First Case of Lyme Arthritis Documented in Prosthetic Knee

The first case of Lyme disease-related prosthetic joint infection and arthritis has been described in the literature.

The affected patient had resolution of symptoms with antimicrobial therapy, highlighting how "early prompt diagnosis and adequate antimicrobial therapy may obviate the need for additional aggressive orthopedic surgical intervention," wrote William F. Wright, DO, MPH, at Memorial Medical Center in York, Pa., and James A. Oliverio, MD, an orthopedic surgeon in Camp Hill, Pa.

In Open Forum Infectious Diseases, they report on a 67-year-old man who presented to an orthopedic outpatient surgical office in November 2015 with a 3-month history of progressive left knee pain and swelling.

The patient underwent a medial compartment uni-compartmental joint arthroplasty of his left knee for degenerative arthritis in November 2014. His knee pain and swelling began in August 2015. He lived in a Lyme endemic region of the U.S. and participated in numerous outdoor activities, but did not report a history of tick bite or rash. He had no history of trauma nor systemic symptoms.

A clinical examination uncovered a moderate joint effusion but no erythema, warmth, instability, or significant pain with range of motion. Borrelia burgdorferi DNA was detected by qualitative, real-time polymerase chain reaction (PCR) of synovial turbid fluid, which also revealed purulent pleocytosis, positive human neutrophil elastase, and alpha-defensin and an elevated level of C-reactive protein, providing support for a diagnosis of periprosthetic joint infection.

Serum laboratory results showed Borrelia burgdorferi antibody enzyme immunoassay screen >5.0 (reference range <0.90), with all 10 IgG Western blot bands reactive.

The patient was treated empirically with oral doxycycline but was then switched to intravenous ceftriaxone once laboratory testing results became available. The patient's left knee pain and swelling resolved without surgical drainage. Synovial fluid analysis 18 days after the end of therapy was negative for detection of Borrelia burgdorferi DNA.

In a literature search of Lyme arthritis using relevant MeSH terms, the authors found eight Lyme-related prospective studies that discussed musculoskeletal manifestations of Lyme disease, but no reported cases in association with periprosthetic joint infection.

Arthritis can arise 6 to 12 months after being infected with tick-borne bacterial pathogen Borrelia burgdorferi sensu stricto. Knee involvement is nearly universal with late-onset Lyme arthritis. Criteria for the diagnosis of late-onset Lyme arthritis are based on exposure within an endemic area in addition to the presence of intermittent attacks of monoarticular or oligoarticular arthritis and an antibody response on enzyme-linked immunosorbent assay (EIA).

All patients with late-onset Lyme arthritis have strongly reactive two-tier testing with a positive EIA or immunofluorescence assay and a positive IgG immunoblot. A positive synovial fluid Borrelia burgdorferi sensu stricto DNA qualitative, real-time PCR test is adjunctive evidence. "Our patient fulfilled these criteria to support the diagnosis of Lyme arthritis," wrote Wright and Oliverio.

Disseminated Lyme disease with hematogenous seeding "provides the best possible explanation of how the organism gained access to the prosthetic joint," they added.

Based upon the history of a unicompartment knee arthroplasty and mild presenting symptoms, the patient did not undergo orthopedic surgical intervention but was instead treated with IV ceftriaxone, 2 g/day, for 6 weeks, with "cessation of knee pain, resolution of joint effusion, normalization of synovial and inflammatory parameters, and negative end-of-therapy detection of Borrelia burgdorferi DNA by PCR."

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First Case of Lyme Arthritis Documented in Prosthetic Knee