- Release of chondrolytic enzymes from neutrophils, synovial cells, and plasma, and ? intra-articular pressure with resulting ischemia rapidly destroys articular cartilage.
- Early Dx, appropriate ABx, and I&D when needed to reach a favorable outcome
- Five classes of diagnostic tests
- Molecular (most commonly used is PCR)
- ? osteomyelitis
- CRP ? as early as the 2nd day (septic arthritis + osteomyelitis) and normalizes later (osteomyelitis alone)
- WBC not useful to distinguish
- ESR normalizes earlier in osteomyelitis alone
- Be cognisant of delayed dx in: neonates, RA, IV drug users, immunosuppression, and deeply situated joints (hip, spine, SI joint)
- May present with unusual clinical findings such as plexopathies with an underlying and unrecognized septic arthritis
- Synovial fluid findings:
- WBC/mlCell TypeSynovial Fluid/BSSmear*C/S
- Bacterial10K->100K>90% PMNs<0.5 ? +
- Fungal3K-30K>70% PMNs0.5-1.0 ? +
- TB10K-20K50-70% PMNs<0.5 ? +
- Viral15-25K, to ? 160K>90% PMNs0.5-1.0--
- Gram stain for bacteria: KOH for fungi: Ziehl-Nielsen for TB
- ? uronic acid and neutral protease activity, even with early intervention
- Detection of bacterial antigen (counter-immunoelectrophoresis, ELISA), or bacterial metabolic end-products (gas chromatography)
- Radiologic evaluation
- Early changes: periarticular osteopenia, joint effusion, soft tissue swelling, joint space loss
- Advanced changes: periosteal reaction, marginal and central erosions, destruction of subchon-dral bone, subluxation or dislocation, intraarticular ankylosis, intraarticular gas or subcutaneous emphysema (common complication from injection by E coli, Serratia, Enterobacter liquefaciens, Clostridium perfringens
- AP under traction stress of hip joint in infant or child may show air or vacuum phenomenon in joint
- Used only in conjunction with joint aspiration (injection of contrast into joint to document needle placement)
- Relieves joint from pressure caused by accumulated fluid or pus
- Findings: destruction of articular cartilage, hypertrophic alterations of synovium, irregular or contracted joint capsule in chronic sepsis and adhesive capsulitis
- Extremely sensitive for detection of joint effusion
- Guidance for needle aspiration
- 99mTc-MDP bone scan reveals an uniform abnormal periarticular distribution, prominent activity on blood pool images on both sides of affected area
4th phase (delayed 24 hr imaging) in equivocal cases: diminution of activity (osteomyeli-tis shows ? activity localized to bone)
- Tc-HMPAO-labeled leukocytes: ? activity
- Gallium scan enhances and complements Tc-MDP scan to improve specificity
- Helpful in needle guidence for joint aspiration
- Findings: water-density fluid, irregularity and narrowing of joint, soft-tissue swelling, articular erosions, subchondral bone destruction, synovial thickening
- MRI findings
- Septic jointNonseptic inflamed joint
- Fluid heterogeneity21%27%
- Synovial thickening68%55%
- Cartilage loss53%30%
- Bone erosions79%38%
- Bone marrow edema74%38%
- Adjacent soft tissue edema78%63%
- T2-weighted images: distension of joint capsule by high signal intensity fluid; infected fluid and blood have intermediate signal intensity and appear inhomogeneous, hyperintensity in soft tissues around affected joints; surrounding bone marrow edema; articular cartilage destruction
- Predisposing conditions
- Bacteremia (S aureus, N gonorrhoeae, H influenzae)
- Contiguous infection (osteomyelitis, decubiti)
- Penetrating wound, joint surgery, intra-articular injection
- Extra-articular focus of infection
- Chronic arthritis, especially RA
- IV drug abuse, immunosuppressive Tx, chronic debilitating disease (malignancy, DM, EtOH)
- Dental procedures
- Group A ? hemolytic Streptococcus involving an IPJ reported
- Bacterial pathogens in different age groups
- <1mo: group B streptococcus, Gram-negative bacilli, S aureus
- <5yrs: S Aureus, H influenzae, Streptococci pyogenes
- Children >5yrs: S aureus, streptococci, H influenza
