Periprosthetic knee infection by Mycobacterium bovis and Candida guilliermondii in the context of a zoonosis: a case report and review of the literature.

INTRODUCTION: Periprosthetic joint infections are a major challenge for treating physicians. Musculoskeletal infections with Mycobacterium bovis are extremely rare, with an assumed incidence of 0.08-0.1%. Consequently, periprosthetic joint infections with Mycobacterium bovis are even less frequent. Fungal periprosthetic joint infections are very rare. No cases of Candida guilliermondii infection of implanted prostheses are described in the literature.

CASE PRESENTATION: An 87-year-old Swiss man with German ethnic origin suffered from symptoms of osteoarthritis of the knee. We present the first described case of periprosthetic joint infection after total knee arthroplasty by both Mycobacterium bovis and Candida guilliermondii in the context of a zoonosis with 14 months of follow-up. The infection was presumed to originate more than 55 years earlier, when these infectious agents were still present in cattle in Switzerland. After diagnosis of the pathogens, our patient was successfully treated with tuberculostatic and mycocide medication, and a two-stage revision knee arthroplasty was performed. The medication was given for 1 year. The postoperative course was normal and he achieved ambulant musculoskeletal rehabilitation. After 14 months of follow-up no further complication emerged. At all routine consultations, there were no indications for joint inflammation, wound healing was normal, and the range of motion was flexion/extension 110/0/0°.

CONCLUSIONS: We found no comparable cases in our literature search. Only a few joint infections by Mycobacterium bovis after intravesical instillation of Bacillus Calmette-Guérin are described. Primary infections without previous Bacillus Calmette-Guérin injection appear to be even less frequent. In cases where mycobacterial infection cannot be ruled out, we recommend cultivating mycobacteria cultures for weeks. In addition, a histological examination of the tissue should be carried out. After diagnosis, the concept of a two-stage reimplantation of total knee arthroplasty with mycostatic therapy for 1 year and antimycotic therapy appears to be effective.