Journal of the Louisiana State Medical Society
TRANSMISSION Mycobacterial articular infections typically occur through one of two methods: direct inocu- lation or disseminated infection. Joint infection with M. kansasii via direct inoculation has been documented in both immunocompromised and immunocompetent patients. 3 Patients usually present withmonoarticular disease and a history of trauma, though recent steroid injection is also a significant risk factor. 6 Patients rarely present with systemic symptoms such as fever or malaise and usually complain of only localized pain and swelling. Disseminated infection leading to joint colo- nization with M. kansasii has almost exclusively been documented in immunocompromised patients, and case reports reveal presentations of both monoarticular and polyarticular disease. Patients can present with systemic symptoms, though subacute presentation with only mild articular complaints is more common. 3 Pulmo- nary infections have been reported to lead to disseminated infections in 35% of those infected with HIV. 4 Joint colonization in the presence of disseminated disease is well documented; how- ever, no study has looked at the likelihood of dis- semination leading to articular manifestations. DIAGNOSIS Healthcare providers should consider myco- bacterial infectionwhen evaluating immunocom- promised patients who present with subacute joint pathology. Aspirates of the infected area
Figure C: Magnetic resonance imaging of right shoulder with contrast agent shows large subacromial subdeltoid fluid collection with extensive synovial thickening and periarticular erosions in the glenohumeral joint, consistent with hypertrophic HIV arthoropathy. No communication between subacromial subdeltoid bursa and glenohumeral joint space is observed.
immunocompetent and immunocompromised patients, but it is much more common in immunocompromised hosts, including HIV-infected patients. 3-4 Louisiana, in particular, has a high incidence of both HIV and M. kansasii and has recorded more co-infections than any other state. 4 RISK FACTORS HIV-infected patients, particularly those with CD4 counts below 100/mm 3 , represent the largest percentage of those with articular mycobacterial infections. 3 Individuals receiving immunosuppressive therapy for inflammatory diseases that affect the joints are also at high risk, such as those with rheumatoid arthritis, psoriatic arthritis, dermato- myositis, lupus, gout, or those receiving intrarticular steroid injections. 3 Previous articular pathologies are thought to promote the colonization of injured tissue and predispose affected individuals to hematogenous spread. 3 Researchers have also described cases of acute-onset articular manifes- tations secondary to immune reconstitution inflammatory syndrome (IRIS). 5
should be sent for histopathologic analysis and cultured for aerobic, anaerobic, fungal, and mycobacterial organisms. A histopathologic analysis should be performed using the fluorochrome technique for optimal sensitivity. Smear analysis is often negative; however, a negative smear does not rule out infection. 3 CLINICAL MANIFESTATIONS Articular manifestations of M. kansasii infections , and particularly infections of the bursae, are extremely rare. In 1999, only 50 cases of Mycobacterium kansasii septic arthritis were described, 3 and another review in 2012 discussed four cases of M. kansasii bursitis. 7 Of the four cases reported, one presentedwithmonoarticular disease while the three others presented with polyarticular disease. 7,8 M. kansasii is seldom reported to infect via direct in- oculation while organisms such as Mycobacterium fortuitum , Mycobacterium chelonae , and Mycobacterium marinum are well-known causes of localized trauma-associated infec- tions. 9 The most common bursal infections associated with these organisms are the olecranon and prepatellar bursae, as
184 J La State Med Soc VOL 166 July/August 2014
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