- Adolescents: S aureus, Neiseria gonorrheae
- Adults: N gonorrhoeae, S aureus, streptococci (including pneumococcus), gram-negative rods
- Fungal pathogens
- Cryptococcocis arthritis occurs mainly in immunocompromised pts
- Often associated with osteomyelitis or disseminated disease
- Latex agglutination test for cryptococcal antigen in body fluids
- Histology: epithelioid granulomas + multinucleated giant cells, lymphocytic infiltration, and inflammatory cells and necrotic areas
- Ag+3 methenamine stain
- Specific joints
- Hip (children)(2nd in incidence after knee in children)
- Duration of sxs (<4days) single best prognosticator in infancy/childhood
- Osteomyelitis and Staphylococcus aureus pathogen also poor prognostic factors
- ? ESR, high normal WBC
- Immediate joint aspiration indicated
- Synovial fluid 28-64K WBC/ml
- Gram stain (? to 40-136K <3yrs of age)
- + BC (?42%), + joint c/s (?82%), + tissue C/S (?91%)
- Consider Hemophilus infulenza between 4mos and 2yrs
- ?? to 0 incidence because of Hemophilus influenza type-b vaccine
- Joint space (tear drop distance) widening
- US can be diagnostic for intraarticular fluid
- Extension from a prevertebral abscess into the hip joint has been reported
- Complication: ischemic necrosis of the captial epiphysisHunka radiographic classification of sequelae of septic hip in children
- I: minimal femoral head collapse
- IIA: deformed femoral head, physis intact
- IIB: deformed femoral head, premature physeal closure
- III: pseudarthrosis of femoral neck
- IVA: complete epiphyseal destruction, intact neck seated in acetabulum
- IVB: complete epiphyseal destruction: neck not seated in acetabulum
- V: complete loss of femoral head and neck
- Rx: 2-4 wks IV ABxs
- Anterior (Smith-Petersen) approach
- Ddx Includes transient synovitis of the hip ("irritable hip")
- ? interferon levels suggests possible viral etiology
- ESR >20mm/hr (>40 in one report) and T >37.5?C identifies 97% of septic hips: WBC >12,000/cc and hx of non-wt bearing are suggestive findings
- Variables (fever, non-wt bearing, ESR ?40mm/hr, WBC >12,000/cc) for septic hip
- 0 variables0.2%
- 1 variable3.0%
- 2 variables40%
- 3 variables 93.1%
- 4 variables 99.6% (59% in a subsequent retrospective study)
- Hx of fever, WBC >12,000/cc, previous health-care visit during the present illness showed a 71% probability of septic arthritis in another study)
- Fever (PO temperature > 38.5?C then ? C-reactive protein (>2.0mg/dL a strong independent risk factor of septic arthritis) then ? ESR then refusal to bear weight, the ? in WBC count in order of effective tools in predicting septic arthritis over transient synovitis of the hip.
- + stool (? blood) culture(s) of Campylobacter jejuni has been reported suggesting a reactive arthropathy
- Nearly ½ have previous aspiration or injection
- Poor result is the rule and may be related to delay in dx
- Late sequelae of neonatal shoulder septic arthritis related to delay in dx: deformed humeral head and shortened humerus (cosmetic more than functional loss)
- Aspiration, IV ABxs early
- Arthrotomy usually required for late dx
- Almost all have other contributing disease
- Reported after mastectomy and XRT for breast carcinoma (think infection, not just metastatic disease)
- Sternoclavicular joint
- Predisposing factors include IV drug use, RA, liver disease, alcohol abuse, DM, renal failure, malignancy, steroid tx, other sites of infection, direct spread from subclavian central line
- May extend into the mediastinum (mediastinitis)
- SI joint
- Hip and buttock pain
- FABERE (flexion, abduction, external rotation, extension) test +
- Plain films negative
- Bone scan may be negative
- CT and MR will be +
- C/S of blood, joint aspirate, or stool (Salmonella enteritidis)
- Surgical debridement with advanced involvement or without improvement with IV ABx after 48hrs
- Facet joints
- Pyogenic arthritis reported after facet joint injection
- ± epidural abscess
- Untreated septic Baker's cyst may result in continued infection
