Septic Arthritis Secondary to Acupuncture in an Immunocompromised Patient With Multiple Comorbid Conditions

Introduction

Acupuncture is a growing trend in alternative medicine [1]. According to the National Institutes of Health, 6.4% of US adults have reported using acupuncture, often to manage pain, anxiety, or other nonemergency health conditions [2]. Although the widespread use of acupuncture is generally considered safe when administered by licensed professionals, its growing use in different clinical populations – most notably those with complex medical and immunocompromised conditions – warrants further scrutiny and focus on the safety of this practice. Most acupuncture-related adverse effects are considered nonserious and include symptoms such as bruising; mild, localized pain; or slight bleeding [3]. Although rare, serious acupuncture-related adverse events can occur and are classified as syncope, organ or tissue injury, systemic reactions, or – most commonly – infection [4]. In cases with serious adverse effects, the joints and back were the most frequent locations for acupuncture needle penetration [3].

Several guidelines exist recommending the use of acupuncture for relieving chemotherapy-induced symptoms such as fatigue, nausea, peripheral neuropathy, and anxiety. However, during 2022 and 2023, an expert panel produced an updated set of guidelines for acupuncture use for oncology patients and provided specific recommendations against the use of acupuncture in cases of profound immunosuppression [5]. A detailed list of “red and amber flags” intended for both physicians and acupuncture practitioners highlighted the importance of recognizing febrile and infective symptoms after acupuncture in patients actively receiving immunosuppressive cancer treatments [5]. Such symptoms should warrant urgent medical review due to the patients’ susceptibility to significant acupuncture-related adverse effects.

Acupuncture-related infection can result from the use of unsterilized needles, repeated use of needles, needlepoint contact with clothing, or lack of skin cleansing before needle insertion [6]. Microorganisms carried into the body by direct inoculation from the acupuncture needle during percutaneous insertion may then be able to spread away from the acupuncture site by means of hematogenous transmission [6]. Staphylococcus aureus is the most common microorganism identified in acupuncture-related infections; Streptococcus, Mycobacterium, and other gram-negative bacteria have also been identified [3].

Staphylococcus epidermidis is a common cause of infection in immunocompromised patients. S. epidermidis naturally resides on the surface of human skin, where it is harmless; however, if it enters the bloodstream, such as through prosthetic or indwelling devices, it can become pathogenic [7]. The presentation of S. epidermidis infection varies but often includes fever, hypotension, and other signs of sepsis [7]. S. epidermidis infections are particularly concerning in immunocompromised patients because the bacteria tend to form biofilms, which impede the natural immune response and effectiveness of antibiotics [8]. Because S. epidermidis is naturally present in the human microbiome, differentiating between infection and contamination can be challenging, often leading to misdiagnosis and subsequent treatment failure [8]. Here, we describe the case of a 69-year-old immunosuppressed man with multiple comorbid conditions who had acute-on-chronic left shoulder pain after undergoing acupuncture treatment.

Case Report

A 69-year-old man was evaluated at our Emergency Department for acute-on-chronic left shoulder pain. The pain had persisted for several months after a fall but had considerably worsened over the past 2 weeks. At the time of the evaluation, he was undergoing immunosuppressive therapy for relapsed multiple myeloma, which had developed 14 years after a stem cell transplant. His current treatment regimen included teclistamab, initiated 12 days earlier and last administered 5 days prior, along with dexamethasone during chemotherapy weeks. He had a history of chemotherapy-induced cardiomyopathy diagnosed 8 months prior, with an ejection fraction of 40%, managed with metoprolol and sacubitril/valsartan.

One year earlier, he had methicillin-resistant S. epidermidis bacteremia, which was successfully treated with a 2-month course of intravenous (i.v.) and oral antibiotics. He also reported chronic back pain after kyphoplasty performed 1 year prior, which had been managed with long-term oxycodone/acetaminophen (7.5 mg every 8 h) and ongoing outpatient care at a chronic pain clinic. His additional medical history included hypertension, chronic kidney disease, pancytopenia, heart failure with reduced ejection fraction, bilateral rotator cuff tears, and a spinal fracture complicated by osteomyelitis requiring surgical intervention.

