Septic ArthritisS. Shadmanfar .M.D

Rheumatologist

pathogens

• Bacterial

• Spirochetes• Fungi• viruses

Septic arthritis =Infectious Arthritis =Bacterial arthritis

Etiology (microbiology)

• Gram positive cocci (80%)– S. aureus

• Gram-negative bacilli (20%)

Bacterial arthritis

Gonoccocal

Non gonoccal

Pathogens • Young adult and adolescents:• N. gonorrhoeae ( most common )

• S. aureus accounts for most

nongonococcal isolates in adults of all ages

EPIDEMIOLOGY

• Incidence:– 40-68/100000/ yr in Prosthetic joint

– 28-38/ 100000/ yr in RA

– 5- 12/ 100000/ yr in Children

– 2-10/ 100000/ yr in General population

EPIDEMIOLOGY• Incidence: 2-10 cases per 100000 in

general population • Ages peak: younger than 5 years and

older 64 years• 1/3 were previously healthy children and

in contrast only 15% were previously healthy adult

Risk Factors• Old age (>80 Y)

• Rheumatoid arthritis• DM• Glucocorticoid therapy• Hemodialysis• Malignancy• TNF inhibitors• IV drug users

Acute bacterial infection

• Acute• Monarticular• Hematogenous• S.aureus• knee

Site of involvement

Site of involvement

• Mono (80-90%)• Knee: 55%• Ankle: 10%• Wrist: 9%• Shoulder: 7%• Hip: 5%• Elbow: 5%• SC: 5%- IV drug abuser• SI: 2%- IV drug abuser• Foot joints: 2%

• Poly (more than 1 joint): – RA

Clinical manifestation

• Mod-sever pain• Effuion• Erythem, swollen joint• Decreased range of motion• fever

Clinical manifestation

• Joint pain• Joint tenderness• Joint swelling• Joint stiffness• Joint warmth• Joint redness• Difficulty moving joint

The most important test

–Direct joint aspiration

• Should be performed in every caseof suspected infection as a

• Diagnostic or therapeutic maneuver

Arthroscopic drainage

Shoulder

Surgical drainage

• Hip

Lab tests• Leukocytosis with left shift• ESR• CRP• B/C + in 50-70% in S.aureus• Synovial fluid smear + in 75% in S.a• S/F culture + >90% in S.a

EXAMINATION OF JOINT FLUID• Measure Normal Inflammatory

Septic• Volume <3.5 >3.5 >3.5

• Clarity Transparent Trans-Opaque Opaque

• Color Clear Yellow Yellow-green

• Viscosity High Low Variable

• WBC/ml <200 2000-100000 >100000

• PMN <25% >50% >95%

• Culture Neg Neg Pos

• Smear Neg Neg Pos

Radiography

• Early:– Predisposing agent – Soft tissue swelling – Joint space widening

• Late (2-3 w):– Erosion – Joint space narrowing

Septic arthritis: early and late changes, hip (radiographs)

Right wrist destruction by Staphylococcus aureus

Treatment :nongonococcal

******Drainage of the pus******

******IV antibiotics are essential******

Treatment :nongonococcal

• B/C & synovial/C• Empirical antibiotic• Direct antibiotic into joint is not

necessary• Drainage of pus arthroscopic drainage for hip,

shoulder

treatment

• Immobilization?

do not require

except for pain control

GONOCOCCAL INFECTION

Gonoccocal arthritis

Epidemiology :

70% infectious arthritis in persons< 40Y

In united states

Gonoccocal arthritis

• DGI: disseminated gonococcal infection• Purulant arthritis

disseminated gonococcal infection (DGI)

• 1-3% N. gonorrhoeae• Women 3 times of men• Fever• Chills• Vesiculopustular skin lesion• Tenosynovitis• migratory polyarthritis

DGI

• S/F : 10,000-20,000 WBC• S/F culture: negative• B/C culture : <45% +• Culture should be obtained : mucosal sites

Gonorrhea: pustule

DGI• Immune reaction to circulating gonococci

• Immune complex deposition in tissues

Gonoccocal septic arthritis

• Monarticular knee ,ankle ,wrist• S/F culture positive• S/F >50000• B/C negative

treatment

Ceftriaxone + ciprofloxacin 7 days

Mycobacterial infection

• Musculoskeletal TB • 1% all TB• 10% extrapulmonary TB

Tuberculous Arthritis

Reactivation of a hematogenously seeded focus

Musculoskeletal TB

• Spine thoracic , lumbar• Peripheral joint hip

knee

wrist

• Bone osteomyelitis• Soft tissue

Tuberculous Arthritis

• Chronic monarthis• Large, weight –bearing hip, knee• Middle-age or older• Underlying disease• Onset insidious• Joint pain, swelling• Sign of inflammation limited

Tuberculous Arthritis

• Constitutional symptoms unusual• PPD test positive• CXR NL• XR erosion , narrowing, osteoporpsis

Tuberculous Arthritis

• Usually hips or knees• Insidious onset

Tuberculosis Of Hip

Tuberculous Arthritis

• S/F 20000 PMN• Synovial AFB Smear positive 20%• Synovial culture positive 80%• Synovial tissue culture “”’’’” 90%

Tuberculous Arthritis

• Diagnose

Best made by :

Histologic and microbiologic examination of synovium

Caseating or noncaseating granulomas

Tuberculous Arthritistreatment

Combination chemotherapy

INH , RIF, ETB, PZA

Viral arthritis

• acute self limited pattern

Respiratory virus ( Parvo virus B19 ) , Rubella

• Chronic infection

Hepatitis B,C- HIV

• Latent infection with potential reactivation

Herpes virus ( Varicell Zoster )

Viral Arthritis

• Parvovirus B19 ,Fifth’s disease in children• Mumps• Rubella and postvaccination( Arthralgia,

Lumbar radiculoneuropathy)

• Hepatitis (B,C)• HIV

Parvovirus B19Fifth’s disease in children

- children• “Slap cheek” appearance• Rare joint disease-

- Adult• Arthritis ( 10 days to 1 month)• Rare skin disease

Parvovirus arthritis

treatment

• Symptomatic• Chronic IVIG