Post-partum polyarthritis associated with a staphylococcal breast abscess

F. Demetriadi, A. Steuer and A. Hall

Wexham Park Hospital, Rheumatology, Slough, UK

Correspondence to: F. Demetriadi. E-mail: francesca{at}demetriadi.demon.co.uk

SIR, A previously healthy 44-yr-old mother of twins presented 4 weeks post-partum, after an uncomplicated Caesarean section, with a 4-day history of widespread pain and swollen hands and feet. There was no history of sore throat, fever or sweats and there were no features to suggest a connective tissue disorder. One week post-partum she had suffered an acute self-limiting diarrhoeal illness during which blood and stool cultures were normal. She had breast-fed for only 10 days after delivery.

On admission, physical examination revealed a pyrexia of 37.7°C. She had desquamating skin on the soles of both feet with marked oedema of both hands and feet. There was evidence of synovitis at her MCP joints, second to fourth PI joints bilaterally, both wrists and both ankles. She also had a marked flexor tenosynovitis of her hands and wrists. Throat swab, blood and urine cultures, high vaginal swab and viral serology including parvovirus were all negative. Anti-streptolysin O titres (ASOT) and anti-DNase B were normal. She was negative for rheumatoid factor, antinuclear antibody, extractable nuclear antigen and double-stranded DNA. CRP was high at 133 mg/l. Haemoglobin was 11.2 g/dl, white cell count 11.0 x 109/l and platelets 343 x 109/l. Chest X-ray was normal.

A diagnosis of a reactive arthritis was considered likely, although post-partum onset of rheumatoid arthritis was also considered a possibility. She was initially treated with diclofenac with no symptomatic benefit. Due to the severity of her symptoms and functional limitation she was given an intramuscular injection of methylprednisolone 120 mg, which only minimally improved her symptoms. Her CRP rose to 170 mg/l and she developed a neutrophil leucocytosis (total count 22.6 x 109/l). There was no obvious source of infection at this time. Two weeks after admission she developed a non-tender, well-defined 3 x 4 cm left breast lump. Ultrasonography confirmed a breast abscess. The abscess was drained surgically and treated with antibiotics. Culture grew a heavy growth of Staphylococcus aureus. After drainage of the abscess there was complete and dramatic resolution of her joint symptoms. Two weeks after drainage of her breast abscess there was no evidence of any synovitis or oedema. Four months later she remains well and off all medication.

There are only a few case reports of concomitant acute inflammatory arthritis and breast abscess in the literature [1, 2]. There have been other cases reported where patients have presented with an acute self-limiting sterile arthritis and a concomitant infection, where there has been a dramatic improvement in arthritic manifestations only after the infection has been treated [3, 4].

The pathogenic mechanism is unclear but the prompt recovery of the patients following appropriate treatment of the breast abscess indicates a direct relationship of the breast infection to the arthritic manifestations. One possibility is that the mechanism may be toxin-mediated. Staphylococcal enterotoxin B, as a superantigen, has been found to induce arthritis in female DBA/1 mice [5]. Moreover, antibodies against the toxic shock syndrome toxin-1 were detected from serum and synovial fluid of a 31-yr-old man with bilateral knee synovitis and effusion secondary to toxic shock syndrome due to Staphylococcus aureus bursitis [6].

In conclusion, we report a patient who developed a sterile inflammatory polyarthritis in the post-partum period secondary to a staphylococcal breast abscess that resolved on drainage and treatment of the abscess. Occult breast infection should be considered in any woman presenting with an inflammatory arthritis in the post-partum period.

The authors have declared no conflicts of interest.

References

  1. Pal B, Jones P, Baildam AD. Acute inflammatory (non-purulent) arthritis concomitant with the development of breast abscess. Scand J Rheumatol 1999;28:123–4.[CrossRef][ISI][Medline]
  2. Al-Allaf AW, Pullar T. Acute non-purulent inflammatory arthropathy associated with Staphylococcus aureus abscess. Scand J Rheumatol 2000;29:133–5.[CrossRef][ISI][Medline]
  3. Siam AR, Hammoudeh M. Staphylococcus triggered reactive arthritis. Ann Rheum Dis 1995;54:131–3.[Abstract]
  4. Varadkan S, Fraser A, Donnelly S, Casey EB. Reactive arthritis in bacterial infection: 2 cases. Br J Rheumatol 1997;36(Suppl. 2):79.
  5. Omata S, Sasaki T, Kakimoto K, Yamashita U. Staphylococcal enterotoxin B induces arthritis in female DBA/1 mice but fails to induce activation of type II collagen-reactive lymphocytes. Cell Immunol 1997;179:138–45.[CrossRef][ISI][Medline]
  6. Gertner E, Inman RD. Aseptic arthritis in a man with toxic shock syndrome. Arthritis Rheum 1986;29:910–2.[ISI][Medline]
Accepted 27 January 2004





This Article
Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Demetriadi, F.
Articles by Hall, A.
PubMed
PubMed Citation
Articles by Demetriadi, F.
Articles by Hall, A.
Related Collections
Rheumatoid Arthritis
Spondylarthropathies