an episode of lupus             pericarditis. In January 1999, deterioration of pain and appear- ance of a fever of 38 ±             38.5 g, combined with a laboratory in¯ammatory syndrome, suggested a pros- thesis             infection, although the patient was receiving antibiotics for a recent Pseudomonas             aeruginosa infection. She was also taking 20 mgad equivalent of prednisone for treatment             of her systemic lupus erythematosus. Standard X-rays of the hip and femur were unchanged             compared to those performed in November 1998. Gallium scintigraphy revealed in- creased             uptake in the acetabulum and proximal part of the left femoral diaphysis. Hip aspiration             revealed a purulent ¯uid and, after six days of growth at 37 g on blood agar, showed             small white colonies identi®ed as Nocardia nova. Identi®cation was con®rmed by the             'Centre National de ReÂfeÂrence des ActinomyceÁtes' (National Actinomycetes Reference             Centre) at Institut Pasteur in Paris; this bacterial strain was identical to the strain             isolated in February 1997. The disk diffusion technique was used to determine antibiotic             susceptibility; these strains were resistant to amox- icillin, amoxicillinclavulanic             acid, cefotaxime, to- bramycin, cipro¯oxacin, cotrimoxazole, but sensitive to imipenem,             erythromycin and amikacin. Antibiotic treatment, adapted to renal function, combining             imipenem (1500 mgad) and amikacin (300 mgad), was started and surgical removal of the             hip prosthesis with traction of the limb was performed 10 d later. After surgery,             antibiotic therapy consisted of erythro- mycin (4 gad) combined with imipenem (1500             mgad) for 35 d then erythromycin alone for two months, with a favourable course allowing             the patient to walk with support six months after the operation. Discussion Human             contamination by Nocardia is essentially airborne, which explains the predominant             clinical manifestations of pneumonia (70 ± 80%), frequently associated with multiple             sites and lung abscesses.1 Haematogenous spread is frequent (50%), predispos- ing to             central nervous system involvement (35%) and soft tissue and skin infections (20%). Skin             involve- ment is sometimes secondary to direct contamination via a wound. Antibiotic             therapy of nocardiosis is based on empirical recommendations due to the absence of             correlation between the in vitro ef®cacy of antibiotics and their clinical ef®cacy and             the absence of controlled clinical trials.4 First-line treat- ment usually consists of             trimethoprim ± sulfamethox- azole (TMP ± SMX), which is frequently effective in vitro             but often only minimally active in vivo, particularly on N. nova.5,6 The             imipenemamikacin combination appears to be clinically more effective than cotrimoxazole,             regardless of the species respon- sible.4,6 Antibiotics must be continued for 3 ± 12             months, depending on the severity of the clinical features. Surgery, especially for             drainage of an abscess or pleurisy, is sometimes justi®ed. Relapses can occur at any             time, especially in pulmonary sites.7 Cerebral or multi-organ lesions are associated             with a poor prognosis. The opportunistic behaviour of Nocardia facilitates the             development of infection in high-risk contexts (cancers, haematological malignancies,             particularly Nocardia infection of joint prosthesis C Arnal et al 305 Lupus lymphoid,             chronic respiratory diseases, immunosup- pressant and corticosteroid treatments,             transplant recipients). Mok et al2 recently evaluated the pre- valence of nocardiosis in             SLE patients to be 2.8%. Systemic lupus erythematosus had usually been diagnosed for             several years and, in more than 80% of cases, was complicated by severe nephropathy with             renal failure andaor requiring immunosuppressant therapy. In this study, all patients             were receiving corticosteroids andaor immunosuppressants, which could constitute a             factor of poor prognosis of nocardiosis.1 Sites of Nocardia infections are the same in             immunocompetent and immunodepressed patients, but cutaneous nocardiosis has been             described more frequently than central nervous system nocardiosis in SLE patients.2 Rare             sites have been reported (lymph nodes, ocular, renal, splenic, laryngeal, hepatic), but             always in combination with at least one of the three 'classical' sites. Two cases of             Nocardia tibiotarsal arthritis have been reported in lupus patients treated with             prednisone following an episode of pulmonary nocardiosis.8 To our knowledge, no other             cases of nocardiosis of a joint prosthesis in the context of SLE has been previously             reported. We also found only one case of primary Nocardia infection of a joint             prosthesis, in a non-immunodepressed subject, in whom sepsis occur- red only six weeks             after arthroplasty.9 In our case, articular nocardiosis occurred a long time after the             pulmonary infection: 23 months after the onset of pneumonia and 11 months after stopping             antibiotics. Recurrence of nocardiosis during SLE has never been described. Navarro et             al10 reported a case of pulmonary nocardiosis relapsing after six months of treatment             with cotrimoxazole in a patient with autoimmune haemolytic anaemia and strongly posi-             tive antinuclear antibodies, but no clinical or other immunological feature allowing             con®rmation of the diagnosis of SLE. However, the follow-up of cases of Nocardia             infection, whether or not complicating SLE, is usually too short or unknown to allow             reliable estimation of the recurrence rate. Wallace et al11 considered that relapses are             rare when antibiotic therapy is prolonged (3 months), particularly with the TMP ± SMX             combination. However, the ef®cacy of these antibiotics remains controversial,             particularly on N. nova,5,6 