pISSN 1598-298X / eISSN 2384-0749

J Vet Clin 36(2) : 126-128 (2019)

http://dx.doi.org/10.17555/jvc.2019.04.36.2.126

Ehrlichia Infection-Related Monoarthropathy in a Dog

Sun-Hong Min, Heung-Myong Woo and Byung-Jae Kang1
Department of Veterinary Surgery, College of Veterinary Medicine and Institute of Veterinary Science,
Kangwon National University, Chuncheon 24341, Korea

(Received: December 07, 2018 / Accepted: March 21, 2019)

Abstract : A 5-year-old male Labrador Retriever that lived outdoors was presented to the animal hospital with a right
hind limb lameness. The lameness had been present for more than 10 days, and there was a severe swelling of the
right stifle joint. The dog underwent physical, laboratory, and radiographic examinations. As a result, the dog was
diagnosed with infectious monoarthropathy secondary to granulocytic ehrlichiosis. The dog received medication for
the rickettsial arthritis and surgical treatment for reconstruction of the soft tissue damage caused by the infection. After
treatment, the function of the dog’s leg was recovered. This report describes a case of atypical monoarthropathy caused
by ehrlichiosis in a dog.
Key words : Ehrlichia spp., monoarthropathy, rickettsial arthritis, granulocytic ehrlichiosis.

Introduction
In Africa, North and South America, and Asia, dogs can be
infected with Ehrlichia spp. through tick bites (10). Ehrli-
chia spp. are gram-negative, obligate intracellular bacteria,
with a size of 0.5-1.5 µm. Clinical signs of canine ehrlichio-
sis are usually nonspecific, such as fever, petechiae, bleeding
disorders, vasculitis, lymphadenopathy, discharge from the
nose and eyes, and acute lameness involving multiple joints.
Non-regenerative anemia, thrombocytopenia, leukopenia, pancy-
topenia, hyperglobulinemia, and hypoalbuminemia can also be
observed (3). Ehrlichiosis can be divided into canine mono-
bearing lameness and mild atrophy of the right hind limb. On
orthopedic examination, the dog had a positive sign on the
cranial drawer and tibial compression tests in the right stifle
joint. A grade 2 right medial patellar luxation (MPL) was
also diagnosed. On radiographs, severe degenerative joint
disease with visible joint effusion, along with osteophytes
and enthesophytes on the patella, fabellae, distal femur, and
proximal tibia, were present (Fig 2). No significant changes
were observed on the blood chemistry analysis. On the com-
plete blood count, the white blood cell count was normal.
However, the total count and percentage of neutrophils in the
synovial fluid were elevated (198 × 10 /l and 95%, reference
9

cytic ehrlichiosis (CME) (9) and canine granulocytic ehrli- range < 2 × 10 /l and 0-6%). Further microscopic examina-
9

chiosis (CGE) (4), depending on the type of cells infected.
Infectious arthritis is not common, affecting 4-10 cases per
100,000 individuals annually in human medicine (6). Infec-
tious arthritis of dogs is also uncommon and is associated
with infection of the synovial fluid (7). Although infectious
arthritis is usually caused by bacteria, it can also be caused
by mycoplasmal, protozoal, rickettsial, and mycobacterial
organisms.
This report presents the diagnosis and treatment with med-
ication and surgery of infectious monoarthritis in a dog caused
by Ehrlichia spp.
tion of the synovial fluid revealed severe, chronic-active,
neutrophilic and lymphoplasmacytic synovitis. Antinuclear
antibodies (ANA) and canine rheumatoid factor (RF) tests
(Idexx Laboratories, Westbrook, Maine) were conducted to
evaluate for immune-mediated disease. Meloxicam (0.1 mg/
kg, q 24 h) and cephalexin (25 mg/kg, q 12 h) were adminis-
tered during the waiting period for the test results. The results

Case
A 5-year-old male Labrador Retriever that lived outdoors
was presented with a right hind limb lameness. The lame-
ness had been present for more than 10 days, and severe
swelling of the right stifle joint was observed on physical
examination (Fig 1). The dog displayed an intermittent weight-
Fig 1. Synovial fluid was aspirated from the right stifle joint for
fluid analysis (A). Intraoperative photograph of the right stifle
1 joint (B). The muscles around the joint and the joint capsule are
Corresponding author.
E-mail : bjkang@kangwon.ac.kr swollen due to the active inflammation.

