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Georges El Hasbani1, Ali Jawad2, Imad Uthman3

Author Affiliations: 

1Research Assistant, Division of Rheumatology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; 2Consultant Rheumatologist, Department of Rheumatology, The Royal London Hospital, London, UK; 3Consultant Rheumatologist, Division of Rheumatology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon

Correspondence to: 

Imad Uthman, Division of Rheumatology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon


Journal Issue: 
Volume 50: Issue 1: 2020
Cite paper as: 
J R Coll Physicians Edinb 2020; 50: 58–9



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Hijama (cupping) is a traditional procedure that involves using special cups to alleviate pain.1 It is not approved for the treatment of any medical condition.2 As the relationship between the therapy and septic arthritis has not been addressed clearly in the literature, we present a case of septic arthritis of the knee induced by Hijama therapy.

A 46-year-old male, previously healthy, presented to the clinic in Beirut, Lebanon, with a 2-week history of acute left knee pain and swelling. The patient reported that he underwent Hijama therapy 1 week prior to the onset of symptoms. There was no other past history of note.

Physical examination revealed a large effusion of the left knee (Figure 1). A total of 10 ml of cloudy fluid was aspirated from the knee. The fluid revealed a white blood cell count of 40,473 cells/µl with 95% neutrophils. The culture grew Staphylococcus aureus sensitive to methicillin. A diagnosis of septic arthritis post Hijama therapy was made, and the patient was started on intravenous antibiotics.

Septic arthritis refers to an infection in a joint due to a bacterial, viral or fungal organism. The most common organism identified in septic arthritis in adults is S. aureus, responsible for around 37–56% of cases.3

There has been a growing body of evidence suggesting that Hijama therapy predisposes to a variety of bloodborne infections, including hepatitis C. A meta-analysis by El-Ghitany et al.4 concluded that Hijama is a significant risk factor for transmission of hepatitis C infection. Since Hijama contributes to the transmission of hepatitis C infection in Saudi Arabia, proper infection control practice has been emphasised in wet-cupping therapy settings.5 Herpes simplex virus infection of the skin has been reported to occur secondary to cupping therapy.6

In our patient, there was no obvious preceding infection. The patient presented with a swollen and tender knee 1 week after receiving wet-cupping therapy. Infections originating from the skin lesions could pass through the bloodstream into other sites, such as the joint, leading to septic arthritis.

Our paper emphasises that potential serious complications could follow cupping therapy, especially the blood-letting type. Fever and a swollen joint following a cupping session should raise suspicion for septic arthritis. Wet-cupping practitioners should practice under aseptic conditions.

Figure 1 Swollen left knee with skin lacerations on the thigh and the knee 3 weeks after wet-cupping therapy


1 Sajid MI. Hijama therapy (wet cupping) – its potential use to complement British healthcare in practice, understanding, evidence and regulation. Complement Ther Clin Pract 2016; 23: 9–13.

2 Brinkhaus B, Dobos GJ. The crisis of medicine and the benefits of complex pain therapy procedures such as cupping: more research needed. Complement Med Res 2019; 26: 145–7.

3 Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol 2008; 20: 457–62.

4 El-Ghitany EM, Wahab MMA, El-Wahab EWA et al. A comprehensive hepatitis C virus risk factors meta-analysis (1989–2013); do they differ in Egypt? Liver Int 2015; 35: 489–501.

5 Madani TA. Hepatitis C virus infections reported in Saudi Arabia over 11 years of surveillance. Ann Saudi Med 2007; 27: 191–4.

6 Jang EJ, Lee dong-youn, Jung L et al. The Koebner phenomenon in erythema multiforme after getting acupuncture and cupping glass therapy. Korean J Dermatol 2011; 49: 809–11.


Financial and Competing Interests: 
No conflict of interests declared