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Infecciones Infecciones osteoarticularesosteoarticulares
Sandra Milena Acevedo RuedaMD Residente 2do año, Medicina Interna UNABNoviembre de 2012
Artritis sépticaArtritis séptica
• 2-10/100.000
• Artritis reumatoide: 28-38/100.000
• Mortalidad: 1-7%
• Morbilidad: 50%
• Artroscopias: 0.14%
• Factores predisponentes (20% no identificables)
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Estudio de cohorte, pacientes con artritis aguda: edad mayor a 80 años, diabetes
mellitus y artritis reumatoide fueron asociados con incremento en la incidencia de artritis séptica (likelihood ratios: 3.5, 2.7, y 2.5,
respectivamente)
Kaandorp CJ, van Schaardenburg D, Krijnen P, et al. Risk factorsfor septic arthritis in patients with joint disease. A prospectivestudy. Arthritis Rheum. 1995;38:1819-1825.
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
• Mordeduras – Gatos– Perros– Humanos– Ratas
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
• Monoarticular 80-90%
• Rodilla 50%
• Poliarticular: AR, DM, inmunosupresión
• Cuadro típico: dolor, limitación (1 a 2 sem)
• Fiebre: 47% (S: 57%)
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
• Cultivo (80-90%)
• Gram (50%)
• Hemocultivos (50-70%)
• Rx, Ecografía
• Gammagrafía, TAC, RMN
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
DXCO ASPECTOCOÁGULO
DE FIBRINACOÁGULO
DE MUCINALEUC POR
mm3 PMN (%)GLUCOSA (%
DEL NIVEL DE LA
SANGRE)
Normal Transparente Negativo Bueno < 200 < 25 < 100
Osteoartros Ligeramente turbio
Pequeño Bueno < 2 000 < 25 < 100
Artritis traumática Sanguinolento
Pequeño Bueno 2 000 < 25 < 100
Artritis reumatoideArtritis reumatoide
Turbio Grande Regular a pobre
5 000 a50 000
> 65 75
Gota aguda Turbio Grande Regular a pobre
5 000 a50 000
> 75 90
Artritis séptica
Purulento Grande Pobre 50 000 a200 000
> 80 < 50
Artritis tuberculosa
Turbio Grande Pobre < 25 000 Variable < 50
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Diagnostic Parameters of Synovial Fluid White BloodDiagnostic Parameters of Synovial Fluid White BloodCell Count and Percent Polymorphonuclear Cells inCell Count and Percent Polymorphonuclear Cells in
Patients with Septic ArthritisPatients with Septic Arthritis
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Gonococcal infection. Pustular lesion overlying the fifth toe in a patient with disseminated gonococcal infection.
Enfermedad gonocóccica diseminada– Artritis gonocóccica– Dermatitis, tenosinovitis, poliartralgias
Artritis gonocóccica:
Mujeres, 1970’s, disminución en 75%
Gram 25%, cultivos 30%
Sx Reiter
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
En artritis gonocóccica: 7-10 días
Otros: 2 a 4 semanas
Anaerobios: Mordeduras
Corticoides sistémicos
Virus
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Chronic arthritis of the knee due to Chronic arthritis of the knee due to Mycobacterium Mycobacterium tuberculosis.tuberculosis.
OsteomielitisOsteomielitis
EPIFISIS
PLACACRECIMIENTO
METÁFISIS
CAPSULA ARTICULAR
VASOEPIFISIARIO
ARTERIANUTRICIA
CAPSULA ARTICULAR
ARTERIA
METAFISIARIA
ARTERIA
NUTRICIA
PERIOSTIO
CORTEZADIÁFISIS
METÁFISIS
LAGOSVENOSOS
EPIFISIS
PLACA EPIFISIARIA
Inflamación del hueso producida por un agente infeccioso. Puede
permanecer localizada o extenderse por el hueso para afectar medula,
cortical, periostio o los tejidos blandos circundantes.
Campbell, Cirugia ortopédica. Terry Canale, et all. 11ª edición. 2007. Mosby
Lew y WaldvogelLew y Waldvogel
• Duración - Aguda - Crónica
• Fuente de infección - Hematógena- Contigua- En presencia de insuf. vascular
Osteomyelitis in Long Bones, JBJS, J Bone Joint Surg Am. 2004;86:2305-2318. Lazzarini, Mader, Calhoun
Vías de infección
Osteomielitis hematógena
Luego de Bacteriemia.
Más frecuente en niños
y ancianos
Afecta a metáfisis de
huesos largos y vértebras.
