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1 67 pissn : , eissn : Case Report J Korean Orthop Assoc 2019; 54: 제 2 형당뇨및골관절염을동반한환자에서발생한 Klebsiella pneumoniae 균에의한화농성관절염 하중원 이상현 박상훈 김태엽 * 국민건강보험일산병원정형외과, * 연세대학교의과대학정형외과학교실 The Septic Knee Arthritis Caused by Klebsiella pneumoniae in a Patient with Type 2 Diabetes Mellitus and Osteoarthritis of the Knee Joong-Won Ha, M.D., Sanghyeon Lee, M.D., Sang-Hoon Park, M.D., and Tae-Yup Kim, M.D.* Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan, *Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea Klebsiella pneumoniae causes that liver abscess mostly, also spread to pneumonia, meningitis, urinary tract infections. Septic arthritis caused by K. pneumoniae is a quite rare and has not been reported in Korea. Therefore, the authors report a case of the septic arthritis in the knee joint caused by K. pneumoniae in a patient with type 2 diabetes mellitus and osteoarthritis of the knee that successfully treated by early detection and arthroscopic synovectomy. Key words: knee, septic arthritis, Klebsiella pneumonia Klebsiella pneumoniae 는 Enterobacteriaceae 분류의그람음성간 균으로서정상인의피부, 구강및장내의인체상재균으로원내 감염을잘일으키는것으로알려져있다. 1) K. pneumoniae 의감염 은대부분원발성간농양을일으키며전이성병변으로폐농양, 뇌수막염, 안내염등의간외합병증을수반하므로간농양없이 타장기에감염을일으키는경우는매우드물며, 2) 건강한성인보 다는장기이식자나인간면역결핍바이러스 (human immunodeficiency virus) 감염자등면역억제자에서발생하는것으로알려져 있다. 3) 또한 K. pneumoniae 감염의간외합병증으로화농성슬관 절염이보고된예는드물며원발성간농양없이화농성슬관절염 이보고된예는더욱드물다. 일부저자들은 K. pneumoniae 에의 Received November 27, 2017 Revised February 13, 2018 Accepted February 23, 2018 Correspondence to: Sang-Hoon Park, M.D. Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea TEL: FAX: orthomania@gmail.com ORCID: 한화농성슬관절관절염을감수성맞는항생제사용과함께관절경적세척술및변연절제술로치료한예를보고한바있다. 4) 이에저자들은제2형당뇨병을가진슬관절골관절염환자에서원발성간농양없이발생한 K. pneumoniae에의한화농성슬관절염을관절천자와조기발견을통한관절경적변연절제술및감수성에맞는항생제사용으로치료한 1예를문헌고찰과함께보고하고자한다. 증례보고 70세남자환자가내원 3주전부터발생한좌측슬관절통증을주소로내원하였다. 과거력상약 40여년간제2형당뇨병으로약물복용중이었고잘조절되고있었다. 슬관절통증에대해타병원에서보존적치료를시행하던중내원 2주전부터타부위의통증이없는고열이발생하여국민건강보험일산병원응급실에서원인미상열 (fever unknown origin) 의증하에고열의원인을확인하기위한흉부및복부컴퓨터단층촬영 (computed tomography, The Journal of the Korean Orthopaedic Association Volume 54 Number Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

68 Joong-Won Ha, et al. CT) 촬영을시행하였다. 이후큰이상소견이확인되지않았고, 보존적치료중에도증세호전되지않아본원응급실에재내원하였다.

혈압 115/54 mmhg, 맥박 99 beats/min, 분당호흡수 20회, 체온 37.

결과슬개상낭주변으로세균성감염이의심되는다량의관절액과함께활액막의감염소견이확인되었 Figure 1.

2 68 Joong-Won Ha, et al. CT) 촬영을시행하였다. 이후큰이상소견이확인되지않았고, 보존적치료중에도증세호전되지않아본원응급실에재내원하였다. 내원당시시행한이학적검사상좌측슬관절의종창, 부종, 동통과압통및이로인한관절운동제한이관찰되었고국소열감과함께전신오한및발열을호소하였다. 혈압 115/54 mmhg, 맥박 99 beats/min, 분당호흡수 20회, 체온 37.9 C 로측정되었으며단순방사선검사상 Kellgren-Lawrence Grade 2의중등도의슬관절골관절염소견이관찰되었다 (Fig. 1). 혈액검사상백혈구수 9,430/mm 3 ( 다핵형백혈구 90.5%), 적혈구침강속도 (erythrocyte sedimentation rate, ESR) 30 mm/h, C-반응성단백 (C-reactive protein, CRP) mg/dl로측정되었다. 관절세침흡입검사에서황색의혼탁한관절액이약 40 ml 천자되었으며백혈구수 75,600/ mm 3 ( 다핵형백혈구 95%), 포도당 181 mg/dl, 단백질 2,955.5 mg/dl 로측정되어급성화농성관절염으로진단하였다. 병변의범위를확인하기위해조영제를사용한슬관절자기공명영상 (magnetic resonance imaging, MRI) 결과슬개상낭주변으로세균성감염이의심되는다량의관절액과함께활액막의감염소견이확인되었 Figure 1. Radiographs show Kellgren-Lawrence Grade 2 osteoarthritis of the left knee. Figure 2. Magnetic resonance imaging show joint fluid collection and synovial thick ening with enhancement in supra patellar pouch. Figure 3. Arthroscopic findings show in fective fluid collection in suprapatellar pouch and intact lateral, medial meniscus.