Approximately 1 month before admission, he had begun physical therapy and acupuncture to address his chronic left shoulder pain. Despite these interventions, his shoulder pain had worsened acutely, prompting his Emergency Department visit. Due to his immunocompromised status, he was taking prophylactic trimethoprim-sulfamethoxazole and acyclovir for infection prevention at baseline. He was ultimately admitted and treated for septic arthritis accompanied by fluid collection.

Physical examination findings showed a diffusely enlarged left shoulder with no overt skin changes (Figure 1). He had normal mentation and affect and was otherwise without acute symptoms. On admission, his blood pressure was 137/94 mmHg; pulse, 91 bpm; oral temperature, 36.9°C; respiratory rate, 20 breaths per minute; Spo2 98%; body mass index, 26.1; and pain, 10 of 10. Laboratory values were as follows: hemoglobin, 13.0 g/dL (reference range, 13.2–16.6 g/dL); mean corpuscular volume, 102 fL (reference range, 80–100 fL); platelet count, 100×103/μL (reference range, 135–317×103/μL); and white blood cell count, 5.7×103/μL (reference range, 3.4–9.6×103/μL), with a left shift. Results of a basic metabolic panel were unremarkable. He had an elevated erythrocyte sedimentation rate of 106 mm/h and a C-reactive protein level of 238 mg/L.

On admission, diagnostic magnetic resonance imaging (MRI) of the left shoulder revealed a large collection of fluid in the bursa (Figure 2). Blood culture results were negative for bacterial infection. An orthopedic surgeon was consulted, and shoulder aspiration was performed. The fluid sample had a total white blood cell count of 91 560 cells/μL and an absolute neutrophil count of 85 150 cells/μL, suggesting an infectious cause. He was treated with i.v. ceftazidime (1 g every 8 h) and variable doses of i.v. vancomycin, with a goal trough level of 10 to 20 μg/mL. Implementing ceftazidime and vancomycin allows for broad-spectrum antibiotic coverage, consistent with the elevated concentration of neutrophils. Ceftazidime targets gram-negative bacteria, whereas vancomycin targets gram-positive bacteria [9]. Targeting both gram-positive and gram-negative bacteria offers comprehensive antibiotic coverage for bacteria that are associated with septic arthritis [9].

The next day, he was taken to the operating room for irrigation and debridement of the left shoulder. A longitudinal incision was made over the deltopectoral interval, and synovial fluid samples were collected for laboratory cultures. A large amount of pus was expressed from the left shoulder joint. In addition, tissue was collected from the rotator interval and subacromial bursa. After samples were collected, irrigation was performed, and hemostasis was achieved. Vancomycin powder was placed into the wound intraoperatively, and the wound was closed.

One day later, Infectious Disease specialists were consulted, and they recommended the addition of metronidazole (500 mg by mouth 3 times per day) to the antibiotic regimen. Metronidazole’s action against anaerobic bacteria makes it an attractive supplementary therapeutic [10]. Fluids in the bursa of the left shoulder likely provided a hypoxic environment that certain bacteria thrive in. Without a confirmed bacterial isolate, prescribing metronidazole contributes to a larger spectrum of antibiotic coverage focused on the primary site of inflammation. Infectious Disease specialists also recommended the continued use of vancomycin. Vancomycin trough levels and kidney function were monitored daily and used to guide dosage adjustments.

Bacterial cultures from the patient’s synovial fluid grew S. epidermidis with antibiotic susceptibilities (Table 1). Consistent with the existing literature, the S. epidermidis isolate demonstrated multidrug resistance [7]. The suspected source of the patient’s septic arthritis and osteomyelitis was the acupuncture treatment that he received in the previous month, which preceded the acute onset of his exacerbated symptoms.

The patient was initially hospitalized for 8 days and was discharged home to complete a 6-week course of antibiotics. His final antibiotic regimen included i.v. vancomycin with dosing based on a trough goal of 10 to 20 mg/L, ceftazidime (1 g 3 times per day), and metronidazole (500 mg orally 3 times per day). Throughout his hospital stay, the vancomycin trough level remained at goal levels. At discharge, he was instructed to obtain a complete blood count with a basic metabolic panel, along with a kidney function panel and vancomycin trough level test twice weekly during the course of i.v. antibiotic therapy.

