We describe a patient with systemic lupus erythematosus (SLE)-like disease on immunosuppressive treatment who developed septic arthritis of the knee involving Legionella dumoffii. Cultures initially remained negative. A broad-range 16S PCR using synovial fluid revealed L. dumoffii rRNA genes, a finding that was subsequently confirmed by positive Legionella culture results

Flendrie, M.

Franssen, M.

Jeurissen, S.M.F.

Klaassen, C.

Kwa, D.

Vos, F.

English

PubMed

Name not available

Septic Arthritis Caused by Legionella dumoffii in a Patient with Systemic Lupus Erythematosus-Like Disease

Wageningen Yield 

JOURNAL OF CLINICAL MICROBIOLOGY, Feb. 2011, p. 746–749 Vol. 49, No. 2
0095-1137/11/$12.00 doi:10.1128/JCM.00606-10
Copyright © 2011, American Society for Microbiology. All Rights Reserved.
Septic Arthritis Caused by Legionella dumoffii in a Patient with
Systemic Lupus Erythematosus-Like Disease
M. Flendrie,1* M. Jeurissen,1 M. Franssen,1 D. Kwa,2† C. Klaassen,2 and F. Vos3
Dept. of Rheumatology, Sint Maartenskliniek Nijmegen, Nijmegen, Netherlands1; Dept. of Medical Microbiology,
Canisius Wilhelmina Hospital, Nijmegen, Netherlands2; and Dept. of Internal Medicine,
Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands3
Received 23 March 2010/Returned for modification 27 June 2010/Accepted 18 October 2010
We describe a patient with systemic lupus erythematosus (SLE)-like disease on immunosuppressive treat-
ment who developed septic arthritis of the knee involving Legionella dumoffii. Cultures initially remained
negative. A broad-range 16S PCR using synovial fluid revealed L. dumoffii rRNA genes, a finding that was
subsequently confirmed by positive Legionella culture results.
CASE REPORT
A 58-year-old female patient with systemic lupus erythema-
tosus (SLE)-like disease was admitted to the Rheumatology
Department of Sint Maartenskliniek Nijmegen, Nijmegen,
Netherlands, in early May 2008 for treatment of septic arthritis
of the right knee. She was known since 2002 to have had
symmetrical peripheral polyarthritis, nailfold lesions, and an-
tibodies against double-stranded DNA and cardiolipin (symp-
toms classified as representing incomplete SLE or an SLE-like
disease). Concurrent immunosuppressive therapy consisted of
administration of methotrexate (7.5 mg) weekly and hydroxy-
chloroquine (400 mg) and prednisolone (10 mg) daily. In the
week prior to admission, the patient had received an intra-
articular injection of triamcinolone acetonide for mild chronic
arthritis of the right knee. Two days later, she developed a
warm, tender, and swollen right knee. The patient had a leu-
kocytosis count of 15.2  109/liter and a slightly increased
erythrocyte sedimentation rate (ESR) (20 mm/h) and C-reac-
tive protein level (22 mg/liter). Twenty milliliters of purulent
aspirate (white blood cell [WBC] count, 78  109/liter) was
obtained. Results for Gram staining (fuchsin counterstain) on
joint aspirate were negative, and results for cultures grown on
standard and mycobacterial media also remained negative. Po-
larized light microscopy did not reveal any crystals in the joint
aspirate. A chest X-ray showed no abnormalities. The tuber-
culin skin test was negative.
The patient was started on flucloxacillin (6 gr/day) and cip-
rofloxacin (400 mg twice daily) intravenously; treatment was
switched to oral therapy after 9 days, after clinical improve-
ment of the arthritis. The total duration of antibiotic therapy
was 6 weeks.
One month later, she was readmitted under suspicion of
recurrent septic arthritis of the right knee. On admission, she
also had arthritis of two metacarpophalangeal (MCP) joints of
the right hand, a purulent blister on the palmar side of the right
thumb, a new systolic heart murmur, and a fever spike (39.1°C
[102.4°F]). Biochemistry showed an increased ESR (58 mm/h)
and C-reactive protein level (160 mg/liter), as well as a slightly
elevated WBC count (10.5  109/liter).
With effort, 1 ml of purulent material was aspirated from the
knee joint; the aspirated material was found to contain an
uncountable but high level of leukocytes. Purulent aspirate was
