1 Introduction

Acute septic arthritis of the knee stands as an urgent orthopedic concern due to the potential for irreversible joint damage if left untreated.¹Clinical manifestations, including warmth, redness, swelling, and pain in the joints coupled with restricted movement, serve as indicators of septic arthritis. Vital laboratory assessments involving inflammatory markers in both serum and joint fluid aid in diagnosing this condition. Typically, the primary culprits behind septic arthritis are gram-positive bacteria like Staphylococcus aureus, Staphylococcus epidermidis, and streptococci.²

2 Case report

A 35-year-old female presented with acute onset and progressively worsening fever, swelling, and pain in her left knee. The patient had received traditional leech therapy for her knee pain.Her symptoms began on the third day of therapy, which lasted for six days. In addition to leech therapy, she was prescribed oral amoxicillin-clavulanic acid 625 mg thrice daily by the traditional healer. On arrival at the hospital, her vital signs were within the normal range. Physical examination revealed multiple deep punch marks over the medial aspect of the knee (Fig. 1), and the knee joint exhibited painful restriction of motion, increased local temperature, redness, swelling, and tenderness.

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Fig. 1 Multiple deep punch marks on medial side of knee as apart of leech therapy.

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Hematological evaluation revealed elevated total leukocyte count (TLC) 16000, erythrocyte sedimentation rate (ESR) 40, and C-reactive protein (CRP)80 levels. The patient had no comorbidities, was not on regular medications, and her serology tests for HIV, HBSAg, and HCV were negative. Diagnostic arthroscopy and debridement were performed, which showed findings consistent with synovitis. A 4 × 2 cm soft tissue mass attached to the underlying joint capsule was removed during the procedure (Figs. 2 and 3). Synovial fluid analysis indicated septic arthritis with turbid appearance, TLC over 78000 per mm3, and more than 95 % polymorphonuclear cells. Glucose level in the synovial fluid was 75 mg/dl, while random blood sugar was 145 mg/dl. Gram staining, aerobic and anaerobic culture reports of the synovial fluid were negative.

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Fig. 2 A 4 cm measuring isolated soft tissue mass removed from infected knee following leech therapy.

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Fig. 3 Cut section of soft tissue mas showing necrosis and hemorrhages.

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Empirical therapy with 1.5 g of cefuroxime, a systemic intravenous antibiotic, was initiated, leading to a significant improvement in the patient's clinical condition and a decline in CRP and TLC levels. The patient was discharged with a one-week course of intravenous antibiotics and a two-week course of oral cefuroxime. Regular follow-ups revealed complete resolution of the disease process after six months.

3 Discussion

Leech therapy, a traditional method for pain relief in South East Asian cultures, traces its origins back to ancient Egyptian civilization, where it was utilized for purging impure blood from the body. Concerns about its safety have arisen due to insufficient evidence, particularly regarding potential infections transmitted by living organisms, as leech sterilization isn't feasible.³

Limited studies have delved into the specific organisms linked to complications arising from leech therapy. This case study centers on a patient who developed culture-negative septic arthritis post-leech therapy. Diagnosis relied on clinical and lab findings as no particular organism was isolated from gram staining or synovial fluid culture. Research is needed to explore whether leech therapy might trigger proteinaceous or receptor-mediated synovial reactions resembling septic arthritis, given previous studies where no organisms were identified in leech therapy-induced synovitis or septic arthritis.

The use of leeches is associated with potential microbial infections, particularly with symbiotic Aeromonas species, ranging from minor wound complications to severe illnesses like meningitis, bacteremia, and sepsis, especially in immunocompromised individuals.^13,14 Medicinal leeches' gut microbiota contains various microorganisms, including Acinetobacter species, Vibrio fluvialis, and Aeromonas hydrophila, which can cause diverse infections, some potentially antibiotic-resistant.^15,16 To mitigate infection risks, healthcare practitioners advocating leech therapy often administer antibiotic prophylaxis before therapy.¹⁷

Septic arthritis of the knee is an orthopedic emergency due to its potential for permanent joint damage and mobility loss.¹² Pathogens can enter joints via hematogenous dissemination, direct injury, puncture wounds, or intra-articular injections, triggering an inflammatory cascade that harms joints through cytokines, proteases, and bacterial toxins.⁴

Diagnosis hinges primarily on clinical examination and synovial fluid analysis.⁵ In this case, synovial fluid analysis and hematological assessments, including total leukocyte count, CRP levels, and histopathological examination, confirmed septic arthritis. However, gram staining and synovial fluid cultures yielded negative results. Lyon et al. observed no significant difference in clinical and laboratory criteria between culture-negative and culture-positive septic arthritis groups.⁶

Clinical judgment plays a pivotal role in diagnosing septic arthritis.⁷ While Staphylococcus species are common pathogens, various microorganisms can cause septic arthritis, underscoring the importance of prompt diagnosis and treatment to avert significant complications.⁸

Challenges arise in antibiotic selection for atypical organisms and patients who received prior antibiotic therapy, as compromised gram staining and negative synovial fluid cultures can impede the process.⁹ Arthroscopic joint lavage, with a success rate of 91–98%, is recommended as a minimally invasive surgical procedure.¹⁰

For culture-negative septic arthritis, empirical therapy using first-line antibiotics is suggested, with efficacy dependent on local antibiotic concentrations. Cefuroxime, a second-generation cephalosporin with excellent tissue and synovial fluid penetration, is commonly chosen.¹¹

In summary, leech therapy-induced septic arthritis is a rare and notable complication. Maintaining a high suspicion level is crucial in the context of traditional invasive intra-articular procedures like leech therapy. Further investigation into antibiotic selection and duration for culture-negative septic arthritis is necessary, given the current gaps in medical understanding.³

4 Conclusion

Culture-negative septic arthritis following primitive leech therapy is a rare occurrence that requires a high index of clinical suspicion. Proper scientific interventions and public awareness can help reduce morbidity and complications associated with traditional intra-articular procedures like leech therapy.

Conflict of interest

None.

Funding/sponsorship

This research received no specific grant from any funding agencies in the public, commercial, or not-for-profit sectors. Institutional Ethical Committee Approval: Not applicable.

Informed consent (patient/guardian)

Detailed written informed consent was obtained for the publication of data, images, and treatment-related documents without any objection.

CRediT authorship contribution statement

M. Jyothiprasanth: First author, Played a substantial role being the chief surgeon and execution of surgical technique along with essential insights into the clinical implications of the case report. C.R. Jithin: Second author and corresponding author, Overseeing the, Conceptualization, case report design, and coordination among all authors, Primarily responsible for the manuscript's organization, review of literature, drafting, and critical revisions. Anita Vincent: Third author, Contributed to the manuscript's revision, plagarism correction and provided valuable inputs regarding the case's clinical aspects. Akhil K. Thomas: Fourth author, Participated in data collection, analysis, and contributed significantly to reference selection along with histhopathological discussions and language correction. P. Sarang: Fifth author, Contributed to the literature review, assisted in data interpretation, and played a pivotal role in the pharmacological aspect of this clinical scenario, All authors reviewed and approved the final version of the manuscript, acknowledging their accountability for the content's accuracy and integrity.