The patient’s antibiotic regimen at discharge was based upon the susceptibility of the S. epidermidis isolate to vancomycin, a result consistent with a study of 183 S. epidermidis samples that all revealed vancomycin susceptibility and multidrug resistance [7]. However, our patient’s course was complicated by the necessity of hospital readmission approximately 2 weeks later for vancomycin-related acute kidney injury after his outpatient laboratory results revealed worsening kidney function and elevated vancomycin trough levels. The Infectious Disease team recommended stopping vancomycin and monitoring daily vancomycin trough levels. Furthermore, they advised transitioning to a 6-week course of oral doxycycline once the vancomycin trough level reached less than 20 μg/mL. The patient showed slow improvement in vancomycin trough levels and kidney function while maintaining appropriate urine output. He was given i.v. fluids, and nephrotoxic agents (eg, sacubitril-valsartan) were withheld due to his acute kidney dysfunction.

Repeat transthoracic echocardiography approximately 1 month after the initial visit to the Emergency Department showed that his ejection fraction had decreased from 40% to 27% in just over 8 months. He began to show clinical features suggestive of heart failure exacerbation and fluid overload, including dyspnea on exertion, increased left pleural effusion, and pedal edema secondary to treatment for acute kidney injury with i.v. fluids. Excess fluid retention as a byproduct of ill-functioning kidneys contributes to volume overload of the heart and is exacerbated by i.v. fluid treatment [11]. Surplus fluid volume reduces heart contractility and expansion by overstretching the heart chambers past their optimal capacity. Additionally, surrounding fluid accumulation – as demonstrated by pulmonary effusion and pedal edema – exerts excess pressure on the heart, further restricting its ability to expand effectively. In this case, the patient’s reduced ejection fraction was secondary to i.v. fluid treatment after acute kidney injury, which had compromised fluid regulation. After an initial attempt at diuresis with i.v. furosemide resulted in worsened kidney function, the decision was made to proceed with therapeutic thoracentesis of left pleural effusion on day 5 of readmission. He was instructed to return to the heart failure clinic after discharge to discuss resuming sacubitril-valsartan. His creatinine level at discharge was 1.9 mg/dL (reference range, 0.7–1.3 mg/dL).

Discussion

Our patient’s septic arthritis secondary to acupuncture therapy highlights the importance of vigilance regarding alternative medicine practices and their potential for serious complications, including acute kidney injury, heart failure, and fluid volume overload, especially in people with compromised immune systems. Evidence is limited, if any, of septic arthritis secondary to acupuncture therapy for immunosuppressed transplant recipients. However, several cases of infectious complications attributed to acupuncture therapy have been previously described.

In a retrospective observational study, Kim et al [3] evaluated 1174 patients with infectious complications associated with acupuncture at the Emergency Department of a tertiary hospital in Korea between 2010 and 2014. Of these patients, 48 had certain causality, with cellulitis being the most common, followed by necrotizing fasciitis and osteomyelitis. Of those 48 patients, 9 were identified as having serious outcomes, such as septic shock, intensive care unit admission, or permanent sequelae due to infection with either methicillin-sensitive or methicillin-resistant S. aureus, Streptococcus agalactiae, Klebsiella pneumoniae, Escherichia coli, or nontuberculous Mycobacterium (unspecified).

Robinson et al [12] described a case of a 67-year-old man with neck cellulitis after receiving acupuncture for cervical spondylosis. MRI showed atlantoaxial septic arthritis without signs of infection of the tissues between the superficial cellulitic area and the atlantoaxial joint. Thus, the direct extension of infection was improbable. More likely, the infection had spread hematogenously, resulting in the seeding of the atlantoaxial joint. The proximity of the arthritis to the acupuncture site appeared to be coincidental, as the patient also had positive blood culture results for methicillin-sensitive S. aureus. Vancomycin was administered i.v. until S. aureus sensitivities were identified, at which point i.v. cephazolin was added and administered via a peripherally inserted central catheter at a dosage of 6 g per 24 h for a duration of 6 weeks. After the 6-week period, the patient was deemed clinically well based on a white blood cell count of 7800 cells/mL (reference range, 4500–11 000 cells/μL) and a C-reactive protein level of 10 mg/L. Similarly, Yang et al [13] reported methicillin-resistant S. aureus–induced discitis resulting from acupuncture, emphasizing the dangers of hematogenous spread from localized infections in such contexts.