also obtained from the blister. Blood cultures grown on stan-
dard media remained negative. Samples of repeated joint as-
pirates and the blister aspirate were inoculated onto standard
and mycobacterial culture media, including direct inoculation
of joint aspirate into mycobacterial blood culture vials (Bactec
13A TB media). Transesophageal echocardiography identified
two round, nonmobile structures 3 mm in diameter on the
aortic valve.
All cultures remained sterile for 12 days, and a 16S broad-
range PCR was additionally performed on joint aspirate ma-
terial after consultation with the medical microbiologist. In
order to avoid false-positive PCR results, the various steps of
the PCR procedure (DNA isolation, pre- and post-PCR han-
dlings) were performed in dedicated separate facilities. DNA
isolation was done using the method described by Boom et al.
(3) with minor modifications. An approximately 500-nucleo-
tide (nt) portion from the 5 end of the 16S rRNA gene was
amplified using broad-range primers (5-CCTAACACATGC
AAGTCGARCG-3 and 5-CGTATTACCGCGGCTGCT-3)
under standard conditions. Negative controls were included
that also underwent the DNA extraction procedure. All PCRs
were performed in duplicate. Amplification reactions spiked
with a small amount of control DNA showed that the purified
DNA samples were free from PCR inhibitors. After 35 cycles
of amplification, a clear PCR product was visible on agarose
gels in both duplicate amplification reactions of the clinical
sample whereas the negative controls showed no amplification
products. The obtained PCR product was purified using SPRI
chemistry (Beckman Coulter, Mijdrecht, Netherlands) and se-
quenced on a MegaBACE 500 automated DNA analysis plat-
form (GE Healthcare, Diegem, Belgium) using a DYEnamic
dye terminator kit (GE Healthcare) as recommended by the
manufacturer. The obtained sequence was compared to the
entries of the GenBank public database using the BLAST
* Corresponding author. Mailing address: Department of Rheuma-
tology, Sint Maartenskliniek Nijmegen, Hengstdal 3, P.O. Box 9011,
6500 GM, Nijmegen, Netherlands. Phone: 0031243659911. Fax.
0031848375279. E-mail: m.flendrie@flen.nl.
† Current address: Dept. of Medical Microbiology, Onze Lieve
Vrouwe Gasthuis, Amsterdam, Netherlands.
 Published ahead of print on 24 November 2010.
746
interface (NCBI BLAST [Basic Local Alignment Search Tool;
http://blast.ncbi.nlm.nih.gov/]) (14). The obtained sequence
was a 100% match to those of Legionella dumoffii. Joint aspi-
rates collected on two separate days were subsequently inocu-
lated on a buffered charcoal yeast extract (BCYE) culture
plate, which was incubated at 37°C (98.6°F) under humidified
conditions. Only one BCYE agar plate was used for isolation
of Legionella species, consisting of a Legionella CYE agar base
(Oxoid, Basingstoke, The United Kingdom) supplemented
with Legionella BCYE growth supplement (Oxoid, Basing-
stoke, The United Kingdom) and Legionella MWY selective
supplement (Oxoid, Basingstoke, The United Kingdom). Both
cultures grew around 15 to 100 colonies after 2 days. DNA
sequence analysis of the grown culture yielded the same se-
quence as obtained earlier using DNA extracted from the
clinical samples.
Treatment with ciprofloxacin (400 mg) three times a day
intravenously and oral rifampin (600 mg) twice daily was
started after obtaining the second specimen. The hand arthritis
improved quickly, but the arthritis of the right knee persisted
until surgical joint drainage was performed to improve recov-
ery. The patient was discharged 5 weeks after admission.
Antibiotic treatment was continued for a total duration of 3
months. One year after admission, no signs of arthritis were
present. A conventional radiograph of the knee showed signif-
icant medial and lateral joint space narrowing, indicating sub-
stantial cartilage loss. Echocardiographical reevaluation after 6
months showed unchanged aorta valve lesions, but no aortic
insufficiency or other signs of heart failure were present.
This report describes a case of septic arthritis caused by L.