También por uso de
catéteres y uso de drogas
e.v.
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Vías de infección
Osteomielitis por foco contiguo
• Luego de fractura abierta ó de cirugía. Asociada a protésis.
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Vías de infección
Osteomielitis por
insuficiencia
vascular
En diabéticos e insuficientes
Vasculares
Afecta principalmente el pie
Curso crónico e insidioso.
Suele no haber dolor.
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Osteomyelitis in Long Bones, JBJS, J Bone Joint Surg Am. 2004;86:2305-2318. Lazzarini, Mader, Calhoun
Cyerny y MaderCyerny y Mader
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Cyerny y MaderCyerny y Mader
Osteomyelitis in Long Bones, JBJS, J Bone Joint Surg Am. 2004;86:2305-2318. Lazzarini, Mader, Calhoun
Cyerny y MaderCyerny y Mader
Signos clínicosSignos clínicos
• Dolor
• Edema
• Fistula
• Febricula o fiebre
• Exudado
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Estudios Estudios
• Rx AP, lat y oblicuas (10 a 14 días)
• Fistulografía
• Gammagrafía (Galio, Tec99, Indio 111)
• Tomografía
• CH, VSG, Proteínas, Tiempos, Uroanálisis, cultivo, antibiograma, hemocultivos, cultivo de fragmento óseo, estudio histopatológico
Contrary to common belief, swab cultures from draining wounds and sinus tracts can be of diagnostic benefit for two
main reasons. First, the identification of certain resistant microorganisms (e.g., methicillin-resistant S. aureus,
vancomycin-resistant enterococcus) indicates the need for infection control measures. Second, the isolation of S. aureus from superficial cultures has a high degree of
correlation with deep cultures
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
T2-weighted axial MR image of the left tibia reveals abnormality of the midportion and proximal portion of the tibia (arrows). During surgery, there was a significant amount of purulence and osteomyelitic bone present. Cultures grew Pseudomona aeruginosa.
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
CT reconstruction image of a nonunited femur fracture6 months after intramedullary nailing. Surgical cultures grewPseudomonas aeruginosa and Propionibacterium acnes.
Principios quirúrgicos en Osteomielitis
• Adecuado drenaje de los tejidos afectados• Desbridamiento • Remoción material• Manejo del espacio muerto• Cierre completo de la herida• Estabilización fractura
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Secuestro: son fragmentos de hueso muerto, y
actúan como un cuerpo extraño dentro de la
lesión.
Involucro: Son capas de hueso nuevo
en crecimiento, se forman alrededor del hueso
existente, y pueden alterar la cicatrización.
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Angiogram of lower extremity reveals
occludedbypass graft in a patient
with diabetes mellitus presenting with
chronic gangrene and osteomyelitis of the foot.
Angiogram of lower extremity reveals
occludedbypass graft in a patient
with diabetes mellitus presenting with
chronic gangrene and osteomyelitis of the foot.
Osteomielitis aguda
• Niños (2 años)
• Metafisis
• Hematógena
• Infección – reacción inflamatoria – necrosis isquémica de la médula – necrosis del hueso - absceso
Osteomyelitis in Long Bones, JBJS, J Bone Joint Surg Am. 2004;86:2305-2318. Lazzarini, Mader, Calhoun
Fuentes
• Foco primario :
- Dentales- Vías urinarias- Respiratorias- Otras
Osteomyelitis in Long Bones, JBJS, J Bone Joint Surg Am. 2004;86:2305-2318. Lazzarini, Mader, Calhoun
• A: INFANCIA
• B: LACTANTE
• C: ADULTO
• A: INFANCIA
• B: LACTANTE
• C: ADULTO
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Antimicrobial Therapy of Antimicrobial Therapy of Osteomyelitis in Adults forOsteomyelitis in Adults forSelected MicroorganismsSelected Microorganisms
Key wrote: “continuous drug over a longperiod of time will lessen the amount of
discharge, but it will not curethe disease because it cannot sterilize dead bone or cavities with necrotic content and
rigid walls.”
Osteomyelitis in Long Bones, JBJS, J Bone Joint Surg Am. 2004;86:2305-2318. Lazzarini, Mader, Calhoun
MANDELL, DOUGLAS, AND BENNETT’S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES. Seventh Edition. Copyright © 2010
Indicaciones Cirugía:
Abscesos óseos subperiosticos ó tejido blandoBacteriemia persistente post a 48-72 de ttoDolor, edema ó fiebre post a 72 de ttoDesarrollo de fistulas Presencia de secuestros óseos