- Ruptured Baker's cyst may be the 1st sign of septic arthritis
- Base antibiotic on results of C/S taken prior to empiric Abx
- IV route initially pending results
- Prolonged (2-4 wks) course. PO Rx may be acceptable depending on organism and extent of infection
- Duration of antimicrobial therapy
- Recommendations in literature variable
- N. gonorrhoeae: 1 wk unless slow response or bony involvement
- S. aureus, gram-negative rods: 4 wks
- H. influenza in children: 2 wks
- Penicillin-sensitive streptococci: 2 wks
- Specific agents
- N gonorrhoeae: Ceftriaxone
- S aureus: Oxacillin or nafcillin. MR: Vancomycin. PCN allergy: 1st generation cephalosporin or vancomycin, clindamycin
- H influenzae: Ampicillin-sensitive: Ampicillin. Ampicillin-resistant: 3rd-generation cephalosporin or Chloramphenicol
- Pneumococci: PCN-sensitive streptococci: PCN. PCN-allergic patient: 1st-generation cephalosporin, Vancomycin
- Gram-negative rods---if sensitive: Ampicillin or cephalosporin alone
- P aeruginosa: aminoglycoside + antipseudomal PCN. Others: Imipenem, Ciprofloxacin, Aztreonam)
- Bacteroides fragilis usually part of a mixed infection or in immunocompromised pts
- Nocardia (nocardiosis) in immunocompromised pts and reported from an olive tree thorn and a rooster claw in healthy pts
- Hematogenous dissemination from the lung in ~45%
- CNS involvement in 20-30% (mortality is 60%)
- Skin and subcutaneous involvement in 10%
- Eye involvement in 3%
- Empiric Rx while awaiting C/S, guided by clinical setting and synovial gram stain
- Gram stain (+ <65%, rarely in GC):
- Gram + cocci: oxacillin or nafcillin unless suspected enterococci (eg UTI), then ampicillin + gentamicin
- Hospitalized patient with intravenous line sepsis or IV drug abuser: vancomycin for possible methicillin-resistant staphylococci
- Gram - coccobacilli (child), suspected H. influenzae: 3rd-generation cephalosporin or chloramphenicol and ampicillin
- Gram-negative cocci (sexually active individual): PCN or ceftriaxone
- Gram-negative rods: aminoglycoside + extended spectrum PCN or cephalosporin
- Gram stain---no organisms seen:
- Child: 3rd-generation cephalosporin (or chloramphenicol) + oxacillin (or nafcillin)
- Adult with underlying immunosuppression: aminoglycoside + vancomycin or oxacillin or nafcillin
- Repeated needle aspiration of joint; frequency of aspiration dictated by rate of reaccumulation of synovial fluid
- Arthroscopic tx esp for knee, also for shoulder and ankle
- Girdlestone arthroplasty may be required when femoral head osteomyelitis is present
- Use of intra-articular antibiotic bead chains reported
- Indications for surgical drainage:
- Concurrent osteomyelitis with sequestrum or abscess
- Loculation or debri prevents adequate drainage by aspiration
- Poor clinical response
- Uncontrolled systemic sepsis secondary to the infected joint
- Passive ROM or assisted-active motion without weight-bearing
- Special Problems
- Gonococcal arthritis
- >70% of septic arthritis between 10-39 years of age
- Venereal infection is usually asymptomatic (Genito-urinary, anogenital, or pharyngeal)
- F>M; especially 1st wk of menstrual cycle, pregnancy, post-partum
- Recurrent episodes associated with complement (C7, C8) deficiency
- Clinical presentation indistinguishable from less common meningococcal arthritis
- Two phases, occur in sequence or individually
- Bacteremic - migratory polyarthritis (commonly wrists, small joints), tenosynovitis, rash
- Blood culture positive in <45%, synovial fluid C/S negative
- Septic arthritis - may follow but never precedes bacteremic phase; monarticular or oligoarticular; synovial fluid cultures + in <50%, blood C/S -
- Dx in pts with - blood and synovial fluid C/S supported by positive urethral, cervical, pharyn-geal or rectal C/S, or prompt response to Abx
- Prognosis good
- Polyarthritis associated with meningococcemia
- Brucellosis (undulant fever)
- Endemic in Saudia Arabia
- Brucella agglutination test
- Gram-negative coccobacilli (short rods)