dumoffii in an immunocompromised patient. It is considered
interesting for several aspects. The pathogen L. dumoffii has
not been reported previously in cases of septic arthritis. Other
Legionella species, especially non-L. pneumophila spp., seldom
cause septic arthritis (1, 2, 5, 9, 11). Furthermore, the pathogen
was not identified by standard bacterial cultures and was first
identified only by applying 16S broad-range PCR. Empirical
antibiotic therapy initiated according to national guidelines
should have been adequate but was not, indicating that when a
first septic arthritis episode is caused by L. dumoffii, the stan-
dard treatment period may need extension in those cases.
Eventually, longstanding antibiotics treatment resulted in com-
plete resolution of the infection, but substantial loss of joint
cartilage had already occurred.
Infections due to Legionella species mostly present as Le-
gionnaires’ disease (caused by L. pneumonia) and, to a lesser
extent, as Pontiac fever, a self-remitting flu-like illness (4, 10).
Legionella pneumonia can be accompanied by severe systemic
illness. Localized extrapulmonary infection is very rare. It may
occur during or following Legionella pneumonia, presumably
resulting from hematogenous spread (10). Wound, soft tissue,
or surgical infections may also occur after direct inoculation of
the skin. Occasionally, no clear route of infection can be es-
tablished and signs of concurrent or preceding pneumonia are
absent. Sites of extrapulmonary infection include the heart
(prosthetic heart valves, myocardium, pericardium), soft tissue
(skin, muscle), lymph nodes, and internal organs (spleen, liver,
kidney) (8, 10). The majority of extrapulmonary Legionella
infections occur in immunocompromised hosts (10).
Legionellae species are fastidious Gram-negative aerobic
bacteria. Over 90% of all Legionella pneumonia and extrapul-
monary legionellosis cases are caused by L. pneumophila (4).
L. dumoffii is one of 20 non-L. pneumophila species that have
been reported to be pathogenic in humans on the basis of their
isolation from clinical specimens (4). L. dumoffii has been
identified in 0.2% to 0.6% of all culture-positive pneumonia
cases in survey studies (12, 13). Reports of extrapulmonary
infection with L. dumoffii are sparse, consisting of a case of
pericarditis and a small cluster of prosthetic valve endocarditis
(10).
Reports of joint infections by Legionellae species are ex-
tremely rare. Six cases of arthritis caused by Legionella bacte-
ria, including the present case, have been described (1, 2, 5, 9,
11) and are summarized in Table 1. Interestingly, oligoarthri-
tis, affecting two or more joints, was described for five patients.
In four cases, culture results were positive. Three patients were
reported as not having had a preceding or concurring case of
pneumonia. In two patients, arthritis was reported to be de-
structive. In one case (case 2 in Table 1), the arthritis was
considered to be reactive instead of septic in nature, as pneu-
monia had occurred 6 months before; the WBC count in sy-
novial fluid was very low and culture results were negative (1).
The patient in the present case was immunocompromised
because of her underlying SLE-like disease, which was
treated with methotrexate and prednisolone. The route of
infection was not identified. A low-grade bacterial infection
is hypothesized, exacerbating the severity of the condition
after an intra-articular injection with triamcinolone ace-
tonide (single-use vial). Libman-Sachs endocarditis compli-
cating the patient’s SLE-like disease is the most likely ex-
planation for the aortic valve abnormalities. L. dumoffii as a
contributing factor was very unlikely, based on the absence
of Duke criteria for the diagnosis of infective endocarditis
and on the lack of validated reports of native valve endo-
carditis caused by any Legionella spp.
Diagnosis of Legionella infections is complicated. Legionellae
species do not grow on standard media. Special media (BYCE)
and adequate processing are needed for optimal isolation (4).
