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Streptococcus Pneumoniae Infection Of The Sacro Iliac Joint – A Case Report And Literature Review

 Andrew O’Brien*, Mike Roberts**, George Ampat*, Judith Bowley**

*Department of Orthopaedics, Southport District General Hospital, Southport, Merseyside, England
**Department of Microbiology, Southport District General Hospital, Southport, Merseyside, England

Address for Correspondence:  

Dr Andrew O’Brien, 
Orthopaedic Dept, Southport Hospital, Town Lane, Kew, 
Southport, England, PR8 6PN
Tel: 01704 547471 ext: 4192


Streptococcus Pneumoniae is a relatively uncommon causative organism of septic arthritis, accounting for 3 – 10 % of cases of septic arthritis. The joints most commonly affected are knee, shoulder, elbow and polyarticular infections1. Streptococcus Pneumoniae infection of the SIJ in an adult is rarely reported2, with only 1 previously reported case in the UK3. We report a rare case of culture proven Streptococcus Pneumoniae sacroiliac joint (SIJ) infection.

J.Orthopaedics 2008;5(1)e9


Streptococcus Pneumoniae; sacroiliac; sacroilitis; septic arthitis

Case Report:

In July 2007, a 69 year old woman presented to the accident and emergency department with a 4 week history of gradually worsening left leg and buttock pain. She did not report any paraesthesia or history of recent trauma. Her past history included cervical spine fusion, IDDM and a previous hysterectomy. In addition she also had unexplained weight loss of 1 stone in 6 weeks.  

On examination the patient was apyrexial. There was no obvious deformity of the spine, no visible erythema or swelling. She was generally tender over the lower lumbosacral region, predominantly on the left side. Both hips were non tender however she was unable to straight leg raise due to pain. Neurovascular examination was normal. The rest of the examination was unremarkable.  

Blood investigations revealed neutrophilia (white cell count 16.0 x109/l) and raised inflammatory markers (C-Reactive Protein 150mg/l and Eythrocyte Sedimentatio Rate 103mm/hr). All other blood tests were normal. Provisional differential diagnoses of occult infection, disc prolapse, multiple myeloma and bone metastases were considered. An urgent Magnetic Resonance Image of her lumbar spine and pelvis was arranged.  

MRI scan revealed a soft tissue mass lying anterior to the cranial aspect of the left sacroiliac joint, measuring 7cm x 7cm x 5cm. These findings were consistent with an abscess and sacroiliitis.

The patient was taken to theatre for incision and drainage and specimens sent for microscopy, culture and sensitivity. The patient was started on broad spectrum intravenous antibiotics until sensitivities were received.  

Post-operatively the patient remained clinically well, with her symptoms improving significantly. Cultures grew Streptococcus Pneumoniae, sensitive to benzylpenicillin. The patient was commenced on high dose intravenous benzylpenicillin, following consultant microbiology advice. The patient completed four weeks intravenous antibiotics and two weeks oral antibiotics.  

During her inpatient stay, the patients weight loss was investigated. CT scan of her abdomen and pelvis revealed a suspected carcinoma of the bowel. She underwent laproscopic right hemicolectomy and made an excellent post-operative recovery.  

Three weeks after discharge serology results were received, indicating serotype 16f. 

Discussion :

Septic arthritis caused by S. Pneumoniae has traditionally been thought to occur infrequently. however literature suggests it may account for 6-10%1,4 of cases of septic arthritis, highlighting the need for greater awareness of this causative organism. Cases of S. Pneumoniae sacroiliitis however, appear to be rare indeed with only 1 previously reported case in the UK3.  

Previous cases have involved children or the elderly with a background of immunosuppression2.  

S. Pneumoniae is a gram positive diplococci commonly causing pneumonia and meningitis in adults and otitis media in children. Less frequently it causes other infections such as endocarditis and septic arthritis. The presentation of a patient with S. Pneumoniae infection may include fever, rigors, vomiting and general systemic upset in addition to features specific to the foci of infection.  

The principle of management for septic arthritis, regardless of the causative organism, involves draining the joint and antibiotic therapy5,6. Drainage can be achieved in a number of ways, including surgical incision and drainage, arthroscopic drainage or repeated needle aspirations. Samples from drainage must be sent for microscopy, culture and sensitivity, and in the meantime broad spectrum intravenous antibiotics should be commenced. Once sensitivities are known, a long course, 4-6 weeks, of appropriate antibiotics can be prescribed, initially intravenous for 2-4 weeks unless the patient remains ill, followed by adequate oral therapy to complete the course7.  

For septic arthritis to develop there is usually a primary focus to begin with, common sites for S. Pneumoniae including pneumonia and meningitis. From there haematogenous spread to the joint can occur. Frequently no primary cause is identified, these infections are thought to originate from a transient bacteraemia, or from a localised source.  

S. Pneumoniae is a common pathological organism, so it may be expected to cause septic arthritis more frequently than it does. The reason for this is not clear but frequently those acquiring it have an element of immunosuppression. Co-morbidities include rheumatoid arthritis, lymphoma, myeloma, malignancy, HIV infection, neutropenia, steroid treatment and diabetes mellitus, to name a few4, 8. In the case we presented the patient had two risk factors, diabetes mellitus and malignancy.  

Prevention of S. Pneumoniae infection involves a vaccination programme in children and identification and vaccination of at risk groups. Two vaccines currently exist, a pneumococcal conjugate vaccine (PCV) containing the 7 most common serotypes, and pneumococcal polysaccharide vaccine (PPV) containing 23 serotypes. PCV is given as part of the childhood vaccination programme between ages 2 months and 2 years, whilst PPV is given all patients aged 65 and over, or those aged 2 or above who are at risk. Conditions included in the at risk group include most chronic diseases (including diabetes mellitus) and immunosuppression9. In the case we presented, the serotype (16f) was not covered by either vaccination.

Conclusion :

Streptococcus Pneumoniae remains an unusual cause of septic arthritis of the SI joint. Management involves drainage of the joint, followed by a long course of appropriate antibiotics after samples have been analysed in the lab. Prevention involves effective management of risk factors and vaccination of groups most susceptible to the organism or that have a higher morbidity. Cases usually involve patients significant co-morbidity.

Reference :

  1. Clin Microbiol Infection 2004; 10: 1037-1039

  2. South Med J 1997 Jun;90(6):649-52

  3. Int J Clin Pract 1998 Apr-May;52(3):206-7).

  4. Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal Septic Arthritis: Review of 190 Cases. Clin Infec Dis 2003; 36: 319-327

  5. Garcia De la Torre I. Advances in the management of septic arthritis. Rheum Dis Clin North Am 2003; 29: 61-75.

  6. Shirtliff M E, Mader J T. Acute septic arthritis. Clin Microbiol Rev 2002; 15: 527-544

  7. James PA, Thomas MG. Streptococcus Pneumoniae Septic arthritis in adults. Scand J Infect Dis. 2000;32(5):491-4.

  8. Musher DM. Streptococcus Pneumoniae. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett’s principles and practice of infectious diseases. 4th ed. Churchill Livingstone, 1995: 1181-26

  9. Department of Health. Chapter 25 Pneumococcus. Immunisation against infectious disease, the green book. 2006


This is a peer reviewed paper 

Please cite as : Andrew O’Brien : Streptococcus Pneumoniae Infection Of The Sacro Iliac Joint – A Case Report And Literature Review

J.Orthopaedics 2008;5(1)e9





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