[An atypical presentation of tuberculosis]. / Een atypische presentatie van tuberculose.

BACKGROUND: In 2020 there were 623 known TB infections in the Netherlands according to the Dutch ministry of health (RIVM). About 4% were located in bones and joints. The incidence of Multi Drug Resistant (MDR) TB in The Netherlands is about 1%. CASE: We describe the case of a 46-year-old female with a painful and swelling of the mid phalangeal bone of the fourth left digit. Quantiferon was positive and PCR of the biopsy for Mycobacterium tuberculosis complex (MTC) in Ziehl-Neelsen staining confirmed tuberculous osteomyelitis. The strain was resistant for rifampicin, isoniazid, ethambutol and pyrazinamid classifying it as MDR. Treatment in a specialized center with second line drugs was indicated due to rare resistance. CONCLUSION: Tuberculosis may manifest anywhere throughout the body, also as an (atypical) swelling of the hand. The golden diagnostic standard for bone and joint TB is biopsy with Ziehl-Neelsen staining.

Obese patients have higher rates of polymicrobial and Gram-negative early periprosthetic joint infections of the hip than non-obese patients.

BACKGROUND: Obese patients are more likely to develop periprosthetic joint infection (PJI) after primary total joint arthroplasty. This study compared the clinical and microbiological characteristics of non-obese, obese and severely obese patients with early PJI, in order to ultimately optimize antibiotic prophylaxis and other prevention measures for this specific patient category. METHODS: We retrospectively evaluated patients with early PJI of the hip and knee treated with debridement, antibiotics and implant retention (DAIR) between 2006 and 2016 in three Dutch hospitals. Only patients with primary arthroplasties indicated for osteoarthritis were included. Early PJI was defined as an infection that developed within 90 days after index surgery. Obesity was defined as a BMI ≥30kg/m2 and severe obesity as a BMI ≥35kg/m2. RESULTS: A total of 237 patients were analyzed, including 64 obese patients (27.0%) and 62 severely obese patients (26.2%). Compared with non-obese patients, obese patients had higher rates of polymicrobial infections (60.3% vs 33.3%, p<0.001) with more often involvement of Enterococcus species (27.0% vs 11.7%, p = 0.003). Moreover, severely obese patients had more Gram-negative infections, especially with Proteus species (12.9% vs 2.3%, p = 0.001). These results were only found in periprosthetic hip infections, comprising Gram-negative PJIs in 34.2% of severely obese patients compared with 24.7% in obese patients and 12.7% in non-obese patients (p = 0.018). CONCLUSIONS: Our results demonstrate that obese patients with early periprosthetic hip infections have higher rates of polymicrobial infections with enterococci and Gram-negative rods, which stresses the importance of improving preventive strategies in this specific patient category, by adjusting antibiotic prophylaxis regimens, improving disinfection strategies and optimizing postoperative wound care.

Prosthetic Joint Infection of a Revision Knee Arthroplasty with Candida parapsilosis.

We report a case of an infected total knee arthroplasty with Candida parapsilosis. The patient was successfully treated with a two-stage exchange arthroplasty, local antifungal treatment, and systemic antifungal treatment. This specific combination therapy to treat C. parapsilosis joint infection has not been previously reported.

Use of gentamicin-impregnated beads or sponges in the treatment of early acute periprosthetic joint infection: a propensity score analysis.

Objectives: Early acute periprosthetic joint infections (PJIs) treated with debridement, antibiotics and implant retention (DAIR) have failure rates ranging from 10% to 60%. We determined the efficacy of applying local gentamicin-impregnated beads and/or sponges during debridement in early PJI. Methods: Patients with early acute PJI, defined as less than 21 days of symptoms and treated with DAIR within 90 days after index surgery, were retrospectively evaluated. Early failure was defined as PJI-related death, the need for implant removal or a second DAIR or antibiotic suppressive therapy owing to persistent signs of infection, all within 60 days after initial debridement. Overall failure was defined as implant removal at any timepoint during follow-up. A 1:1 propensity score matching was performed to correct for confounding factors. Results: A total of 386 patients were included. Local gentamicin was applied in 293 patients (75.9%) and was withheld in 93 patients (24.1%). Multivariate analysis demonstrated that the use of local gentamicin was independently associated with early failure (OR = 1.97, 95% CI = 1.12-3.48). After propensity matching, early failure was 40.3% in the gentamicin group versus 26.0% in the control group (P = 0.06) and overall failure was 5.2% in the gentamicin group versus 2.6% in the control group (P = 0.40). These numbers remained when solely analysing the application of gentamicin-impregnated sponges. Conclusions: Even after propensity score matching, failure rates remained higher if local gentamicin-impregnated beads and/or sponges were administered in early acute PJI. Based on these results, their use should be discouraged.