Difficulties of diagnosis and therapeutic approach in trichinella spiralis infection overlapped with bilateral knee infectious arthritis

Niculescu Victor, Popa Andreea, Iarca Ionut, Butan Victor - med. students - Facultatea de Medicina Brasov, anul IV, Universitatea Transilvania Brasov - Romania Nanescu Ciprian (physician) - Spitalul Clinic de Urgenta Bucuresti , Clinica Ortopedie Traumatologie ,Bucuresti Romania

INTRODUCTION
Gender: Female Clinical manifestations at admission:
pain and significant impairment of knees functionality sepsis and visible signs of illness fever (39oC)

Lab work
Acute Inflammatory Syndrome leukocytosis - 20.000/ml Acute Renal Failure Creatinine clearance: 2,3mg/dl; Urea: 102mg/dl; HCO3: 12; pH: 7,14; bE: -7; Na: 138mg/dl

MRI imaging test was performed on her legs, thies, pelvis, abdomen and thorax Bilateral thies fasciotomy - immediate lab exam invalidated the necrotizing fasciitis suspicion Bacterial endocarditis, pulmonary and cerebral abscesses - best fit for the new diagnosis CT scans - argued against the new diagnosis Tienam was administered Neurological signs occurred: generalized myoclonus. Stoping the Tienam administration and adding neurological therapy - the patient fully recovered from generalized myoclonus

Radiology results
bilateral gonarthrosis

Two weeks after necrotizing fasciitis suspicion

New result came from the lab: Trichinella spiralis parasites have been identified in the tissue sample removed from the thie within the fasciotomy Immunohistochemistry test confirmed the infection (CD 68+ - histiocytes, HF 35+ - striated muscle tissue, CD 15 - negativet) Therapy: antihelminthic agent - Albendazol and anti-inflammatory corticosteroid - Medrol Simultaneous infections with multiresistant S. aureus and Acinetobacter - local secretions cultured positively and immunology test confirmed (CA 19.9(149 UI), CA 15.3(28,8 UI), CA 125(235 UI) si scazute ale C3(0,8 UI)).

Knee arthrocentesis
purulent discharge (200ml/left knee, 120ml/right knee)

Bone

Cut-away view of joint

Ligament Synovium Cartilage Synovial fluid Bone

courtesy of http://www.lifescript.com

Treatment
Fibula Head

Emergency arthrotomy
Purulent discharge Inflammatory infiltrate Pseudomembranes and advanced stage gonarthrosis signs (osteophytes, erosion of the articular cartilages, meniscus tearing and articular space narrowing) Therapeutic irrigation, arthroscopic debridement, intra-articular instillation/aspiration

Discussion
Ozone injection therapy for both knees, two weeks before admission Septic exposure within 48 hours after ozone therapy (the patient undergoes hydrotherapy in public pool) Trichinella Spiralis infection Overlapping of arthritis with parasitic infection Possibility of parasitic infection occurring within hospitalization Neoplasia or autoimmune disease susceptibility due to tumor markers positivation

10 days post-surgery
Sudden onset of acute pulmonary edema signs and fever Edema and swelling of the lower extremity Bilateral leg fasciotomy revealed a purulent secretion from the deep posterior compartment of the leg. Admission to ICU due to recurrent cardiorespiratory events Thoracic-abdominal computed tomography scan - showed no disseminated infection or abcesses. Suspicion of necrotizing fasciitis - due to local signs of muscle tissue hyporeactivity and tissue depletion Saphenous Vein and Nerve Posterior Tibial Artery, Vein and Nerve Patella
courtesy of http://www.acpmedicine.com

Tibia

Case particularities
Ozone injection therapy for both knees is part of the protocol regarding advanced stage of arthritis Possible septic inoculation of bacterial agents when injecting ozone compound and the severity of bilateral knee septic arthritis could sustain the idea of insufficient disinfection of the skin or faulty puncture techniques Septic exposure within 48 hours after ozone therapy (the patient undergoes hydrotherapy in public pool) could argue for out of hospital infection

Peroneal Artery

Lateral Malleolus Superficial Peroneal Nerve Fibula

Anterior Compartment Lateral Compartment Interosseous Membrane Superficial Peroneal Nerve

Anterior Tibial Artery, Vein and Deep Peroneal Nerve