Septic Arthritis

By:
Pawan KB Agrawal,
Resident MDGP, Year II, IOM,
30th December 2014, Tuesday.
 OUTLINE

• Introduction
• Pathophysiology
• Clinical features
• Diagnosis
• Differentials
• Treatment
• Complications
• Prognosis
• References
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 INTRODUCTION

• Infection of joint space.

• often bacterial but could be
fungal or viral.
• rheumatologic emergency as
joint destruction occurs rapidly
and can lead to significant
morbidity and mortality.

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 INTRODUCTION

• Prevalence:range from 8 to 27
%
• a 2007 systematic review that
included a total of 6242
patients with acutely painful
joints showed 653 (10 percent)
had septic arthritis1.

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 INTRODUCTION

Predisposing factors:
Elderly >60 years
Diabetes mellitus
Rheumatoid arthritis
Prosthetic joint
Recent joint surgery
Skin infection, cutaneous ulcers
IV drug abuse, alcoholism
Previous intra-articular injection
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 PATHOPHYSIOLOGY

• S aureus is the most common

cause of septic arthritis in all age
groups. Among those aged 15-
50 years, N gonorrhea runs a
close second, especially among
those who are sexually active.

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 PATHOPHYSIOLOGY

• In the elderly, the

immunocompromised and in
those patients who have had
intravascular devices or urinary
catheters inserted, infection with
a Gram-negative enteric bacillus
is more common.

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 PATHOPHYSIOLOGY

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 PATHOPHYSIOLOGY

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 CLINICAL FEATURES

Usually present with a single

painful swollen joint.
Low grade fever, local rise in
temperature & impaired range of
motion.
The knee is involved in more
than 50 % of cases followed by
hip, shoulder, elbow, ankle &
wrist 2.

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 CLINICAL FEATURES

20 % of septic joint infections

are polyarticular3.

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 CLINICAL FEATURES
Joint affected Attitude
1.Knee Flexion
2. Hip Flexion, abduction
& internal rotation.
3. Shoulder Adduction &
internal rotation.
4. Elbow Flexion & mid
pronation
5. Wrist Flexion
6. Ankle
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Planter flexion
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 DIAGNOSIS

Arthrocentesis
usually purulent with
increased count (50,000 to
150,000 cells/mm3)
The synovial fluid glucose is
often depressed and lactic acid
concentration is elevated.

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 DIAGNOSIS

Arthrocentesis
usually purulent with
increased count (50,000 to
150,000 cells/mm3)
The synovial fluid glucose is
often depressed and lactic acid
concentration is elevated.
Synovial fluid culture

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 DIAGNOSIS

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 DIAGNOSIS

X-ray:
The earliest findings are soft
tissue swelling around the
joint and a widened joint
space from joint effusion.
Displacement of adjacent fat
pads may be present,
especially in infants and
children.

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 DIAGNOSIS

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 DIAGNOSIS

Later, joint-space narrowing

could be found as articular
cartilage is destroyed. Loss
of visualization of the white
cortical line over large areas
of the joint surface soon
ensues as bone destruction
begins to develop.

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 DIAGNOSIS

Blood cultures are positive in

about 50 percent of cases.
Elevations of CRP are usually
present, though the sensitivity
of the ESR test in patients with
septic arthritis is inconsistent 4,5.

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 DIAGNOSIS

Computed tomography (CT), or

magnetic resonance imaging
(MRI) are far more sensitive
than plain films in early septic
arthritis.
MRI:
Synovial enhancement and
the presence of a joint effusion
& perisynovial soft tissue
edema.
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 DIAGNOSIS

Radionuclide bone scans:

technetium-99m
methyldiphosphonate
increase in isotope
accumulation in areas of
osteoblasts and increased
vascularity

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 DIFFERENTIALS

Gout
Pseudogout
Transient synovitis
Rheumatoid arthritis
Viral arthritis
Lyme disease

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 TREATMENT

Principle:
Antibiotics
Joint drainage &
Joint rest.

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 TREATMENT

General support: analgesics,

antipyretics and joint splintage
for first few days.
Definitive care:
IV antibiotics for initial 1-2
wks followed by oral
antibiotics for 3-4 wks.

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 TREATMENT

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 TREATMENT

Concurrent systemic corticosteroids

are also supposed to shorten
duration of illness with less residual
joint damage and dysfunction7.

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 TREATMENT

Joint drainage: needle

aspiration or open.
Older children with early
septic arthritis can often be
treated by repeated closed
aspiration ; however, if there
is no improvement within 48
hours, open drainage is
necessary.

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 TREATMENT

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 TREATMENT

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 TREATMENT

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 TREATMENT

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 TREATMENT

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 FOLLOW UP

• Once general condition is satisfactory

and the joint is no longer painful or
warm, further damage is unlikely.
• If articular cartilage has been
preserved, gentle and gradually
increase active movements.
• If articular cartilage has been
destroyed the aim is splinting to keep
the joint immobile while ankylosis is
awaited.
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 FOLLOW UP

• If deformity is present,
subsequent osteotomy should
be planned to correct it.

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 COMPLICATIONS

Partial or complete destruction

of epiphysis.
Retarded growth
Ankylosis
Osteomyelitis
Sepsis

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 PROGNOSIS

Poor outcome predictors:

Age older than 60 years
Infection of hip or shoulder
Underlying RA
Persistent positive findings.
Delay in therapy.

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 PROGNOSIS

Irreversible loss of joint function

in 25-50%
Mortality ranges from 5-15%6.

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 TOM SMITH ARTHRITIS

Septic arthritis of hip in infancy

Results in complete destruction
of cartilaginous femoral head.
Presentation is a child in his
preschool age with painless limp
Affected limb is shorter
X-ray shows complete absence
of head and neck of femur.

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 REFERENCES
1. Margaretten ME, Kohlwes J, Moore D,
Bent S. Does this adult patient have
septic arthritis? JAMA 2007; 297:1478.
2. Goldenberg DL. Septic arthritis and other
infections of rheumatologic significance.
Rheum Dis Clin North Am 1991; 17:149.
3. Dubost JJ, Fis I, Denis P, et al.
Polyarticular septic arthritis. Medicine
(Baltimore) 1993; 72:296.
4. Ernst AA, Weiss SJ, Tracy LA, Weiss NR.
Usefulness of CRP and ESR in predicting
septic joints. South Med J 2010;
103:522.
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 REFERENCES
5. Hariharan P, Kabrhel C. Sensitivity of
erythrocyte sedimentation rate and C-
reactive protein for the exclusion of
septic arthritis in emergency department
patients. J Emerg Med 2011; 40:428.
6. Kaandorp CJ, Krijnen P, Moens HJ, et al.
The outcome of bacterial arthritis: a
prospective community-based study.
Arthritis Rheum 1997; 40:884.
7. Sharff, K. A. (2013). Clinical
Management of Septic Arthritis. Curr
Rheumatol Rep .

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• THANK YOU …

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