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Systemic inflammatory markers and aspiration cell count may not differentiate bacterial from fungal prosthetic
Colten D Bracken1, Elie F Berbari, Arlen D Hanssen
1Mayo Medical School, Mayo Clinic, Rochester, MN, USA, bracken.colten@mayo.edu.
Background:
Fungal periprosthetic joint infections (PJIs) are rare. Fewer than 200 cases have been reported in the literature. The characteristics of systemic inflammatory markers and joint aspirate cell count analysis obtained in patients with fungal PJIs have not been fully assessed. The ability to diagnose involvement of fungal PJI preoperatively may optimize the surgical and medical management of these patients.
Questions/Purposes:
We determined whether preoperative systemic inflammatory markers and total synovial fluid leukocyte count and neutrophil percentage were different between patients with fungal and bacterial PJI.
Methods:
We reviewed the medical records of 44 patients with culture-positive diagnosed fungal PJIs treated at our institution between January 1, 2002, and December 31, 2011, in this study. This represented 1.2% of the total 3822 PJIs treated at our institution during the study period. The mean values for C-reactive protein, erythrocyte sedimentation rate, leukocyte count, and neutrophil percentage of patients with purely fungal PJIs were compared to those of 59 patients with bacterial PJIs treated by one surgeon during the same time period.
Results:
The mean erythrocyte sedimentation rate values for fungal and bacterial PJIs were 40 mm/hour (95% CI: 30, 50 mm/hour) and 41 mm/hour (95% CI: 33, 49 mm/hour), respectively (p=0.61). The mean C-reactive protein values for fungal and bacterial PJIs were 42 mg/L (95% CI: 22, 62 mg/L) and 65 mg/L (95% CI: 43, 88 mg/L), respectively (p=0.42). The mean total nucleated leukocyte counts for fungal and bacterial PJIs were 11,928 (95% CI: 3906, 19,950) with 81% (95% CI: 75%, 88%) neutrophils and 36,901 (95% CI: 21,822, 51,921) with 73% (95% CI: 65%, 81%) neutrophils, respectively (leukocyte count: p=0.19; neutrophil percentage: p=0.55).
Conclusions:
Early detection of fungal PJI is needed, but systemic inflammatory markers and synovial fluid cell count analyses from aspirations do not discriminate whether an infection may be of fungal origin.
Level Of Evidence:
Level IV, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.
Insights
Fungal periprosthetic joint infections (PJIs) are rare and difficult to diagnose preoperatively. Systemic inflammatory markers and synovial fluid analysis do not reliably distinguish fungal from bacterial PJIs.
Area of Science:
- Orthopedics
- Infectious Diseases
- Medical Diagnostics
Background:
- Fungal periprosthetic joint infections (PJIs) are uncommon, with fewer than 200 reported cases.
- Preoperative diagnostic markers for fungal PJI are not well-established.
- Optimizing management of fungal PJI requires improved diagnostic capabilities.
Purpose of the Study:
- To compare preoperative systemic inflammatory markers and synovial fluid cell counts between fungal and bacterial PJI.
- To assess the utility of these markers in differentiating fungal from bacterial PJI.
Main Methods:
- Retrospective review of 44 patients with fungal PJI and 59 patients with bacterial PJI.
- Analysis of C-reactive protein, erythrocyte sedimentation rate, and synovial fluid leukocyte count and neutrophil percentage.
- Comparison of mean values between fungal and bacterial PJI groups.
Main Results:
- No significant differences were found in erythrocyte sedimentation rate (p=0.61) or C-reactive protein (p=0.42) between fungal and bacterial PJI groups.
- Mean synovial fluid leukocyte counts (p=0.19) and neutrophil percentages (p=0.55) were not significantly different between the groups.
- Fungal PJIs represented 1.2% of all PJIs treated at the institution during the study period.
Conclusions:
- Current systemic inflammatory markers and synovial fluid analysis lack the ability to differentiate fungal PJI from bacterial PJI.
- Early detection of fungal PJI remains a clinical challenge.
- Further research is needed to identify reliable preoperative diagnostic tools for fungal PJI.
