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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 62-66

Lepra reaction mimicking prosthetic joint infection following total hip replacement: An unusual complication


Department of Orthopaedics, All Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Web Publication13-Jun-2016

Correspondence Address:
Alok C Agrawal
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.183949

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  Abstract 

Joint replacement is a highly effective intervention that significantly improves patients' quality of life. Infection is a dreadful complication in total hip replacement (THR). Managing the prosthetic joint infection is a difficult task for surgeon. In today's era, patients with chronic mycobacterial infections are also treated with total hip arthroplasty. We are reporting a case who had lepromatous leprosy 5 years back treated as per the schedule who developed lepra reaction later. After treatment of lepra reaction, the patient developed avascular necrosis of femoral head. A hybrid THR was done for that to the patient. The report discusses lepra reaction following THR mimicking acute infection. In the literature, there are no reported cases of lepra reaction in a patient with THR done. Our case report presents with the dilemma of diagnosis between infection and lepra reaction following THR.

Keywords: Lepra reaction, prosthetic joint infection, total hip replacement


How to cite this article:
Agrawal AC, Sahoo B, Sakle H. Lepra reaction mimicking prosthetic joint infection following total hip replacement: An unusual complication. J Orthop Traumatol Rehabil 2015;8:62-6

How to cite this URL:
Agrawal AC, Sahoo B, Sakle H. Lepra reaction mimicking prosthetic joint infection following total hip replacement: An unusual complication. J Orthop Traumatol Rehabil [serial online] 2015 [cited 2019 Nov 13];8:62-6. Available from: http://www.jotr.in/text.asp?2015/8/1/62/183949


  Introduction Top


Infection is a dreaded complication in total hip replacement (THR) surgery. The preoperative preparations include assessing the patient for any evidence of infection clinically as well as by blood investigations, namely complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and levels of serum proteins to assess the immunity.[1]

Patients with chronic mycobacterial infections are also treated with total hip arthroplasty after controlling the infection. Adequate antibiotic/antitubercular/antileprotic treatment and infection-free period of 5 years recommended initially were reduced to an infection-free period for 2 years, then to 6 months, and now a negative ESR, serum protein level >3.5 g/dl, and a hemoglobin concentration above 10 g/dl.[1],[2]

We are reporting a case who had lepromatous leprosy 5 years back treated as per the schedule who developed lepra reaction later. This lepra reaction was treated with steroids and on stopping steroids, it recurred. The patient became dependent on steroids and developed avascular necrosis of the right femoral head. A hybrid THR was done to the patient after stopping steroids. The report discusses lepra reaction following THR, mimicking acute infection.


  Case Report Top


A 44-year-old male was diagnosed with Hansen's disease and treated for 2 years. This patient following treatment developed erythema nodusum leprosum Type 2 lepra reaction, which responded to steroids. The patient developed lepra reaction repeatedly and continued taking steroids (prednisolone 40 mg orally per day) for more than 4 months at a stretch being steroid-dependent. Four years later, he developed pain in the right hip and was diagnosed as a case of avascular necrosis of the right femoral head with early osteoarthritis based on X-rays and magnetic resonance imaging scan [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: X-ray showing the avascular necrosis of both femoral head

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Figure 2: Lateral view of right femoral head showing AVN

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Figure 3: MRI showing collapse with marrow odema and stress fracture

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Figure 4: MRI showing collapse with marrow odema and stress fracture

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The patient took opinion from an orthopedic surgeon and was treated by a hybrid THR [Figure 5] and [Figure 6]. The patient was discharged after 1 week from the hospital on antibiotics, but following discharge, he developed fever, red painful inflamed skin lesions in both lower limbs, marked edema of hands, feet, and face, increasing muscular weakness, enlarged inguinal group of lymph nodes, scrotal swelling, and epididymo-orchitis. Diagnostic aspiration was done from the upper thigh which revealed suppurative inflammation. A week following these symptoms, the patient developed a nontraumatic dislocation of the right hip.
Figure 5: Postoperative X-ray pelvis with both hips A.P. view, showing total hip arthroplasty in acceptable position

