布鲁杆菌关节假体周围感染的诊断与治疗

Clinical features of brucellosis periprosthetic joint infection

目的探讨布鲁杆菌关节假体周围感染的临床表现、诊断特征、治疗策略选择与转归。方法2010年1月至2018年12月解放军总医院第一医学中心和河北医科大学附属第三医院收治的布鲁杆菌关节假体周围感染(periprosthetic joint infection,PJI)患者6例,男5例,女1例;年龄(61.5±11.5)岁(范围45~79岁);体质指数(23.0±2.8)kg/m^2(范围18.4~26.1 kg/m^2)。5例为农村居民,1例为城市居民;4例为农民,1例为牧民,1例无业;1例有疫区接触史,1例曾从事屠宰行业;急性PJI 3例,慢性PJI 3例。3例为膝关节PJI,其中1例因膝关节绒毛结节滑膜炎接受初次全膝关节置换术、2例因膝关节骨关节炎接受初次全膝关节置换术;3例为髋关节PJI,其中1例因强直性脊柱炎累及双髋接受初次全髋关节置换术、2例因股骨头坏死接受初次全髋关节置换术。3例表现为全身发热,5例局部伤口红肿,4例合并窦道。入院当日5例有实验室检查,其中3例血C-反应蛋白升高、5例红细胞沉降率升高、5例血白细胞介素-6升高、2例血谷丙转氨酶升高。6例均有不同程度的受累关节活动受限:3例髋关节受累患者平均屈曲75°,伸直0°;3例膝关节受累患者平均屈曲67°,伸直-8°。X线片表现:1例假体松动伴感染,1例局部软组织肿胀。2例术中行冰冻切片检查的患者均有病理中性粒细胞计数阳性,关节周围组织或关节液布鲁杆菌培养阳性者4例(1例为混合感染),血布鲁杆菌抗体阳性2例。结果急性PJI中2例采用保留假体清创及更换衬垫术、1例采用二期翻修术;慢性PJI中1例采用二期翻修术、2例采用一期翻修术。抗生素治疗中均使用了利福平、多西环素等布鲁杆菌特异性抗生素,疗程3~12周。出院前5例血C-反应蛋白及红细胞沉降率降至正常范围,2例血白细胞介素-6降至正常范围(有1例未检测),4例血谷丙转氨酶降至正常,5例体温降至37.3℃以下。1例术后间断出现发热,并于2个月后出现切口红肿渗液,输注左氧氟沙星后痊愈。至末次随访时所有患者感染均未复发,影像学检查显示假体在位良好。结论对布鲁杆菌PJI,布鲁杆菌培养阳性及布鲁杆菌抗体阳性具有特异性的诊断价值;治疗上采用保留假体的清创术或翻修术,结合布鲁杆菌特异性的抗生素治疗,通常能取得较好的疗效。

Objective To explore the clinical manifestations,diagnostic characteristics,treatment strategies and outcomes of patients with brucellaperi prosthetic joint infection(PJI).Methods The medical records of 6 patients with brucella PJI in the First Medical Center of Chinese PLA General Hospital and the Third Hospital of Hebei Medical University from January 2010 to December 2018 were retrospectively analyzed,including 5 males and 1 female,aged 61.5±11.5 years(range 45-79 years)with body mass index 23.0±2.8 kg/m^2(range 18.4-26.1 kg/m^2).Five cases lived in the countryside,1 in the city.Four cases were farmers,while two cases were herder and unemployed.One case had contact history in the epidemic area,and 1 case had been in the slaughter industry.Three cases were with knee PJI,of which 1 patient underwent total knee arthroplasty due to knee joint villous nodular synovitis and 2 patients due to knee osteoarthritis.Three patients had hip PJI of which 1 patient underwent total hip arthroplasty due to spondylitis and hip ankylosis and 2 cases due to femoral head necrosis.Three cases were with acute PJI,while other 3 cases were with chronic PJI.Three cases showed fever,while 5 cases had local wounds swelling.A total of 4 cases were complicated with sinus tracts.Five cases had laboratory examinations on the day of admission of which 3 cases had elevated blood C-reactive protein(CRP)and 5 cases with increased erythrocyte sedimentation rate(ESR).Five cases were with increased blood interleukin-6(IL-6),2 cases with increased blood alanine transaminase(alanine transaminase,ALT).All cases had varying degrees of restricted movement of the affected joints.The normal range of motion of the hip joint was from 10°to 130°.The average range of motion of 3 patients with hip joint involvement was from 0°to 75°.The normal range of motion of the knee joint was 10°-135°.Three patients with knee joint involvement had an average range from-8°to 67°.One case showed loosening of the right hip prosthesis with infection and 1 case showed local soft tissue swelling.Other cases showed no obvious abnormalities in X-rays.Two patients who underwent frozen pathological examination during the operation had positive pathological neutrophilcounts.Four cases had positive Brucella culture in joint tissues or synovial fluid(1 case with mixed infection)and 2 cases had blood Brucella antibody positive.Results Among the 3 cases of acute PJI,two of them were treated with debridement,antibiotics,irrigation and retention.One case was treated with two-stage revision.Among the 3 cases of chronic PJI,one was treated with two-stage revision and 2 were treated with one-stage revision.Brucella-specific antibiotics such as rifampicin and doxycycline were used in the antibiotic treatment with the course of antibiotics 3 to 12 weeks.At the time of discharge,the CRP and ESR dropped to the normal range(CRP 0-0.8 mg/dl,ESR 0-20 mm/1 h)in all cases except for the second case.Interleukin 6 was not tested in the sixth case before discharge.In the remaining 5 patients,the blood interleukin 6 fell to the normal range(0-5.9 pg/ml)in 2 cases,and the blood ALT was in the normal range(0-40 U/L)in 4 cases.The body temperature of the second case was 37.3℃,while the other cases dropped below 37.3℃.In the second case,fever occurred intermittently after surgery.Thus,the incisionwas reddened and swollen and exuded 2 months after the operation.The patient recovered after intravenous infusion of levofloxacin.Until the last follow-up,all patients had no recurrence of infection.Imaging examination comfirmed that the prosthesis was in good position.Conclusion For patients with Brucella PJI,Brucella culture positive and Brucella antibody positive have specific diagnostic significance.Different surgical strategies will be adopt based on the patient's symptoms and the duration of infection.Surgery combined with Brucella specific antibiotic treatment can usually achieve satisfied therapeutic outcomes.