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Actinobacillus ureae septic arthritis in a returning traveler from Gambia: A case report and a review of literature

B. Soerajja Bhoelan

University Medical Center Utrecht, Utrecht, The Netherlands

Marco Goeijenbier

University Medical Center Utrecht, Utrecht, The Netherlands

Carla van Tienen

University Medical Center Utrecht, Utrecht, The Netherlands

Lennert Slobbe

University Medical Center Utrecht, Utrecht, The Netherlands

DOI: 10.15761/MRI.1000117

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Abstract

We present, to our knowledge, the second case of a Actinobacillus ureae septic arthritis in a returning traveller from The Gambia with a past medical history of monoclonal gammopathy of undetermined significance complicated by a severe polyneuropathy of the lower extremities.

Background

Actinobacillus ureae, formerly known as Pasteurella ureae [1], is a non-motile and non-sporing Gram-negative rod [2]. Together with the genera Haemophilus it constitutes the family of Pasteurellaceae [3]. It is rarely reported as a causative infectious micro-organism in humans [4-6]. A. ureae was first isolated in human sputum in three patients with chronic rhinosinusitis [4]. Later, it was also detected in routine sputum testing in patients without any respiratory symptoms and was therefore believed to be a commensal of the respiratory tract [5].

Symptoms may occur in the presence of damage of the upper respiratory tract or bronchial tree or a compromised immune system [5]. Arthritis caused by A. ureae is even more rare, as only one single case has been described in the literature [7]. Here, we report the second published case of septic arthritis due to A. ureae, with a possibly tropical origin.  

Case report

A 67-year-old man presented at the emergency department, twenty-four hours after returning from a fourteen-day holiday to The Gambia. He suffered from a swollen, red and painful left foot, which had started three days before admission. The day before admission the patient also had developed fever up to 39 degrees Celsius. In The Gambia, he had resided in several hotels and resorts. He had received adequate travelling immunization and had used atovaquone/proguanil as malaria prophylaxis. His past medical history revealed a polyneuropathy caused by a monoclonal gammopathy of undetermined significance (MGUS), resulting in frequently occurring wounds on the soles of his feet. In The Gambia, he mentioned to have walked barefoot almost constantly. At presentation, no wounds were noticed at the affected foot, apart from a partially removed nail of the first digit.   

His vital signs comprised a body temperature of 39.2 degrees Celsius and a tachycardia of 118/min with a blood pressure of 110/68 mmHg. Physical examination confirmed warmth and swelling of the left foot, mainly located around the ankle as can be seen in figure 1, without evident loss of motion. Laboratory testing revealed elevated inflammation parameters (C-reactive protein of 189.9 mg/L and white blood cell count of 14.5*10^9/L) (Figure 2). No other abnormalities were detected. Blood cultures were taken.

Due to the severity of infection, he was hospitalized to be treated with flucloxacillin 1000 mg four times a day intravenously under the suspicion of a cellulitis. The next day, he had increasing loss of motion of the affected ankle with worsening pain and swelling. Arthritis was confirmed after aspiration of purulent fluid by an ultrasound guided diagnostic synovial puncture. Furthermore, the blood cultures revealed growth of gram-negative rods. At this point the antibiotics were switched to ceftriaxone 2000 mg once a day intravenously.

Both the cultures of blood and synovial aspirate eventually revealed the presence of A. ureae, determined by matrix-assisted laser desorption/ionization time-of-flight analyzer (MALDI-TOF, Bruker).  An overview of antibiotics susceptibility testing is given in table 1.

Table 1: Antibiotic susceptibility testing.

 

MIC (µg/mL)

Penicillin

0.25

Amoxcillin/clavulanate

0.125

Meropenem

0.032

Ceftriaxone

<0.002

Ciprofloxacin

0.032

MIC: Minimum Inhibitory Concentration

Antibiotic regimen was narrowed to benzylpenicillin 1x10^6 IE four times a day intravenously. The infection parameters declined and the body temperature normalized. The pain and loss of motion improved gradually. An arthroscopic irrigation with saline was performed to potentiate bacterial eradication and to restrict intra-articular damage. Repeated scrupulous investigation revealed a wood splinter deep under the skin of the heel of the affected foot, which may potentially have functioned as a portal of entry, although the extracted nail seems to be an alternative legitimate explanation.

The intravenous benzylpenicillin regimen was continued for two weeks. After two weeks, he was discharged from the hospital. Antibiotic treatment was switched to levofloxacin (500mg twice daily) orally for another four weeks. Our patient fully recovered without any sequelae, including normal ankle joint function.

