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Septic Knee Arthritis: An Extremely Rare Complication of Nephrotic Syndrome

Fotiadis E*, Lyrtzis Ch*,  Kenanidis E*, Hytas A*, Ntovas Th*, Koimtzis M*.

* General Hospital Of Veria, Orthopaedic Department, Greece

Address for Correspondence:

Fotiadis Elias
Orthopaedic Surgeon
Meg. Alexandrou 33
57013, Oreokastro, Thessaloniki
Tel: +30 2310 699583
Fax: +30 2310 694192


J.Orthopaedics 2007;4(3)e11


Septic arthritis may occur in patients of any age. The bacteria can infect the joint by hematogenous route, by direct inoculation of a wound or by direct extension of an adjacent osteomyelitis. The most common causative agents of septic arthritis in elderly people are Staphylococcus Aureus, β-Haemolytic streptococcus and Gram negative bacteria such as Klebsiella and Salmonella 1. The signs of septic arthritis are fever, pain, swelling, heat, erythema and the loss of joint’s movement. Diagnosis is confirmed with biochemical examination and culture of synovial fluid 1.

The main factor in determining the outcome of an infection is the immune status of the host. The immune status can be weak by cancer, diabetes mellitus, alcoholism, acquired immunodeficiency syndrome, or corticosteroid therapy. Patients with nephrotic syndrome are also immunocompromised hosts susceptible to infections 2. An extremely rare complication of nephrotic syndrome is the development of septic arthritis. It is the first case of septic Knee arthritis in literature which is caused by nephrotic syndrome.

The most common bacterial agents developed in these patients are Staphylococcus Aureus, Streptococcus Pneumonia and Escherichia Coli 2. However, other agents like Cryptococcus Neoformans 3 and Campylobacter Jejuni 4 are reported in patients with nephrotic syndrome.

Several mechanisms of immunosuppresion have been reported 5,6. The nephrotic syndrome is a disorder, and not a disease, where the kidneys have been damaged. Its characteristic pentad is massive proteinuria and that leads to hypoproteinemia (hypoalbunemia), hyperlipidemia with elevated cholesterols, triglycerides and other lipids, and edema.

We present a case of septic knee arthritis, caused by staphylococcus Aureus in a 68-year-old man, as an extremely rare complication of nephrotic syndrome.

Case Report:

A 68-year-old man has visited our hospital, complaining of acute knee pain without previous trauma, for the last 24 hours. On physical examination we found erythema, swelling and high temperature over his left knee. The general symptoms were temperature 38,7oC, malaise and anorexia. There was an unknown history of nephrotic syndrome, although the patient mentioned mild periorbital and ankle edema in the last month. He mentioned the continued receipt of anti-inflammatory drugs for the last two months, because he suffered from a tendonitis of supraspinatus muscle, as well. His laboratory results were: White Blood Cells 18000/mm3 with 82% polymorphonuclear cells, C - reactive protein 27,9mg/dl and Erythrocyte Sedimentation Rate 76mm/h. Uric acid, Rheumatoid factor, antinuclear antibodies, C3 and C4 were negative.  A knee radiograph and computer tomography scan showed degenerative changes of osteoarthritis. (Figure 1 a, b, c).

Figure 1. a. Clinical view of infection of the Knee’s joint

Figure 1. b. X-ray anteroposterior view shows degenerative changes of osteoarthritis.

  Figure 1.c. CT of the Knee did not show any bone abscess.


Joint aspiration was performed and synovial fluid was taken for biochemical examination and cultures. Synovial fluid was turbid and purulent. Methicillin Resistant Staphylococcus Aureus was isolated from the culture of synovial fluid. For the isolation was used sheep blood agar 5%. Synovial fluid analysis with the biochemical parameters analyzer Cobas Integra 800 (Roche,Basel,Switzerland) showed White Blood Cells 78000/mm3, with 80% polymorphonuclear cells, protein 3,6gr/dl and glucose 26mg/dl.

We did not detect the existence of nephrotic syndrome and septic knee arthritis was initially treated with arthroscopic debridment. We started intravenous antibiotic therapy, consisting of 1gr Vancomycin twice daily, according to antibiogramma, as well.

The symptoms were the same after one week therapy. The patient was screened meticulously and we found serum albumin 2,4g/dl, albumin in urine 4,6gr/24h, cholesterol 288mg/dl and triglycerides 230mg/dl, which revealed the diagnosis of nephrotic syndrome.

The nephrotic syndrome was treated by nephrologists and we continued the intravenous antibiotic therapy for 3 weeks. The joint was immobilized in a cast for 1 week and after that we started continuous passive movement. After one week of therapy the condition of the patient improved slowly. The local signs, the sedimentation rate and C – reactive protein levels had returned to normal. The antibiotic therapy was continued by an intramuscular injection of teicoplanin daily for other 3 weeks. The patient was followed-up for 18 months and he did not show any clinical sign of recurrence.   

