Diş Tedavisini Takiben Gelişen, Streptococcus anginosus’a Bağlı, Omuz Eklemini Tutan Bir Septik Artrit Olgusu

Abstract

Romatolojik acil durumlar içinde sınıflanan septik ya da piyojenik artrit olarak da bilinen bakteriyel artritler erken tanı konulamaz ve uygun tedavi yapılamazsa kalıcı eklem harabiyetine yol açabilmektedir. Enfeksiyonun oluşma yolu ve hastaya bağlı risk faktörlerine göre enfeksiyon etkenleri değişkenlik gösterir. Tüm olgularda en sık görülen etkenler % 75-80 oranında Gram pozitif koklardır ancak immün yetmezlik, iv ilaç alışkanlığı, ileri yaşlar veya iatrojenik olgularda gram negatif basiller de etken olabilirler. Streptococcus anginosus grubu bakteriler hareketsiz, fakültatif anaerop, diğer tüm streptokoklar gibi katalaz negatif gram pozitif koklar olup özellikle ağız boşluğu olmak üzere tüm gastrointestinal sistemin normal florasında bulunur. S.anginosus’a bağlı enfeksiyonların diğer streptokok enfeksiyonlarından farklı olarak en önemli karakteristiği apse oluşturma eğilimidir ve diğer düşük virülanslı streptokoklardan farklı olarak izolasyonunda gerçek patojen olarak kabul edilmelidir. Diş apseleri, gingivit gibi minör oral kavite enfeksiyonlarından, derin boyun enfeksiyonlarına, metastatik akciğer, karaciğer, beyin apselerine yol açabilmektedir. Literatürde kemik ve eklem tutulumu çok nadiren bildirilmiştir. Bu sunumda sol omuzda şişlik ve ağrı şikayeti ile başvuran immün kompetan, 64 yaşındaki kadın hastada, diş tedavisinden bir ay sonra gelişen septik artrit tablosu bildirilmektedir. Hastanın başvurusundaki sinoviyal sıvı incelemesinde 26,000 lökosit/mm3, % 82 polimorfonükleer lökosit saptanması ve gram boyamada mikroorganizma görülmemesi üzerine ampirik piperasilintazobaktam+daptomisin iv tedavisi başlanmıştır. Kültür sonucunda dördüncü günde S.anginosus üremesi saptanınca piperasilin-tazobaktam kesilip tedaviye iv daptomisin ile devam edilerek 14 güne tamamlanmıştır. Hasta amoksisilin-klavulanik asit 1000 mg 2x1 oral antibiyoterapi ile taburcu edilmiş, iki hafta sonunda kontrolünde klinik iyileşme saptanarak tedavisi sonlandırılmıştır.

Keywords

• diş tedavisi
• septik artrit
• Streptococcus anginosus

A Case of Septic Arthritis of Shoulder Joint Due to Streptococcus anginosus Following Dental Treatment

Abstract

Septic arthritis is classified in acute rheumatologic emergencies and prompt diagnosis and treatment is critical for prognosis since the infection may lead to permanent destruction. Etiology varies due to routes of infection and host factors. Gram positive cocci are responsible in most of the cases (75-80 %) but in case of immune supression, elderly patients, intravenous drug usage and iatrogenic cases, Gram negative bacilli may also be involved. S.anginosus group are non-motile, facultative anaerobe and catalase-negative Gram-positive cocci that are recognized as normal flora of the human oral cavity and gastrointestinal tract. The unique characteristic of the S.anginosus group that sets these streptococci apart from other pathogenic streptococci is their ability to cause abscesses and should be considered as true pathogens when isolated. Infections vary from dental abscesses, gingivitis and other periodontal infections to deep neck infections, metastatic lung, liver, intra-abdominal and brain abscesses. In the literature soft tissue infections, septic arthritis and osteomyelitis are very rarely reported. In this case report we present a case of septic arthritis due to S.anginosus in an otherwise immunocompetant 64 year old woman that presented with pain and swelling of the left shoulder one month after a dental treatment. The sinoviyal fluid analyses revealed a WBC count of 26,000/mm3 with 82 % polymorphonuclear leukocytes with a negative Gram stain. The patient was started on ampirical intravenous treatment with piperacilin-tazobactam and daptomycine. At the fourth day, the synovial fluid culture results yielded S.anginosus, then piperacilin-tazobactam was stopped and daptomycine continued till the 14th day. The patient was discharged with oral amoxiciline-clavulanic acid 1 gr/day for 14 days. After two weeks the therapy was stopped due to clinical improvement.

Keywords

• dental treatment
• septic arthritis
• Streptococcus anginosus

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