Discussion

To the best of our knowledge, we reported, the second known case of septic arthritis due to Actinobacillus ureae in a traveler returning from The Gambia. A Medline search was performed using the terms ‘Actinobacillus ureae’, ‘Pasteurella ureae’ and ‘infection’, as this micro-organism is uncommonly recognized as a causative infectious agent in humans [4-6]. Twenty-nine cases of infections caused by A. ureae were identified [6-32]. The most frequently reported infection was meningitis. Only one case concerned arthritis [7]. An overview is given in table 2. Interestingly, the case of arthritis of Kaur et al. and our patient both concern A. ureae arthritis possibly acquired in Africa. However, no specific associations with the tropics are currently known from literature. Besides, both cases originate from varying demographic locations.

Table 2: An overview of literature

Case

Year

Gender

Age

Localisation

Relevant history

Antibiotics (AB)

Duration  AB

Additional therapy

Outcome

1[7]

2004

F, 59

Arthritis, multifocal

Rheumatoid arthritis treated
with anti-TNF-alfa and methotrexate
Trip to Kenya
Several skin abrasions

IV piperacillin/
tazobactam and ciprofloxacin
Oral ciprofloxacin

 

6 weeks

Wound debridement
Articular irrigation
Subtotal synovectomy

Survived

2[8]

1968

M, 2

Bacteraemia

Malnutrition

N/A

N/A

N/A

Died

3[9]

1996

M, 65

Bone marrow

Rheumatoid arthritis

IV benzylpenicillin

Oral tetracyclin

2 weeks

2 weeks

-

Survived

4[10]

1995

N/A

Bronchitis, chronic

N/A

N/A

N/A

N/A

N/A

5[11]

1981

N/A

Bronchopneumonia

N/A

N/A

N/A

N/A

N/A

6[12]

1981

M, 19

Bronchopneumonia

Bacteraemia

Liver cirrhosis

N/A

N/A

N/A

Died

7[13]

1979

F, 2 days

Conjunctivitis

Premature newborn

Ocular chloramphenicol

N/A

Ocular saline

Full recovery

8[14]

2007

F, 4

Conjunctivitis

-

amoxicillin/

clavulanate

5 days

-

Full recovery

9[15]

1993

M, 59

Endocarditis

Previous S. aureus endocarditis

Periodontal surgery without AB prophylaxis

IV gentamicin

IV piperacillin

Oral cefotiam

5 weeks

6 weeks

N/A

-

Survived

10[16]

1988

M, 27 months

Otitis media

-

Oral amoxicillin/

clavulanate

10 days

-

Full recovery

11[17,18]

1961

M, 39

Meningitis

-

N/A

N/A

N/A

Survived

12[19]

1966

M, 48

Meningitis

Alcohol abuse

Skull fracture

N/A

N/A

N/A

Survived

13[20]

1967

M, 16

Meningitis

-

N/A

N/A

N/A

Died

14[21]

1978

F, 53

Meningitis

Bacteraemia

Intracranial surgery

N/A

N/A

N/A

Survived

15[22]

1983

M, 40

Meningitis

Endocarditis

Schizophrenia

Alcohol abuse

Odontal infection

N/A

N/A

N/A

Coma

16[23]

1983

M, 55

Meningitis

Bacteraemia

Insulin-dependent diabetes

Ampicillin

N/A

-

Survived

Hearing loss

17[24]

1983

M, 54

Meningitis

Previous skull fracture

Alcohol abuse

Penicillin

N/A

N/A

Survived

18[25]

1985

M, 6

Meningitis

Previous skull fracture

IV ampicillin and chloramphenicol

N/A

-

Survived

19[26]

1989

M, 52

Meningitis

Previous skull fracture

Chronic sinusitis

ampicillin

2 weeks

N/A

Survived

20[18]

1987

M, 26

Meningitis

Bacteraemia

Alcohol abuse
Two pneumococcal meningitis
in history Previous skull fracture

IV cefotaxime and penicillin

8 days

Neurosurgical repair of fistula from lamina cribrosa and nasal cavity

Survived

21[27]

1994

M, 25

Meningitis

HIV-positive

Head trauma

IV ceftriaxone switched to IV penicillin

N/A

-

Survived

22[28]

1995

M, 17

Meningitis

Skull fracture

Dural tears

IV penicillin and ceftazidime

N/A

Frontal craniotomy with partial debridement left frontal lobe

Repair dural tears

Survived

Complete neurological recovery

23[29]

2002

M, 22

Meningitis

Previous neurosurgery

Skull fracture

IV ceftriaxone

10 days

-

survived

24[17]

2009

M, 75

Meningitis

Waldenström’s macroglobulinaemia

IV cefotaxime

Oral amoxicillin

15 days

1 week

-

Survived

25[30]

1978

M, 14

Meningo-

encephalitis

Previous basal skull fracture

Dural tear

 

