Nontyphoidal salmonellosis causes significant morbidity, is transmitted via fecal-oral route, and is a worldwide cause of gastroenteritis, bacteremia, and local infections [
A 38-year-old male patient was admitted via the emergency department with knee pain of 15 days duration and new onset fever. His history revealed that a general practitioner assessed him when his pain first started. There was no history of preceding trauma. He was treated symptomatically. Painful joint stiffness and effusion were noted on physical examination. However, the patient was afebrile (36.8°C), and no local warmth was detected around the knee joint either. He was observed to have many tattoos on his body. His previous medical history also included the use of prednisolone (24 mg/day) and azathioprine (
All of these findings were considered as consistent with septic arthritis of the knee. Open debridement was performed. The drain could be removed at postoperative sixteen day due to prolonged drainage. Culture and antibiotic susceptibility testing of the intraoperative knee joint fluid sample results were obtained on postoperative seventh day and demonstrated
A 54-year-old male patient with a known history of diabetes mellitus and chronic lymphocytic leukemia was admitted to the emergency department with fever, tremor, cold sensation, productive cough, and fatigue. At presentation, his laboratory results were as follows: WBC: 135,000/mm3 (4.000–10.000/mm3), CRP: 2.6 mg/dl (0-1 mg/dl), and ESR: 98 mm/h (<20 mm/h). He was admitted to the hospital with the diagnosis of pneumonia. He was started on moxifloxacin on the recommendation of the infectious disease department. On the second day of his hospitalization, he was referred to the orthopedics and traumatology department due to new onset right hip pain and not being able to bear weight on his right side. Examination revealed restricted and painful flexion and internal rotation in his right hip joint. X-ray examination of the right hip was unremarkable except for slight degenerative changes consistent with his age. However, ultrasonography of the hip demonstrated increased intra-articular fluid in the hip joint. Purulent fluid was aspirated from hip joint under ultrasonographic guidance. Leukocyte count of the joint fluid was 3.840/mm3 with 90% polymorphonuclear leucocytes. He underwent arthrotomy and debridement of the right hip immediately with the diagnosis of septic arthritis. Culture and antibiotic susceptibility testing of the hip joint fluid sample results revealed
Septic arthritis is an orthopedic emergency. The gold standard of treatment is joint debridement and antibiotic therapy according to the culture results. Physiotherapy should be initiated early in the postoperative period to prevent limitation of motion. Smith et al. reported that enzymatic destruction begins by the eighth hour after the inoculation. By the 48th hour, 40% of the glycosaminoglycan is lost, and collagen breakdown occurs in a period of few days in septic arthritis [
WBC counts in the synovial fluid are typically above 50.000/mm3 in septic arthritis. McCuthan and Fisher demonstrated that 50% of patients with positive culture results may have 28.000/mm3 or less WBC count in the synovial fluid. However, these patients were immune compromised [
Clinicians should be cautious that the WBC count in the synovial fluid can be below 50.000/mm3 in immune compromised individuals with septic arthritis. The inflammatory response can be deficient or the microorganism can be atypical. Virulence of salmonella is different from staphylococcus species since local or systemic fever is usually not observed. Restriction of joint motion, which is classically seen in the early period of septic arthritis, can be delayed in salmonella species. There is a subtle or no increase in warmth around superficial joints such as the knee. These cases require a high index of suspicion in the interest of time and in initiating appropriate treatment.
We emphasize that joint infections can be caused by atypical bacteria like salmonella species in immune compromised individuals. These patients may present atypical clinical and laboratory findings. Therefore, salmonella species must always be borne in the differential diagnosis of septic arthritis in a clinically relevant setting.
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The authors declare that they have no conflict of interest.
No funds were received in support of this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this paper.