3 69 Septic Knee Arthritis Caused by Klebsiella pneumoniae 다 (Fig. 2). MRI상 T1 조영증강에서는저음영, T2 조영증강에서는고음영으로보이는대퇴하부의골수염의심소견이관찰되었으나이는본원영상의학과전문의의판독에의해감염에의한침윤보다는반응성의골수변화로확인되었다. 이에골수염은배제하고퇴행성골관절염에동반된화농성슬관절염으로진단하여내원당일관절경을이용한좌측슬관절탐색술을시행하였고 Gachter state III의염증소견이관찰되었다 (Fig. 3). 관절내세척술, 변연절제술및활액막제거술을시행하였고수술후슬관절내의다른합병증은확인되지않았다. 관절세침흡입및술중관절액의균배양검사와혈액배양검사상모두 K. pneumoniae 가동정되었고내원당시에는 vancomycin (1 g/twice a day [bid]/d) 과 3세대 cephalosporin (2 g/bid/d, ceftriaxone sodium) 을경험적으로함께사용하였으나항생제감수성검사상 3세대 cephalosporin 에감수성을보여이를계속정주하였다. K. pneumoniae의감염병소를찾기위해흉부및복부 CT와함께안구내염확인을위한전안부및안저검사시행하였으나감염소견이확인되지않았다. 술후 5주째환자증세매우호전된양상관찰되었고혈액검사상백혈구수 6,210/mm 3 ( 다핵형백혈구 69.4%), ESR 66 mm/h, CRP 3.24 mg/dl로확인되어본원감염내과전문의와상의후경구항생제인 cefixime 100 mg/bid/d로전환하여퇴원하였다. 이후술후 6주째외래추시상감염의재발소견은확인되지않았으며혈액검사상백혈구수 4,950/mm 3 ( 다핵형백혈구 67.1%), ESR 55 mm/h, CRP 1.11 mg/dl로측정되었다. 술후 10개월외래추시상슬관절운동범위 로확인되었고감염의재발소견은확인되지않았으며혈액검사상백혈구수 8,510/mm 3 ( 다핵형백혈구 77.%), ESR 23 mm/h, CRP 0.46 mg/dl로측정되었다. 고찰 K. pneumoniae에의한화농성슬관절염은매우드문질환이다. 보고된문헌또한드물어 Lin 등 5) 은 2009년까지영어로작성된의학논문중당뇨를앓고있는환자중반복적인 K. pneumoniae 감염에의한화농성관절염이 19예확인되었다고보고하였다. Silke 등 4) 은 K. pneumoniae에의한화농성슬관절관절염을감수성맞는항생제사용과함께관절경적세척술및변연절제술로치료한 2예를보고하였으나그두명이신장이식을받은면역억제된환자여서본증례와는차이가있다. 본증례의경우당뇨병을장기간앓았으나혈당강하제사용으로혈당수치는잘조절되고있던 70세남자환자에서원발병소없이 K. pneumoniae에의한세균성화농성관절염이발생하였다. 성인에서세균성화농성관절염의가장흔한원인균은 Staphylococcus aureus이며호발빈도는기저질환에따른개인간의차이는있으나 37%-67% 정도로알려져있다. 6) 이와는대조적으로그람음성균에의한세균성화농성관절염은 9%-20% 호발하며 Escherichia coli가가장흔한원인균으로알려져있다. 7) 신생아나고령의환자, 당뇨등의만성질환을앓아온환자등면역력이낮은환자는그람음성균에의한세균성화농성관절염발생가능성이높다. K. pneumoniae는이중화농성관절염을발생하는비율이매우낮으며, 간농양, 폐렴, 요로감염등의 1차감염후혈행성전파를통한 2차감염으로화농성관절염을일으키는것으로알려져있다. 3) 본증례에서확인된 K. pneumoniae에의한화농성관절염은혈행성전파에의한것으로생각되며화농성슬관절염의심시조기에관절세침흡입검사및배양검사를시행하여감수성에맞는항생제를사용하는것이치료에도움이되는것으로생각한다. 화농성슬관절염치료의기본원칙은관절내농양의배농과세척과함께감수성에맞는항생제를사용하는것이다. 관절내농양의배농과세척을하는데있어관절경적세척술및변연절제술을일차적으로시행할수있으나논문에따라재발하는빈도를 6%-42% 정도로보고하고있다. 8,9) 일부저자들은관절절개술및관절성형술을통한침습적인치료로재발을막을수있다고보고하고있으나 10) 본증례에서는관절경적세척술, 변연절제술및활액막제거술로좋은결과를얻을수있었다. 관절세침흡입검사로시행한관절액배양검사및혈액배양검사에서모두 ceftriaxone sodium에감수성을가진 K. pneumoniae가동정되었으며감수성결과에맞게항생제치료를시행하였다. 고령및장기간당뇨병을앓아면역력이저하된환자에서본증례처럼특이한균주에의해서도화농성슬관절염이발생할수있기때문에화농성슬관절염의심환자진료시환자의과거력을정확하게확인하고이에따른조기치료및정확한균동정에따른감수성있는항생제의사용이중요할것으로생각한다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Maroncle N, Balestrino D, Rich C, Forestier C. Identification of Klebsiella pneumoniae genes involved in intestinal colonization and adhesion using signature-tagged mutagenesis. Infect Immun. 2002;70: Hsieh PF, Lin TL, Lee CZ, Tsai SF, Wang JT. Serum-induced iron-acquisition systems and TonB contribute to virulence in Klebsiella pneumoniae causing primary pyogenic liver abscess. J Infect Dis. 2008;197: Lee HC, Chuang YC, Yu ML, et al. Clinical implications of hypermucoviscosity phenotype in Klebsiella pneumoniae