IV ampicillin

N/A

-

Survived

26[6]

1989

M, 44

Peritonitis

Alcohol abuse

Liver cirrhosis

Denver shunt

IV clindamycin

IV ampicillin and gentamicin

5 days

 

10 days

-

Survived

27[31]

1976

M, 47

Pneumonia

Previous alcohol abuse

Emphysema

Multiple rib fractures

N/A

N/A

-

Died

28[32]

2000

M, 28

Pneumonia

AIDS

Hepatitis type C

IV ceftriaxone

10 days

-

Survived

29[17,18]

1984

M, 47

Septicaemia

Alcohol abuse

Liver cirrhosis

N/A

N/A

N/A

Died

Infections with A. ureae seem to be associated with several comorbidities. A substantial part of the meningitis cases was associated with skull fractures or intracranial surgery. Both the current case and the case of arthritis of Kaur et al.  concern patients with skin damage. Several patients had a hampered immune system, due to Waldenström’s macroglobulinaemia, HIV-positivity and use of immunosuppressive agents. Whether this suggests that disruption of immunity not only predisposes to infection in general, but also to infection with A. ureae specifically remains unclear.

The laboratory tests used in this case were CRP, an acute phase protein, and WBC. Both were elevated and in combination with the clinical signs this raised the suspicion of an infection. This was confirmed with bacterial growth in the blood and synovial aspirate cultures.

Routine incubation of the blood and synovial fluid led to rapid identification of the A. ureae. Three blood culture sets (two on the day of admission and one on the second day) were incubated and the aerobic bottles became positive within 14 hours (BACTEC, BD). The synovial fluid grew in the blood culture media and not on the directly inoculated agar, but this could be due to the fact that the synovial fluid was collected after antibiotics were started. In conclusion, the A. ureae grew within 24 hours on blood agar plates and was identified by the MALDI-TOF.

A. ureae can be adequately treated with beta-lactam antibiotics. Alternative options include tetracyclins, sulfonamids/trimethoprim, macrolids and aminoglycosides, which was confirmed from our antibiotic susceptibility tests.

Additionally, in treating septic arthritis it must be considered to perform joint irrigation as to potentiate bacterial eradication and limit intra-articular damage [33]. In both our and the formerly described case of A. ureae, residual damage was not reported.

A. ureae seldom is a causative infectious agent of septic arthritis. Currently available literature might suggest an association with disruption of immunity.  We recommend to routinely perform blood or synovial cultures in patient with arthritis, which may sometimes detect uncommon pathogens, for which antibiotic susceptibility guided treatment can be initiated. 

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. 

References

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  16. 2021 Copyright OAT. All rights reserv
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  24. Grewal P, Fonseca K, Andrews HJ (1983) Pasteurella ureae meningitis and septicaemia. J Infect 7: 74-76. [Crossref] 
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  26. Yagupsky P, Simo A, Gorodischer R (1985) Pasteurella ureae meningitis as complication of skull fractures. Eur J Clin Microbiol 4: 589-590. [Crossref] 
  27. Morlat P, Duthil B, Gin H, Ragnaud JM, Aubertin J, et al. (1989) [Actinobacillus ureae meningitis. Apropos of a case]. Pathol Biol (Paris) 37: 1099-1101. [Crossref] 
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Editorial Information

Editor-in-Chief

Kazuhisa Bessho
Kyoto University

Article Type

Case Report

Publication history

Received date: June 11, 2017
Accepted date: July 20, 2017
Published date: July 24, 2017

Copyright

© 2017 Bhoelan BS. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Bhoelan BS, Goeijenbier M, van Tienen C, Slobbe L (2016) Actinobacillus ureae septic arthritis in a returning traveler from Gambia: A case report and a review of literature. Med Res Innov. 1: DOI: 10.15761/MRI.1000117

Corresponding author

M. Goeijenbier, MD

Erasmus Medical Centre, Department of Virology, 's-Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands,
Tel: 0031 (0)6-22415084

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Figure 1. Redness and swelling of the left ankle due to septic arthritis with a damaged first digit’s nail.

Figure 2. Course of C-reactive protein (CRP) and white blood count (WBC) during hospitalization. Day 0 = day of admission. Antibiotic switches were made on day one from flucloxacillin to ceftriaxone and on day four to benzylpenicillin. Arthroscopic irrigation took place on the fifth day, which can explain the temporary increase in body temperature

Table 1: Antibiotic susceptibility testing.