Isolation from joint aspirates after the use of mycobacterial
media and chocolate agar media has been reported anecdotally
(see Table 1) (2, 9). The urinary antigen test is sensitive only
for identification of infections with L. pneumophila serogroup
1. Antibody detection by enzyme-linked immunosorbent assays
(ELISA) may lack sensitivity and specificity, and conversion to
seropositivity may take several weeks. In isolated extrapulmo-
nary infections, underreporting may be an even greater issue
because of the absence of pulmonary symptoms.
Improved diagnostic methods are needed, and 16S broad-
range PCR may be a valuable diagnostic aid. In cases of cul-
ture-negative septic arthritis, 16S broad-range PCR techniques
can aid in identifying the causative microorganism. The tech-
nique identifies 16S ribosomal DNA sequences that are spe-
cies-specific for many microorganisms (6). The fast result, ob-
tained within 36 to 72 h, is a major advantage, especially for
septic arthritis, which often results in extensive joint destruc-
tion in cases of delayed treatment initiation. Besides culture-
negative infections, PCR can also aid in pathogen identifica-
VOL. 49, 2011 CASE REPORTS 747
T
A
B
L
E
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us
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st
.
748 CASE REPORTS J. CLIN. MICROBIOL.
tion in situations where antibiotics already have been initiated
or in cases with polymicrobial culture results. Disadvantages
include the possibility of false-positive results. Positive 16S
PCR results have been reported more often (at a differential of
up to 20%), in cases of patients who have underlying inflam-
matory joint diseases, as rheumatoid arthritis and reactive ar-
thritis (6, 7). The reasons for these results are speculative.
Bacterial DNA may be retained for longer periods of time in
joints which are chronically inflamed. Another explanation is
that the risk for contamination may be higher in specimens
from chronically inflamed joints, as they may contain a higher
level of endogenous free DNA serving as carrier DNA for
bacterial DNA traces picked up during the PCR procedures. It
warrants the use of many controls in each PCR procedure to
ensure correct interpretation of the data.
In conclusion, we describe a very unusual pathogen, L. du-
moffii, as a cause of septic arthritis in a clinical emergency with
significant morbidity and mortality. The case illustrates that
the absence of signs and symptoms of pulmonary involvement
does not exclude a Legionella infection. It further underlines
the possibility of applying 16S broad-range PCR as a novel
solution to the diagnostic problems encountered in cases of
culture-negative septic arthritis.
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VOL. 49, 2011 CASE REPORTS 749


A greedy algorithm for aligning DNA sequences.

Analysis of 525 samples to determine the usefulness of PCR amplification and sequencing of the 16S rRNA gene for diagnosis of bone and joint infections.

Blood culture-negative endocarditis in a reference center: etiologic diagnosis of 348 cases. Medicine

Chromosomal DNA from a variety of bacterial species is present in synovial tissue from patients with various forms of arthritis. Arthritis Rheum.

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Infection due to Legionella species other than L.

Legionella pneumophila arthritis: use of medium specific for mycobacteria for isolation of L. pneumophila in culture of articular fluid specimens.

Legionella pneumophila serogroup 4 isolated from joint tissue.

Legionella spp. and Legionnaires’ disease.

My foot hurts”: a flare of rheumatoid arthritis?

Rapid and simple method for purification of nucleic acids.

Reactive knee and ankle joint arthritis: abnormal manifestation of Legionella pneumophila.

Reactive Legionella pneumophila arthritis diagnosed by polymerase chain reaction.

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Septic Arthritis Caused by Legionella dumoffii in a Patient with Systemic Lupus Erythematosus-Like Disease

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