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Periprosthetic joint infection: Beware of primary immunodeficiency
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Have you come across patients who have had multiple different infections, such as urinary tract infections, skin abscesses, dental infections and so on? You may even know of patients who have developed multiple periprosthetic joint infection. Although multiple risk factors for surgical site infection such as obesity, uncontrolled diabetes and immunosuppressive conditions are recognized, there are some patients who, despite lack of any of these predisposing factors, are incredibly “prone” to infection.
In recent years the concept of “primary immunodeficiency” has been introduced to describe adult patients with no predisposing factors for infection who develop variety of infections. It is estimated that one in 1,200 people in the United States may be afflicted with primary immunodeficiency that may manifest in adulthood. Around 180 disorders have been described that place adult patients at risk of multiple infections.
Warning signs
Investigators interested in this concept have developed 10 clinical “warning signs” that could be used to identify adult patients with primary immunodeficiency conditions.
According to information from the Jeffrey Modell Foundation, the warning signs include: one case of pneumonia a year for more than 1 year, two or more new ear infections within a year, chronic diarrhea occurring with weight loss, and two or more new sinus infections within a year without an allergy. Other warning signs include recurrent viral infections, the need for intravenous antibiotics to clear infections, and deep abscesses of the skin or internal organs. In addition, family history of primary immunodeficiency, persistent thrush or fungal infections on the skin or elsewhere, and infection with normally harmless tuberculosis-like bacteria round out the list.
Javad Parvizi
The principle behind the screening is that some of these patients may have a reversible or treatable immunodeficiency. We have had an interest in this concept and have investigated patients at our institution. In one of our institutional studies that involved survey of 185 patients with severe periprosthetic joint infection (PJI), 27 patients (14.5%) presented with two or more “warning signs” of primary immunodeficiency. After detailed evaluation, 24 of these patients were found to have other risk factors that most likely attributed to their septic episodes. The remaining three patients were believed to have primary immunodeficiency. One of these patients, upon further investigation, was found to have hypogammaglobulinemia.
Genetic basis
Further development in the field of medicine has been the recognition that all disease states have a genetic basis. Since the sequencing of human genome, there has been plethora of “genome wide association” studies that unravel the genetic link of disease states. It is certainly plausible that there is a genetic contribution to development of surgical site infection. In fact a recent study provided signal towards this possibility.
Our patients continue to suffer PJIs with immense social and psychological cost. It is our duty to seek novel avenues to combat this devastating condition. Recognition of the fact there may be an immunological basis for infection is a step in that direction.
References:
Boyle JM. J Clin Immunol. 2007;doi:10.1007/s10875-007-9103-1.
Jeffrey Modell Foundation. 10 Warning Signs of Primary Immunodeficiency for Adults. National Primary Immunodeficiency Resource Center. www.info4pi.org/aboutPI/index.cfm?section=aboutPI&content=warningsignsadult&CFID=1874245&CFTOKEN=6a4cfd400ac21927-57D340F3-02A6-6818-34664F17B8474FF8
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Disclosure: Parvizi is a consultant to Zimmer, Smith & Nephew, 3M and Convatec.