Discussion :

The morbidity and mortality of acute septic arthritis are significant especially at young children and elderly people.  Bone and cartilage destruction are the main complications of septic arthritis in adults. The knee joint is the most frequent affected. Septic arthritis of the hip, shoulder, ankle, wrist, elbow, tarsal, sacroiliac, acromioclavicular and sternoclavicular joints is less frequent 1. Diagnosis is documented with analysis of blood and synovial fluid parameters. The isolation and identification of pathogen microorganism confirm the infection. Age is an important factor in determining the causative microorganism of septic arthritis. The most common microorganisms found in elderly people are Staphylococcus Aureus, β-Haemolytic streptococcus and Gram negative bacteria such as Klebsiella and Salmonella 7. Staphylococcus Aureus is the causative agent in the half of these patients 7. The joint can be infected by direct invasion, by blood spread from another site or by direct spread from a adjacent bone abscess 1. The most causative organisms of septic arthritis in people with immune deficiencies are Mycoplasma, Staphylococcus, Streptococcus, and Haemophillus 8.

Soft tissue infections, due to immune system disorder, can occur in nephrotic syndrome. Nephrotic patients have increased risk of infection because of several mechanisms. The fluid collections help bacteria to grow easily, dilute local humoral immune factors and in combination with the fragile skin create sites of entry. Also the loss of IgG, complement and factor B reduce the ability to eliminate encapsulated organisms 2.

This is the first case of septic Knee arthritis in literature which caused by nephrotic syndrome. We treated the patient, according to the three principles of the treatment, with antibiotic therapy in combination with arthroscopical debridment and rest of the joint in a stable position 1. The isolated microorganism was MRSA and we used according to antibiogramma Vancomycin. This antibiotic is the primary choice for the treatment of MRSA 9. Arthroscopic drainage and debridment is an alternative treatment for the knee and other joints like shoulder, elbow and ankle 1. The debridment must be performed within 72 hours from the initial symptoms.  Fibrinoid material and infected debris can be removed with lavage. After the acute stage of infection, the passive movement of the knee should be start. The early continuous passive movement prevents the adhesions and helps the nutrition of the cartilage, during the healing phase of septic arthritis 10. The patient must use crutches for 2 weeks.

However, in our case this treatment did not have good results, initially. So, the patient was screened meticulously for other abnormalities because there was not a history of a previous trauma. We found hypogammaglobulinemia, increased loss of albumin with urine, and high rates of cholesterol and triglycerides, which revealed the diagnosis of nephrotic syndrome. The main sign in nephrotic patients is edema. The patient had reported mild periorbital and ankle edema in the last month, but this element was not evaluated properly. Either previous joint trauma or past medical history of arthritis increases the risk of septic arthritis development.

When nephrologists treated the nephrotic syndrome, the patient’s condition was improved. We though that in our patient, hypogammaglobulinemia caused by nephrotic syndrome, was the main cause of immune system defect with total IgG less than 180mg/dl and one of the main factors of maintenance of infection. This reason is responsible for the fail of initial therapeutic strategy.

In septic arthritis of unknown origin, nephrotic syndrome should be considered among one of the causes. This case is the first description in literature of septic Knee arthritis which was developed in a patient with nephrotic syndrome. 

Reference :

  1. Park LA, Dlabach AJ.  Infectious arthritis In: S.Terry Canale eds. Cambpell’s operative orthopaedics, 10th ed.  St Louis : CV Mosby-Year book Inc., 2003: 685-689.
  2. Johnson RJ, Rennke H, Feehally J.  Introduction to glomerular disease: Pathogenesis and classification.  In: Johnson RJ and Feehally J eds. Comprehensive clinical Nephrology, 2th ed. St Louis : CV Mosby Co, 2003: 255-269.
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  4. Simon CH, Markusse HM. Campylobacter Jejuni Arthritis in secondary amyloidosis. Clin Rheumatology. 1995 Mar; 14(2):214-6.
  5. Fiser R.T, Arnold W.C, Charlton R.K, Steele R.W, Childress S.H, Shirkey B. T-lymphocytes subsets in nephrotic syndrome. Kidney Int. 1991;40 :913-6.
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  7. Stimmler MM. Infections arthritis: tailoring initial treatment to clinical findings. Infect Arthritis. 1996; 99: 127.
  8. Sordet C, Cantagrel A, Schaeverbeke T, Sibilia J. Bone and joint disease associated with primary immune deficiencies. Joint Bone Spine. 2005 Dec;72(6):503-14.
  9. Hamed KA, Tam JY, Prober CG. Pharmacokinetic optimization of the treatment of septic arthritis.  Clin Pharmokinet. 1996; 31(2):156-63.
  10. Salter RB, Bell RS, Keeley FW. The protective effect of continuous passive motion on living articular cartilage in acute septic arthritis: an experimental investigation in the rabbit.  Clin Orth Relat Res.  1981; (159):223-47.


This is a peer reviewed paper 

Please cite as :Septic Knee Arthritis: An Extremely Rare Complication of Nephrotic Syndrome

J.Orthopaedics 2007;4(3)e11





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