126
 Ehrlichia Infection-Related Monoarthropathy in a Dog
Fig 2. Medio-lateral (A, B) and craniocaudal (C, D) radiographs
of the stifle joints on the first visit to the hospital. Severe degen-
erative joint disease is evident in the right stifle with joint effu-
sion and active periosteal reaction of the right distal femur,
proximal tibia, and patella.
of both tests were negative. Based on the laboratory results,
infectious arthritis of the right stifle joint was suspected. An
arthrotomy was then performed to lavage and debride the
joint. During the procedure, a sample of the synovial tissue
was obtained for aerobic culture and sensitivity. No growth
was observed after 2 days on the aerobic culture. Therefore,
real-time polymerase chain reaction (RT-PCR) tests were per-
formed to identify other sources of infection. On the RT-PCR
tests of the synovial fluid, only Ehrlichia spp. was positive.
Based on the results of all diagnostics, monoarthritis caused
by Ehrlichia spp. was suspected. Thus, doxycycline (5 mg/
kg, q 12 h) was administered for 3 months. After completing
the medication, the dog showed improved weight-bearing on
the right hind limb, and the amount of synovial fluid col-
lected by the arthrocentesis was decreased to less than 0.5
ml. Radiographs of right stifle joint also showed a reduction
of joint effusion through decreased radiopacity. In addition,
the total cell count in the synovial fluid had decreased to 6 ×
10 /l, and no etiologic agents were found.
9
However, the normal structure of the affected stifle joint
had been destroyed because of the soft tissue damage caused
by the infection. Therefore, the dog showed residual lame-
ness due to cranial cruciate ligament rupture (CCLR) and
MPL of the right stifle joint. For treatment, a tibial plateau
leveling osteotomy (TPLO) surgery for the CCLR with a 3.5
mm TPLO plate and soft tissue reconstruction surgery for the
127
Fig 3. Radiographs of the right stifle joint after tibial-plateau-
leveling osteotomy (A, B). Radiographs of the right stifle joint
2 months later, showing the lateral suture and tibial tuberosity
transposition performed for treatment of the patellar luxation
caused by internal rotation of the tibia (C, D).
MPL were performed (Fig 3). When the dog was rechecked
at the animal hospital 6 months later, there was no tibial
thrust. However, a grade 4 MPL of the right stifle joint was
present and was thought to be due to the internal displace-
ment of the tibia secondary to the CCLR. An additional sur-
gery (tibial tuberosity transposition and lateral suture for anti-
rotation of the tibia) was performed for treatment of the MPL
(Fig 3). The TPLO plate was also removed at the time of sur-
gery. On physical examination 2 months later, the dog’s right
hind limb musculature and range of motion were closer to
those of the normal limb. In addition, patellar luxation and
tibial thrust were not observed, and the gait pattern was
improved almost to the normal.
Discussion
Infectious arthritis can be affected by three mechanisms as
follows: (a) direct invasion by microbes, (b) immune-medi-
ated inflammation related to microbes, and (c) autoimmunity
related to microbes (9). In this case, infectious arthritis was
diagnosed based on cytology of the synovial fluid, since the
total cell count with infectious arthritis is typically 50-267 ×
10 /l, with 1-10% mononuclear cells and 90-100% neutro-
9
phils. However, systemic antibodies against Ehrlichia spp.
were not detected. On the other hand, Ehrlichia spp. were
found on the analysis of the synovial fluid; therefore, the
128 Sun-Hong Min, Heung-Myong Woo and Byung-Jae Kang
large amount of synovial fluid was suspected to be an inflam-
matory response to the infection. Based on laboratory results
and the dog’s environment, direct invasion by microbes was
the most likely route of infection. There was no evidence of a
direct infiltration of microbes through the skin of the stifle on
the physical examination; however, the dog was presented to
the animal hospital after a period of time since the onset of
the infection. It is estimated that the antibiotic treatment for
the causative agent alone was improved without the use of
immunosuppressive drugs, and this was caused by the direct
invasion of the causative agent. Broad antibiotic agent and
non-steroidal anti-inflammatory drug (NSAID) were prescribed
before the confirmation of tests. Medications can help
improve symptoms. However, due to the characteristic of the
disease, it will not be able to get treatment if causative agent
is not removed.
Most cases of arthritis caused by ehrlichiosis involve a
non-erosive polyarthritis, along with systemic disease, due to
CGE infection (potentially Anaplasma phagocytophilum or
E. ewingii) (5). On the other hand, the probability of lame-
ness occurring due to CME infection is 2.5-10% (11). Unfor-
tunately, in this case, only the Ehrlichia genus was identified,
and the specific species could not be determined.
In this case, the dog had only a monoarthropathy, without
systemic lesions, despite the 10-day long suspected length of
infection. It can be hypothesized that the pathogen was pres-
ent in the right stifle joint, causing inflammation in that area.
The precise mechanism of the tick-borne bacterial infection
within the joint could not be ascertained; nevertheless, we
demonstrated that monoarthropathy can be caused by Ehrli-
chia spp. infection. In addition, other infectious agents could
not be ruled out; however, infection related to Ehrlichia spp.
was supported by the positive response to treatment with
doxycycline. There are few case reports on infectious bacte-
rial monoarthritis caused by trauma (1,2). Unlike monoarthri-
tis caused by trauma, this case showed the similar symptoms
without suspicion of traumatic lesion. It has been reported
that infection by bacteria in the joints lasting 10 to 14 days
can exacerbate joint conditions and cause a poor prognosis
(12). In this case, the dog’s right stifle joint was left untreated
for at least 10 days after infection. On examination, the dog
showed severe arthritis, along with considerable soft tissue
damage. Due to the delayed treatment, the dog’s lameness
did not completely resolve after treatment of the arthritis
caused by the Ehrlichia spp. Therefore, rapid diagnosis and
treatment of arthritis caused by Ehrlichia infection is needed.
Conclusion
To the author’s knowledge, no cases of monoarthritis caused
by ehrlichiosis have been reported in dogs. This case demon-
strates that ehrlichiosis can cause monoarthritis without other
systemic signs. Therefore, although ehrlichiosis most com-
monly manifests systemic signs, it may also present with
localized lesions, such as monoarthropathy.
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