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Septic Arthritis

  • Diagnosis
  • 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
  • Serologic
  • Radiographic/scintographic
  • Histologic
  • Culture
  • 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
  • Normal60-600mononuclear0.8-1.0--
  • 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
  • Radiographs
  • 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
  • Arthrography
  • 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
  • US
  • Extremely sensitive for detection of joint effusion
  • Guidance for needle aspiration
  • Scintigraphy
  • 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
  • CT
  • 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
  • Effusion79%82%
  • 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
  • Shoulder
  • 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
  • Knee
  • Untreated septic Baker's cyst may result in continued infection
  • Ruptured Baker's cyst may be the 1st sign of septic arthritis
  • Treatment
  • Base antibiotic on results of C/S taken prior to empiric Abx
  • Bactericidal
  • 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:
  • Neonates:
  • Child: 3rd-generation cephalosporin (or chloramphenicol) + oxacillin (or nafcillin)
  • Adult with underlying immunosuppression: aminoglycoside + vancomycin or oxacillin or nafcillin
  • I&D
  • 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:
  • Hip
  • 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
  • Immunosupressants
  • 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
  • Organisms
  • S aureus (? Methicillin resistance) most common
  • Streptococci, esp. group A streptococci
  • Gram - rods (Pseudomanas, Serratia, Klebsiella)
  • Septic hip in paraplegics
  • Girdlestone
  • 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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