Tularemia caused by Francisella tularensis is a zoonotic infection of the Northern Hemisphere that mainly affects the skin, lymph nodes, bloodstream, and lungs. Other manifestations of tularemia are very rare, especially those with musculoskeletal involvement. Presenting in 2016, we diagnosed two cases of periprosthetic knee joint infections (PJI) caused by Francisella tularensis in Europe (one in Switzerland and one in the Czech Republic). We found only two other PJI cases in the literature, another knee PJI diagnosed 1999 in Ontario, Canada, and one hip PJI in Illinois, USA, in 2017. Diagnosis was made in all cases by positive microbiological cultures after 3, 4, 7, and 12 days. All were successfully treated, two cases by exchange of the prosthesis, one with debridement and retention, and one with repeated aspiration of the synovial fluid only. Antibiotic treatment was given between 3 weeks and 12 months with either ciprofloxacin-rifampin or with doxycycline alone or doxycycline in combination with gentamicin. Zoonotic infections should be considered in periprosthetic infections in particular in culture-negative PJIs with a positive histology or highly elevated leukocyte levels in synovial aspiration. Here, we recommend prolonging cultivation time up to 14 days, performing specific PCR tests, and/or conducting epidemiologically appropriate serological tests for zoonotic infections, including that for F. tularensis.

Department of Infectious Diseases České Budějovice Hospital České Budějovice Czech Republic

Department of Orthopaedics Balgrist University Hospital University of Zurich Zurich Switzerland

Department of Orthopedic Surgery České Budějovice Hospital České Budějovice Czech Republic

Division of Infectious Diseases and Hospital Epidemiology University Hospital Zurich University of Zurich Zurich Switzerland

Faculty of Health and Social Sciences University of South Bohemia České Budějovice Czech Republic

Institute of Medical Microbiology University of Zurich Zurich Switzerland

Institute of Pathology University Hospital Zurich University of Zurich Zurich Switzerland

Tropical and Infectious Diseases Unit Royal Liverpool University Hospital Liverpool United Kingdom

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