- Septic hip > knee > foot > SI joint and others
- Fever (91%), animal contact or ingestion of unpasteurized milk, splenomegaly (46%), arthralgias (26%)
- Hip dislocation and osteonecrosis of the hip have been reported
- Spondylitis and spondylodiscitis
- Fever more common than in TB spondylitis
- M:F = 2.8:1 (occupational exposure)
- L>C spine (T rare) (spine most common bony site)
- ? psoas abscess
- Paravertebral abscess in 5%
- Radiculopathy in 21%
- Myelopathy in 10.5%
- Multiple foci of spinal involvement in 20%
- Brucella granuloma can cause extradural compression
- MRI with ? signal on T1-weighted images and ?d on T2-weighted images
- Brucella melitensis has been cultured from a phalanx, radiographically resembling "phalangeal microgeodic syndrome of childhood"
- Synovial schistosomiasis (bilnarziasis)
- Hip infection has been reported
- Caused by trematodes of genus Schistosoma
- 180-200,000,000 infected throughout the world
- 37% in Egypt infected (have a high index of suspicion)
- Septic arthitis in RA
- ? septic arthritis incidence may be due to
- Damaged joint
- ? chemotaxis
- ? PMN phagocytosis
- ? synovial bactericidal activity
- Ulcerated RA nocules or decubiti may be source of infection
- 80% S aureus; also streptococci, gram - rods
- Misleading clinical picture
- ? pain or swelling
- ? fever
- Absent leukocytosis
- Resembles underlying disease flare-up (except polyarticular infection not likely)
- Poor prognosis if Rx delayed (23% mortality, 34% poor local results)
- IV drug abuse infections (nonGC)
- Atypical presentation: progressive pain/swelling for weeks to months, ? fever, ? leukocytosis
- Affects predominantly fibrocartilaginous joints, ? associated osteomyelitis
- S aureus (? Methicillin resistance) most common
- Streptococci, esp. group A streptococci
- Gram - rods (Pseudomanas, Serratia, Klebsiella)
- Septic hip in paraplegics
- Vastus lateralis transposition
- External fixation X3-6 wks
- Chronic monarticular arthritis infectious causes
- Viral monarthritis
- Effusion, painless ROM
- Coxsackie-B triad: oral ulcerations, hepatitis, (monarthritis)
- Cocksackie-B antibody titers (B1-B5)
- Rubella, mumps best able to replicate intra-articularly
- Lyme arthritis
- Arthritis in 60-80% and chronic arthritis in 10% of pts; 8% have sacroiliitis
- Atraumatic spontaneous hemarthrosis has been reported
- Tick--borne disease (<30% report contact): Borrelia burgdorferi
- May-August in New England; January-May in Pacific northwest
- Synovial fluid: WBC 500-25,000 WBC/mm3, cryoglobulins, total protein 4.3-9 gm/dl, PCR analysis of the synovial fluid: silver stain of synovial tissue for spirochetes, ELISA test for antibodies to B burgdorferi
- ? ESR
- Skin: erythema migrans
- Tx-early: doxycycline 100mg BID PO X21 days; -late:2g ceftriaxone QD IV X14 days
- Sporotrichal arthritis
- Sporothrix: saprophytic fungus endemic in Missouri/Mississippi river valleys
- Many with myeloproliferative syndromes (megaloblastic anemia)
- Knee up to 60%, hand and wrist (24-52%) of pts with farm related jobs
- >¾ with significant EtOH intake
- ?¼ have skin nodules, indolent infection without infectious type findings (0-9% with fever)
- ? ESR
- Mean delay in dx 12 mos
- IV amphotericin, ? PO ketoconazole, ? PO itraconazole, intraarticular amphotericin B
- Synovectomy yields diagnostic tissue in >60%
- Arthrodesis if joint is destroyed
- Melioidotic septic arthritis
- Caused by (gram - bacillus) Burkholderia pseudomallei
- Found in NE Thailand and should be considered if the pt is indigenous or recently has travelled to SE Asia
- "Eosinophilic synovitis"
- Blood WBC averages 11,2000/mm3 with 6% eosinophils
- Synovial fluid WBC 1200-20,5000 with 60-90% eosinophils
- Responsive to diethylcarbamazine 100mg PO TID X3wks
- Occurs in an area where filariae infection is endemic (ie, India)
- Septic arthritis after procedures
- Following arthroscopy
- ? risk with steroid injection
- Following intrarticular viscosupplementation
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