Carolinas Research Day 2021

Aeromonas hydrophila and Klebsiella pneumoniae Septic Arthritis in a Pediatric Patient Kaitlyn Wright, OMS4, Daniel Schlepphorst, OMS4, Hanna S. Sahhar, MD, FAAP, FACOP. Edward Via College of Osteopathic Medicine-Carolinas, Spartanburg, SC.

CBR-2

Abstract

Case Report

Discussion

Septic arthritis (SA) is a common infection in pediatrics and can be life-threatening if not managed appropriately and in a timely manner. In the pediatric population, it can lead to joint destruction or deformity due to increased vascularity of the metaphysis, which houses the growth plate. In this case study, we present a 17-year-old male with a penetrating wound to the knee without joint capsule injury due to a water sport injury. Initially, arthrocentesis for culture and sensitivity was not performed due to negative physical exam and imaging of the joint. Days later, after abscess formation and persistence of infection despite empiric antibiotic use for typical SA pathogens, including Pseudomonas aeruginosa , joint aspiration revealed infection due to Aeromonas hydrophila and Klebsiella pneumoniae . This case presentation shows the importance of arthrocentesis in diagnosis of potential SA, especially in cases where a rare pathogen, such as Aeromonas hydrophila , may be the culprit based on history or physical exam. • SA in a pediatric patient can be fatal or cause significant morbidity if not treated appropriately and in a timely manner. • There has been an increase in antibiotic resistance in pathogens that commonly cause SA. • Delay in arthrocentesis, as well as culture and sensitivity from the joint aspirate, could delay appropriate treatment. • This case report discusses SA due to a rare pathogen, A. hydrophila ( commonly found in water in warm climates), and K. pneumoniae in a pediatric patient. Introduction

• 17-year-old male to emergency department (ED) for right knee laceration due to water sport injury • Initially prescribed oral antibiotics after negative imaging and discharged home. • Return to ED the following day due to worsening of symptoms and physical appearance and he was admitted. • Empiric antibiotics were started (vancomycin and cefepime) for Pseudomonas coverage. • Lab values showed increase in white blood cells, C- reactive protein, but normal erythrocyte sedimentation rate, negative blood cultures (x2), and negative magnetic resonance imaging (MRI) for SA or osteomyelitis. • Joint aspiration on day four yielded infection with A. hydrophila and K. pneumoniae with likely resistance to cefepime. • Wound debridement and change of antibiotics to trimethoprim-sulfamethoxazole and ciprofloxacin due to resistance.

References • Err on the side of caution and be clinically suspicious for SA in traumas near a joint. • Acquire arthrocentesis early in the patient’s visit or admission. • Culture and sensitivity from joint aspirate may yield different results than blood cultures and are important due to an increase in resistant pathogens. 1. Patrick J. Danaher, USAF MC, William P. Mueller, USAF MC, Aeromonas hydrophila Septic Arthritis, Military Medicine, Volume 176, Issue 12, December 2011, Pages 1444–1446, https://doi.org/10.7205/MILMED-D-11-00211 2. Herndon WA, Knauer S, Sullivan JA, Gross RH. Management of septic arthritis in children. J Pediatr Orthop . 1986;6(5):576-578. doi:10.1097/01241398-198609000-00009 3. Nunez-Atahualpa L, Matta EJ. Septic Arthritis Imaging: Practice Essentials, Radiography, Ultrasonography. https://emedicine.medscape.com/article/395381-overview. Published November 12, 2019. Accessed September 23, 2020. 4. Krogstad, P., MD. (2019, April 30). Bacterial arthritis: Treatment and outcome in infants and children (908751960 715574048 M. M. Torchia MD, 908751961 715574048 S. L. Kaplan MD, 908751962 715574048 W. A. Phillips MD, & 908751963 715574048 S. C. Li MD, PhD, Eds.). Retrieved August 27, 2020, from https://www.uptodate.com/contents/bacterial-arthritis-treatment-and-outcome-in- infants-and-children?search=arthrocentesis septic arthritis pediatrics 5. Munoz, G., MD. (2020, April 21). Surgical Treatment of Septic Arthritis (908749360 715572331 T. M. DeBerardino MD & 908749361 715572331 J. Krishnan MBBS, FRACS, PhD, Eds.). Retrieved August 27, 2020, from https://emedicine.medscape.com/article/1268369-overview We would like to acknowledge and thank Dr. Hanna S. Sahhar for his continual support of our work on this project. Acknowledgements • It is imperative to diagnose and treat SA by means of arthrocentesis with culture and sensitivity when you are clinically suspicious. • A. hydrophila is a rare pathogen in SA, but due to the injury taking place in brackish waters, it should be kept in mind. • Have clinical suspicious for resistance and/or a less common pathogen when empiric antibiotics do not show signs of helping. • Arthrocentesis with culture and sensitivity produces minimal morbidity, and usually, the benefits outweigh the risks. Conclusions

Table 1. Images of the affected knee over time at hospital.

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