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Case Reports

Indian Pediatrics 2000;37: 552-554

Septic Arthritis Due to Ureaplasma Urealyticum
Sunil Sethi
Meera Sharma
S.S. Gill*

From the Departments of Medical Microbiology and Orthopedics*, Postgraduate Institute of Medical Educaton and Research, Chandigarh 160 012, India.

Reprint requests: Dr. Meera Sharma, Additional Professor, Department of Microbiology, PGIMER, Chandigarh 160 012, India.

Manuscript Received: August 23, 1999;
Initial review completed: September 20, 1999;
Revision Accepted: November 3, 1999

Ureaplasma urealyticum is commonly found in the normal female genital tract(1) and has been implicated in chorioamnionitis(2), post partum infection(3), urethritis(4), infection stones(5) and respiratory infection especially in newborns(6). Septic arthritis due to U. urealyticum especially in hypogamma-globulinemic patients has been reported in literature(7-9) but none from our country. The current report describes a case of septic arthritis in which U. urealyticum was isolated from synovial fluid.

 Case Report

A 10-year-old girl presented to Orthopedics Department in March 1999 with one month history of pain and swelling of left knee joint. She had fever, weight loss, movement limitation, joint painful to palpation, pain on joint movement and had history of trauma to the left knee joint while playing. She was also having symptoms suggestive of urethritis for last three months and was taking antibiotics as prescribed by the private practitioner.

On examination, the knee was warm with erythema of the overlying skin and moderate effusion. Fine needle aspiration cytology (FNAC) of left knee showed straw colored fluid and the smears made from this fluid showed mild to moderate cellularity, composed of 18000 WBC/mm3 with 75% polymorpho-nuclear cells and few lymphocytes. No organism was seen on Gram stain or acid fast stains or on stains to detect fungi. The fluid was cultured on to blood agar, Mc-Conkey agar, Lowenstein Jensen media and Sabouraud’s dextrose agar for aerobic and anaerobic bacteria, mycobacteria and fungi, respectively. Cultures for mycoplasma were performed using pleuropneumonia like organisms (PPLO) broth and agar with urea and phenol red for U. urealyticum and arginine and phenol red for Mycoplasma hominis. All cultures were sterile except for PPLO broth with urea and phenol red which showed color change from yellow to pink. The broth was sub-cultured on to PPLO agar plates which grew small colonies (15-30 um) of U. urealyticum after two days. The organisms were further identified by standard methods(10): (a) growth in medium at pH-6; (b) hydrolysis of urea; (c) b-hemolysis; (d) hemadsorption; (e) inhibition of growth by thallium acetate (0.01 w/v) and erythromycin; and (f) growth inhibition and metabolic inhibition test. Radiograph of the left knee showed slight erosions and effusion. The blood chemistry and complete blood cell count were normal; the erythrocyte sedimentation rate was 45 mm/hour.

Initially, this patient was admitted to some private hospital and received therapy with ampicillin, ciproflox, and cephalexin which showed no improvement in her conditions. After isolation of U. urealyticum from synovial fluid, antibiotics were switched on to tetra-cycline and the patient reported improvement. The signs and symptoms subsided after 10 days of therapy.

 Discussion

We feel that on the basis of clinical and microbiological evidences presented above, Ureaplasma urealyticum was responsible for the septic arthritis that developed in this patient. To our knowledge, this is the first report of septic arthritis due to Ureaplasma urealyticum from our country. Vittecoq et al.(11) have isoalted Ureaplasma urelyticum from the joint in an immunocompetent individual with destructive polyarthritis initially suggestive of septic arthritis. However in literature, there has been now increasing evidence that U. urealyticum recovered from joints of hypogammaglobulinemic patients with septic arthritis are the cause of disease(7–9,12–15). In the current report, the patient was apparently healthy but the immune status was not evaluated formally. U. urealyticum is capable of producing pyogenic infection and it produces very mild inflammation. This organism is easily overlooked as it is not routinely sought and is only suspected if routine cultures are negative or the condition is unresponsive to broad spectrum antibiotics. A positive culture for mycoplasmas/ureaplasmas, especially from a normally sterile site and particularly in the absence of other micro-organisms, is sufficient justification for treatment of patients suffering from a condition known to be caused by or associated with ureaplasmas. This child had a rapid clinical response to tetracycline.

U. urealyticum is part of normal flora of female lower urogenital tract and thus mechanism of spread to the target joint may be hematogenous. Dissemination infection has been reported in otherswise healthy individuals. This patient was having persistent urethritis and U. urealyticum arthritis is known to be associated with the former condition. More studies are needed, especially in immuno-suppressed individuals to evaluate the association of mycoplasma/ureaplasma with septic arthritis since these organisms may represent a cause of opportunistic infection.

 References
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  2. Cassell GH, Waites KB, Gibbs RS, Davis JK. Role of Ureaplasma urealyticum in amnionitis. Pediatr Infect Dis 1986; 5: S247-S252.

  3. Eschenbach DA. Ureaplasma urealyticum as a cause of postpartum fever. Pediatr Infect Dis 1986; 5: S258-S261.

  4. Stimson JB, Hale J, Bowie WR, Holmes KK. Tetracycline-resistant Ureaplasma urealyticum: A cause of persistent non-gonococcal urethritis. Ann Intern Med 1981; 94: 192-194.

  5. Grenabo L, Hedelin H, Pettersson S. Urinary infection stones caused by Ureaplasma urealyticum: A review. Scand J Infect Dis 1988; 53 (Suppl): 46-49.

  6. Waites KB, Rudd PT, Crouse DT, Can upp KC, Nelson KG, Ramsey C. Chronic Ureaplasma urealyticum and Mycoplasma hominis infections of central nervous system in preterm infants. Lancet 1988; 1: 17-21.

  7. Poggio TV, Orlando N, Galanternik L, Grinstein S. Microbiology of acute arthropathies among children in Argenitina: Mycoplasma pneu-moniae and hominis and Ureaplasma urealyticum. Pediatr Infect Dis J 1988; 17: 304-308.

  8. Furr PM, Taylor-Robinson D, Webster ADB. Mycoplasmas and ureaplasmas in patients with hypogammaglobulinemia and their role in arthritis: Microbiological observations over twenty years. Ann Rheum Dis 1994; 53: 183-187.

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  11. Vittecoq O, Schaeverbeke T, Favre S, Daragon A, Biga N, Combon-Michot C, et al. Molecular diagnosis of Ureaplasma urealyticum in an immunocompetent patient with destructive reactive polyarthritis. Arthritis Rheum 1997; 40: 2084-2089.

  12. Webster ADB, Taylor Robinson D, Furr PM, Asherson GL. Mycoplasma (ureaplasma) septic arthritis in hypogammaglobulinemia. BMJ 1978; i: 478-479.

  13. Stuckey M, Quinn PA, Gelfand EW. Identifica-tion of Ureaplasma urealyticum in a patient with polyarthritis. Lancet 1978; ii: 917-920.

  14. Kraus VB, Baraniuk JN, Hill GB, Allen NB. Ureaplasma urealyticum septic arthritis in hypogammaglobulinemia. J Rheumatol 1988; 15: 369-371.

  15. Jorup-Ronstrom C, Ahl T, Hammarstrom L, Smith CIE, Rylander M, Hallander H. Septic osteomyelitis and polyarthritis with ureaplasma in hypogammaglobulinemia. Infection 1989; 17: 301-303.

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