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Figure 6: Postoperative X-ray right hip with femur showing total hip arthroplasty in acceptable alignment

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The dislocated hip was reduced under image intensifier control and general anesthesia, and the limb was kept in an abduction splint [Figure 7]. The patient was diagnosed as a case of infected THR and was started on broad spectrum heavy antibiotics when he presented to us.
Figure 7: X-ray showing the reduced dislocated hip maintained in abduction splint

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On presentation, the patient had high fever, red painful multiple enlarged lymph nodes, generalized symptoms of painful swelling of joints, enlarged inguinal group of lymph nodes and testes, and painful inflamed skin lesions on both the lower limbs.

He was investigated where it was found that he was having hemoglobin of 10.8 g/dl, total leukocyte count of 8600 cells/cmm, differential count of polymorphs of 86, ESR of 85 mm at the end of first hour (AEFH), CRP of 166.1, and serum albumin of 2.5 g/dl. These features were suggestive of acute pyogenic infection, most probably pertaining to the right hip. To confirm, it was decided to go for a diagnostic tap (ultrasonography [USG] guided) of the right hip and do a USG of abdomen and pelvis and blood cultures.

Blood culture report came negative and sonography of abdomen, pelvis, and hip was reported as normal. This is when a detailed history of patient was taken and it was found that the patient was treated in the past for steroid-dependent lepra reaction following 2 years of complete treatment for Hansen's disease.

A dermatologist was contacted who diagnosed this patient to be having Type 2 lepra reaction and prescribed the patient with prednisolone 40 mg orally daily, colchicine 0.5 mg b.d., calcium lactate, ranitidine 150 mg daily, and cefuroxime 500 mg b.d.

Within hours of starting treatment, the patient became afebrile and by the next day, the swelling started to subside, skin lesions started disappearing, and he was regaining appetite. The patient was discharged ambulatory after 3 days on treatment along with clofazimine 100 mg t.i.d. and was found to be comfortable on follow-up [Figure 8].
Figure 8: Clinical picture of patient after control of lepra reaction

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  Discussion Top


Nearly, 1-2% of hip arthroplasties become infected and mostly are caused by Gram-positive organisms, particularly coagulase-negative staphylococcus and Staphylococcus aureus.[1]

Early or acute infections may be characterized by pain, fever, wound discharge, or erythema.

ESR >30 mm/h and CRP >10 mg/L are reasonably sensitive and specific for diagnosis of infection. Early postoperative infections are managed on the basis of virulence of organism, status of the wound and surrounding soft tissues, and physiological status of the patient, and the options include debridement and irrigation with antibiotic solution followed by 6 weeks of intravenous antibiotics based on culture and sensitivity of the joint fluid or tissues.[1]

Joint replacement is a highly effective intervention that significantly improves patients' quality of life, providing symptom relief, restoration of joint function, improved mobility, and independence. Prosthetic joint infection (PJI) remains one of the most serious complications of prosthetic joint implantation. The management of PJI almost always necessitates the need for surgical intervention and prolonged courses of intravenous or oral antimicrobial therapy.[2],[3],[4],[5] According to the modified definition, a definite PJI is present when:

  1. There is a sinus tract communicating with the prosthesis, or
  2. A phenotypically identical pathogen is isolated by culture from two or more separate tissue or fluid samples obtained from the affected prosthetic joint, or
  3. When three of the following five criteria exist:


  1. Elevated serum erythrocyte sedimentation rate and serum C-reactive protein concentration.
  2. Elevated synovial white blood cell count or change on leukocyte esterase test strip.
  3. Elevated synovial polymorphonuclear percentage.
  4. Positive histological analysis of periprosthetic tissue.
  5. A single positive culture.[5]


In the literature, there are no reported cases of lepra reaction in a patient with THR done. Our case report presents with the dilemma of diagnosis between infection and lepra reaction following THR.