In another case study, Tseng et al [14] described a 61-year-old man with infectious sacroiliitis, a rare form of septic arthritis, that developed 3 days after he underwent acupuncture over the right buttock region for the treatment of lower back pain. MRI showed an inflamed area over the right iliac bone and the right portion of the sacrum, prompting physicians to begin administering i.v. cefazolin at a rate of 1 g every 8 h. On the third day of admission, blood culture results showed methicillin-sensitive S. aureus to be the cause of the infection. The i.v. cefazolin was stopped and replaced by i.v. oxacillin administered at a dosage of 2 g per 4 h for 14 days. The patient was then placed on oral ciprofloxacin and rifampicin for the next 14 days and achieved full remission.

In 2 separate cases [15,16], patients were reported to have implanted instrumentation causing infection after acupuncture. Callan et al [15] described a 15-year-old girl who underwent acupuncture after spinal fusion and required serial irrigation and debridement with implant removal, resulting in a Pseudomonas and aerobic diphtheroids infection. This case is an example of infection caused by the contamination of existing instrumentation due to acupuncture. Kruse et al [16] reported Mycobacterium goodii–related septic arthritis in an adult with a prosthetic knee who received acupuncture therapy. This case furthers the notion of instrument-related infection secondary to acupuncture at or near the site of device implantation.

Finally, Liu et al [17] reported a case of a 50-year-old woman with progressive pain in the left side of her neck, shoulder, and upper chest after acupuncture. Computed tomography revealed septic arthritis over the left sternoclavicular joint, and methicillin-sensitive S. aureus bacteremia was detected. The patient was successfully treated with an undisclosed i.v. antibiotic regimen.

In a previous study of 183 S. epidermidis tissue isolates, all were susceptible to vancomycin [7]. However, in 111 of 183 isolates, the minimum inhibitory concentration of vancomycin was greater than 2 mg/L, which increased the risk of nephrotoxicity in these patients. Our patient required treatment with vancomycin, which ultimately led to nephrotoxicity and acute kidney injury.

Our case underscores the intricate challenges in managing complex clinical scenarios, particularly for immunocompromised patients with multiple comorbid conditions. Effective management strategies were implemented through a multidisciplinary collaboration involving an Orthopedic surgeon, Infectious Disease specialists, and Internal Medicine physicians. Prompt diagnosis, appropriate antibiotic therapy, and surgical intervention were vital for addressing the infection and mitigating its sequelae.

This case was a unique manifestation of acupuncture-related septic arthritis in an immunocompromised patient, adding to the growing body of evidence regarding the potential risks associated with such therapies. Ensuring timely intervention and optimal patient outcomes requires awareness among health care professionals, which can be achieved through history taking and considering alternative medicine practices in the differential diagnosis.

Care management for patients who undergo acupuncture relies on both the health care professional and the patient. Minimizing the gap between sterility guidelines and clinical implementation should be the top priority [3]. Practitioners can reduce the prevalence of procedure-related adverse events by implementing common sterility practices, including sterilizing needles between puncture sites or using single-use, stainless steel needles to prevent site contamination [2]. Patients must also be cognizant of the inherent risk of acupuncture: even when sterility guidelines are implemented, the risk of adverse events still exists [3]. Patients should seek qualified and experienced practitioners and notify their physician of any health changes after an acupuncture procedure in a timely manner to minimize potentially harmful manifestations [2,3].

Conclusions

Our patient’s septic arthritis secondary to acupuncture therapy highlights the risks associated with alternative medicine practices as potential sources of serious infections in immunocompromised patients. It also underscores the importance of fostering interdisciplinary collaboration and promoting evidence-based practices in managing the care of patients with diverse medical histories and treatments. Continued vigilance, research, and dissemination of findings are essential to enhancing our understanding of the risks associated with alternative medicine modalities, particularly for vulnerable patient populations.