in contrast with the amoxicillindoxycy- cline combination             used in our case to treat the pulmonary infection.12 Furthermore, the risk of             haematogenous spread during nocardiosis is not decreased by antibiotic therapy.1 Various             elements in our case argue in favour of haematogenous spread from the pulmonary site of             nocardial infection to the hip prosthesis: the frequency of this form of spread,             identi®cation of the same strain of Nocardia, absence of hip pain before the episode of             pulmonary nocardiosis, absence of signs of prosthetic loosening or appearance of             granuloma on X-rays performed three months before the pneumonia. Conclusion Nocardial             infection is rare, but has an unpredictable course, even in response to treatment. We             report the ®rst case of recurrence of pulmonary nocardiosis in an extrapulmonary site in             a patient with corticosteroid- treated systemic lupus erythematosus. This case             emphasizes both the opportunistic behaviour of Nocardia infections, which often occur in             a context of immunodepression, facilitated in this case by systemic lupus erythematosus             and prolonged corti- costeroid therapy, and the risk of recurrence even after prolonged             treatment of an initial site of infection. We suggest that the amikacinimipenem             combination might be the treatment of choice for nocardiosis in lupus patients. This             case also emphasizes the frequency of opportunistic and non-opportunistic infections in             systemic lupus erythematosus and the need for precise assessment of lupus patients             present- ing with suspected infection. References 1 Lerner PI. Nocardia species. In:             Mandell GL, Bennett JE, Dolin R (eds). Mandell, Douglas and Bennett's principles and             practice of infectious diseases. 4th ed. vol. 2. New York: Churchill Livingstone, 1995             pp. 2273 ± 2280. 2 Mok CC, Yuen KY, Lau CS. Nocardiosis in systemic lupus erythematosus.             Semin Arthritis Rheum 1997; 26: 675 ± 683. 3 Frazier AR, Rosenow EC III, Roberts GD.             Nocardiosis: a review of 25 cases occurring during 24 months. Mayo Clin Proc 1975; 50:             657 ± 663. 4 McNeil MM, Brown JM. The medically important aerobic actinomy- cetes:             epidemiology and microbiology. Clin Microbiol Rev 1994; 7: 357 ± 417. 5 Lerner PI.             Nocardiosis. Clin Infect Dis 1996; 22: 891 ± 905. 6 Boiron P. ActinomyceÁtes aeÂrobies.             Rapport d'activiteÂ du Centre National de ReÂfeÂrence des mycoses humaines, des             antifongiques et des actinomyceÁtes.. UniteÂ de mycologie, Institut Pasteur, Paris,             1998. 7 Stropes L, Bartlett M, White A. Multiple recurrences of nocardial pneumonia. Am             J Med Sci 1980; 280: 119 ± 122. 8 Wongthim S, Udompanich V, Charoenlap P et al.             Pulmonary nocardiosis in Chulalongkorn Hospital. J Med Assoc Thai 1991; 74: 271 ± 277. 9             Robinson D, Halperin N. Nocardia asteroides infection of an Austin- Moore             hemiarthroplasty in a nonimmunocompromised host. Bull Hosp Jt Dis Orthop Inst 1989; 49:             107 ± 110. 10 Navarro EE, Tupasi TE, Verallo VM et al. Disseminated histoplas- mosis             with unusual cutaneous lesions in a patient from the Philippines. Am J Trop Med Hyg             1992; 46: 141 ± 145. 11 Wallace RJ Jr, Septimus EJ, Williams TW Jr et al. Use of             trimethoprim-sulfamethoxazole for treatment of infections due to nocardia. Rev Infect             Dis 1982; 4: 315 ± 325. 12 Wallace RJ Jr, Brown BA, Tsukamura M et al. 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<dateIssued encoding="w3cdtf">2000-05</dateIssued>
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<abstract lang="en">The authors report the case of a 43-year-old woman suffering from severe systemic lupus erythematosus treated with long-term prednisone, who developed Nocardia nova infection on a hip prosthesis. Sepsis occurred about two years after an episode of pulmonary nocardiosis with the same Nocardia species, that was successfully treated by 12 months of antibiotics. A good outcome of the joint infection was observed in response to antibiotics and removal of the prosthesis. Nocardiosis is a rare infection, acting as an opportunisticinfection, facilitated in the present case by systemic lupus erythematosus and chronic corticosteroid therapy. Nocardia infections mainly affect the lungs, skin and central nervous system; these last two sites are mostly due to haematogenous spread, a frequent event. Treatment is based on antibiotics, usually continued for 3 ‐ 12 months, especially because of the risk of relapse. The imipenem ‐ amikacin combination appears to be more effective than trimethoprim ‐ sulfamethoxazole. To our knowledge, this is the first case report of Nocardia nova joint prosthesis infection also presenting as late septic spread of pulmonary nocardiosis, complicating corticosteroid-treated systemic lupus erythematosus.</abstract>
<subject><genre>keywords</genre>
<topic>nocardiosis</topic>
<topic>recurrence</topic>
<topic>joint prosthesis</topic>
<topic>systemic lupus erythematosus</topic>
<topic>corticosteroid therapy</topic>
</subject>
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<identifier type="ISSN">0961-2033</identifier>
<identifier type="eISSN">1477-0962</identifier>
<identifier type="PublisherID">LUP</identifier>
<identifier type="PublisherID-hwp">splup</identifier>
<part><date>2000</date>
<detail type="volume"><caption>vol.</caption>
<number>9</number>
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<detail type="issue"><caption>no.</caption>
<number>4</number>
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<extent unit="pages"><start>304</start>
<end>306</end>
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<identifier type="DOI">10.1191/096120300680198917</identifier>
<identifier type="ArticleID">10.1191_096120300680198917</identifier>
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Nocardia infection of a joint prosthesis complicating systemic lupus erythematosus

Nocardia infection of a joint prosthesis complicating systemic lupus erythematosus

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