Leprosy is a chronic granulomatous infectious disease involving mainly the skin and peripheral nerves caused by Mycobacterium leprae. The current prevalence in our country is 0.88/10,000 population.[6]

Lepra reaction can be of Type 1 (localized, delayed hypersensitivity) or Type 2 (generalized immune complex reaction). Severe reactions may be characterized by presence of red, painful, tender subcutaneous nodules, high fever, general malaise, swelling of hands and feet along with involvement of other vital organs such as kidneys, liver, and bone marrow. Treatment involves bed rest, analgesics, steroids, clofazimine, and thalidomide.[6],[7]

Type 2 occurs more often in the patients around the lepromatous leprosy pole of the leprosy spectrum with a heavy load of bacilli. Type 2 reactions affect 20% of lepromatous leprosy and 10% of borderline leprosy cases, in which a high bacterial load and diffuse infiltration in skin lesions are regarded as important risk factors.[7],[8] A Type 2 reaction is characterized by painful and tender red papules or nodules on the skin, the typical signs of erythema nodosum (i.e., why Type 2 also refers to erythema nodosum leprosum), accompanied by systemic symptoms including fever, joint pain, edema, proteinuria, and malaise.[7],[8] Neuritis may also be part of the Type 2 reaction; however, it is usually milder compared with Type 1 reactions [9] Type 2 reactions may occur in the early stages of the treatment; however, the majority of the cases present 2-3 years after leprosy diagnosis, while some patients developed episodes as late as 7 years after starting treatment [10] Most patients experience multiple acute episodes or a chronic Type 2 reaction lasting more than 6 months or even years.[11] In fact, 65% of cases had multiple episodes of Type 2 reaction, requiring management with long courses of prednisolone and additional clofazimine for periods of up to 5 years.[11]

Type 2 reactions can often last for months or even years, and so there is a risk of people becoming dependent on steroids. This makes the reactions very hard to manage, with the result that it can become difficult to reduce and eventually terminate the treatment. Type 2 reactions can be treated with a combination of prednisolone and clofazimine.[12]


  Conclusion Top


PJI post-THR is a dreadful complication. While managing these cases, the treating surgeon needs to be vigilant and needs to note the past history in detail with complete physical examination. Lapromatous reaction mimicking PJI has not been reported in literature. Interdepartmental referrals are useful for diagnosis and treatment of unusual complications and avoid unnecessary expenditure on investigations, antibiotics as well as an unwanted revision surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Diagnosis and management of prosthetic joint infection: Clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013;56:e1-25.  Back to cited text no. 1
    
2.
Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004;351:1645-54.  Back to cited text no. 2
    
3.
Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med 2004;350:1422-9.  Back to cited text no. 3
    
4.
Sia IG, Berbari EF, Karchmer AW. Prosthetic joint infections. Infect Dis Clin North Am 2005;19:885-914.  Back to cited text no. 4
    
5.
Shahi A, Parvizi J. Prevention of periprosthetic joint infection. Arch Bone Jt Surg 2015;3:72-81.  Back to cited text no. 5
    
6.
Current Leprosy Prevalence in India ≬ WHO Fact Sheet; 2006.  Back to cited text no. 6
    
7.
Britton WJ, Lockwood DN. Leprosy. Lancet 2004;363:1209-19.  Back to cited text no. 7
    
8.
Walker SL, Lockwood DN. The clinical and immunological features of leprosy. Br Med Bull 2006;77-78:103-21.  Back to cited text no. 8
    
9.
Kahawita IP, Lockwood DN. Towards understanding the pathology of erythema nodosum leprosum. Trans R Soc Trop Med Hyg 2008;102:329-37.  Back to cited text no. 9
    
10.
Saunderson P, Gebre S, Byass P. ENL reactions in the multibacillary cases of the AMFES cohort in central Ethiopia: Incidence and risk factors. Lepr Rev 2000;71:318-24.  Back to cited text no. 10
    
11.
Kumar B, Dogra S, Kaur I. Epidemiological characteristics of leprosy reactions: 15 years experience from north India. Int J Lepr Other Mycobact Dis 2004;72:125-33.  Back to cited text no. 11
    
12.
Tamplin M, Nash J, Almond T. The International Federation of Anti-Leprosy Associations (ILEP) 2002 ILEP, London.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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