4 70 Joong-Won Ha, et al. isolates: association with invasive syndrome in patients with community-acquired bacteremia. J Intern Med. 2006;259: Silke S, Kate B, David G. Septic arthritis due to extended spectrum beta lactamase producing Klebsiella pneumoniae. Joint Bone Spine. 2007;74: Lin CJ, Lin CY, Li WY, et al. Repeated bacteremia with subsequent septic arthritis caused by Klebsiella pneumoniae capsular serotype K57 in a patient with diabetes. Clin Infect Dis. 2009;49: Ohl CA, Forster D. Infectious arthritis of native joints. In: Mandell GL, Bennett JE, Dolin R, ed. Mandell, douglas, and bennett s principles and practice of infectious diseases. 6th ed. Philadelphia: Elsevier; Chew LC. Septic monoarthritis and osteomyelitis in an elderly man following Klebsiella pneumoniae genitourinary infection: case report. Ann Acad Med Singapore. 2006;35: Stutz G, Kuster MS, Kleinstück F, Gächter A. Arthroscopic management of septic arthritis: stages of infection and results. Knee Surg Sports Traumatol Arthrosc. 2000;8: Vispo Seara JL, Barthel T, Schmitz H, Eulert J. Arthroscopic treatment of septic joints: prognostic factors. Arch Orthop Trauma Surg. 2002;122: Kirpalani PA, In Y, Choi NY, Koh HS, Kim JM, Han CW. Two-stage total knee arthroplasty for non-salvageable septic arthritis in diabetes mellitus patients. Acta Orthop Belg. 2005;71:

5 71 pissn : , eissn : Case Report J Korean Orthop Assoc 2019; 54: 제 2 형당뇨및골관절염을동반한환자에서발생한 Klebsiella pneumoniae 균에의한화농성관절염 하중원 이상현 박상훈 김태엽 * 국민건강보험일산병원정형외과, * 연세대학교의과대학정형외과학교실 Klebsiella pneumoniae 의감염은대부분원발성간농양을일으키며전이성병변으로폐렴, 뇌수막염, 요로감염등의간외합병증을수반한다. K. pneumoniae 감염의간외합병증으로화농성슬관절염이보고된예는드물며원발성간농양없이화농성슬관절염이보고된예는더욱드물다. 이에제2형당뇨병을가진슬관절골관절염환자에서원발성간농양없이발생한 K. pneumoniae 에의한화농성슬관절염을조기발견하고, 관절경적치료로호전된 1예를보고하고자한다. 색인단어 : 슬관절, 화농성관절염, Klebsiella pneumonia 접수일 2017 년 11 월 27 일수정일 2018 년 2 월 13 일게재확정일 2018 년 2 월 23 일책임저자박상훈 10444, 고양시일산동구일산로 100, 국민건강보험일산병원정형외과 TEL , FAX , orthomania@gmail.com, ORCID 대한정형외과학회지 : 제 54 권제 1 호 2019 Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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untitled Case Report J Korean Orthop Assoc 2012; 47: 64-68 http://dx.doi.org/10.4055/jkoa.2012.47.1.64 www.jkoa.org 슬관절골관절염환자에서발생한 Streptococcus sanguis 에의한화농성슬관절염 Septic Knee Arthritis Caused by Streptococcus