 

MIC (µg/mL)

Penicillin

0.25

Amoxcillin/clavulanate

0.125

Meropenem

0.032

Ceftriaxone

<0.002

Ciprofloxacin

0.032

MIC: Minimum Inhibitory Concentration

Table 2: An overview of literature

Case

Year

Gender

Age

Localisation

Relevant history

Antibiotics (AB)

Duration  AB

Additional therapy

Outcome

1[7]

2004

F, 59

Arthritis, multifocal

Rheumatoid arthritis treated
with anti-TNF-alfa and methotrexate
Trip to Kenya
Several skin abrasions

IV piperacillin/
tazobactam and ciprofloxacin
Oral ciprofloxacin

 

6 weeks

Wound debridement
Articular irrigation
Subtotal synovectomy

Survived

2[8]

1968

M, 2

Bacteraemia

Malnutrition

N/A

N/A

N/A

Died

3[9]

1996

M, 65

Bone marrow

Rheumatoid arthritis

IV benzylpenicillin

Oral tetracyclin

2 weeks

2 weeks

-

Survived

4[10]

1995

N/A

Bronchitis, chronic

N/A

N/A

N/A

N/A

N/A

5[11]

1981

N/A

Bronchopneumonia

N/A

N/A

N/A

N/A

N/A

6[12]

1981

M, 19

Bronchopneumonia

Bacteraemia

Liver cirrhosis

N/A

N/A

N/A

Died

7[13]

1979

F, 2 days

Conjunctivitis

Premature newborn

Ocular chloramphenicol

N/A

Ocular saline

Full recovery

8[14]

2007

F, 4

Conjunctivitis

-

amoxicillin/

clavulanate

5 days

-

Full recovery

9[15]

1993

M, 59

Endocarditis

Previous S. aureus endocarditis

Periodontal surgery without AB prophylaxis

IV gentamicin

IV piperacillin

Oral cefotiam

5 weeks

6 weeks

N/A

-

Survived

10[16]

1988

M, 27 months

Otitis media

-

Oral amoxicillin/

clavulanate

10 days

-

Full recovery

11[17,18]

1961

M, 39

Meningitis

-

N/A

N/A

N/A

Survived

12[19]

1966

M, 48

Meningitis

Alcohol abuse

Skull fracture

N/A

N/A

N/A

Survived

13[20]

1967

M, 16

Meningitis

-

N/A

N/A

N/A

Died

14[21]

1978

F, 53

Meningitis

Bacteraemia

Intracranial surgery

N/A

N/A

N/A

Survived

15[22]

1983

M, 40

Meningitis

Endocarditis

Schizophrenia

Alcohol abuse

Odontal infection

N/A

N/A

N/A

Coma

16[23]

1983

M, 55

Meningitis

Bacteraemia

Insulin-dependent diabetes

Ampicillin

N/A

-

Survived

Hearing loss

17[24]

1983

M, 54

Meningitis

Previous skull fracture

Alcohol abuse

Penicillin

N/A

N/A

Survived

18[25]

1985

M, 6

Meningitis

Previous skull fracture

IV ampicillin and chloramphenicol

N/A

-

Survived

19[26]

1989

M, 52

Meningitis

Previous skull fracture

Chronic sinusitis

ampicillin

2 weeks

N/A

Survived

20[18]

1987

M, 26

Meningitis

Bacteraemia

Alcohol abuse
Two pneumococcal meningitis
in history Previous skull fracture

IV cefotaxime and penicillin

8 days

Neurosurgical repair of fistula from lamina cribrosa and nasal cavity

Survived

21[27]

1994

M, 25

Meningitis

HIV-positive

Head trauma

IV ceftriaxone switched to IV penicillin

N/A

-

Survived

22[28]

1995

M, 17

Meningitis

Skull fracture

Dural tears

IV penicillin and ceftazidime

N/A

Frontal craniotomy with partial debridement left frontal lobe

Repair dural tears

Survived

Complete neurological recovery

23[29]

2002

M, 22

Meningitis

Previous neurosurgery

Skull fracture

IV ceftriaxone

10 days

-

survived

24[17]

2009

M, 75

Meningitis

Waldenström’s macroglobulinaemia

IV cefotaxime

Oral amoxicillin

15 days

1 week

-

Survived

25[30]

1978

M, 14

Meningo-

encephalitis

Previous basal skull fracture

Dural tear

 

IV ampicillin

N/A

-

Survived

26[6]

1989

M, 44

Peritonitis

Alcohol abuse

Liver cirrhosis

Denver shunt

IV clindamycin

IV ampicillin and gentamicin

5 days

 

10 days

-

Survived

27[31]

1976

M, 47

Pneumonia

Previous alcohol abuse

Emphysema

Multiple rib fractures

N/A

N/A

-

Died

28[32]

2000

M, 28

Pneumonia

AIDS

Hepatitis type C

IV ceftriaxone

10 days

-

Survived

29[17,18]

1984

M, 47

Septicaemia

Alcohol abuse

Liver cirrhosis

N/A

N/A

N/A

Died