SEPTIC ARTHRITIS

Definition

Epidemiology

Risk Factors

Non-gonococcal bacterial
arthritis

By: Irene Fornoles

Infectious arthritis is a form of

joint inflammation caused by a
germ. The germ can be a
bacterium, a virus or a fungus.
infection of the joints usually
occurs after a previous infection
elsewhere in the body.
There is usually only one joint
involved, though sometimes two
or three joints can become
infected. Mostly, infectious
arthritis affects the large joints
(shoulders, hips, knees), but
smaller joints (fingers, ankles) can
also be involved.
2-10 cases per 100,000 in the
general population
30-70 cases per 100,000 in
patients with immunological
disorders or deficiencies, and joint
replacements
Gonococcal: women 3x > men,
<40 y/o,
menses,
pregnancy
Medications that suppress
immune system
Intravenous drug abuse
Past joint injury, disease, surgery
Diabetes Mellitus
Rheumatic diseases
Malignancy
Immune deficiency disorders

RISK:
1. rheumatoid arthritis ( secondary
to S. aureus )
2. Diabetes mellitus
3. glucocorticoid therapy
4. hemodialysis
5. malignancy
6. Tumor necrosis factor inhibitors
(etanercept and infliximab)

Pathogenesis

HEMATOGENEOUS

Etiologic Agent

Bacteria enter the joint from the

bloodstream (hematogeneous);
from a contiguous site of infection
in bone or soft tissue;
by direct inoculation during
surgery, injection, animal or
human bite, or trauma.

Most common route in all age groups

1. Bacteria escape from synovial
capillaries, which have no limiting
basement membrane, and within
hours provoke neutrophilic
infiltration of the synovium.
2. Neutrophils and bacteria enter the
joint space; later, bacteria adhere
to articular cartilage.
3. Degradation of cartilage begins
within 48 h as a result of
increased intraarticular pressure,
release of proteases and cytokines
from chondrocytes and synovial
macrophages, and invasion of the
cartilage by bacteria and
inflammatory cells.
Infants:
- Group B streptococci
- G(-) enteric bacilli
- S. aureus
Children less than 5y.o:
- S. aureus
- Streptococcus pyogenes (Group A
streptococcus)
- Kingella kingae
Young adult & Adolescents:
- N. gonorrheae
Adult of All Ages:
- S. aureus
Older Adults:
- G(-) bacilli
- -hemolytic streptococci
Post-surgery:

S. aureus

Other G(+) bacteria and

G(-) bacilli

Coagulase (-) staphylococci

are unusual

Except
after
implantation
of
prosthetic
joints or arthroscopy
Anaerobic
organisms,
often
in
association with aerobic or facultative
bacteria

Human
bites
(Eikenella
corrodens or other oral flora)

Decubitus
ulcer
or
intraabdominal abscesses spread
into adjacent joints
Bites and scratches from cats and other
animals:

Pasteurella multocida

By: Waldemar Zenas Mandolang

Harrisons 18th Edition
0
HISTORY
Severe pain of rapid onset in a red, swollen joint suggests acute septic
arthritis.
Fever, chills, warmth, redness are seen in septic arthritis.
NONGONOCCOCAL BACTERIAL
ARTHRITIS
Monoarticular
Most commonly affected: KNEE
Inoculation or a bite: small joints
of the hands and feet
IV Drug users: infections of the
spine, sacroiliac joints, and
sternoclavicular joints.
RA patients: Polyarticular
infection
Pain : MODERATE to SEVERE
around the joint
Extremely painful, red, warm and
swollen joints.
Inflamed, Swollen joint
Effusion
Muscle Spasm
Decreased range of motion
Fever (102 to 103 F)
Malaise
Anorexia
Less commonly, Chills

GONOCCOCAL ARTHRITIS
Monoarticular
Migratory arthritis and
tenosynovitis
Fever
Chills
Rash
Articular symptoms
Small papules progress to
hemorrhagic pustules.
Dermatitis-Arthritis syndrome
-- bacteremia, fever, polyarthralgia,
tenosynovitis (usually of the hands and
fingers), and multiple maculopapular,
vesicular, pustular, or necrotic skin
lesions.
-- Rash
-- Asymmetrical arthritis
Septic Arthritis
-- affecting one or a few joints or frank
polyarthritis.

MAE RAZEL R. ACQUIOBEN

MED 2 - SECTION A

Septic Arthritis (SA)

Diagnosis
SYNOVIAL FLUID ANALYSIS

Value/Finding

Normal:

<180cells /microliter
Predominantly mononuclear

Acute bacterial infections:

100,000/microliter
(25,000-250,000/microliter)

Crystal-induced, rheumatoid, and

other noninfectious inflammatory
arthritides

<30,00050,000 cells/L

Mycobacterial and fungal infections

10,00030,000/L
5070% neutrophils and the remainder
lymphocytes

DEFINITIVE DIAGNOSIS of infectious

process:

Nongonococcal Bacterial Arthritis

SYNOVIAL FLUID ANALYSIS
Turbid, serosanguinous, or frankly
purulent
Gram stained smears: large
number of neutrophils
Total protein and lactate
dehydrogenase*: elevated
Glucose*: Depressed
Crystals: gout/pseudogout
resembles SA clinically (both
occasionally occur together)
Synovial smears: S aureus,
streptococci
( 30-50% gram (-) and other
bacteria)
Culture: positive >90% of the
cases

Stained smears of synovial fluid

Culture of blood and synovial fluid
Nucleic acid amplification (NAA)based assays and immunologic
techniques (detect microbial nucleic
acids
Gonococcal Bacterial Arthritis
Synovial fluid analysis
consistently (-)
BLOOD CULTURES: (+) in <45%
Synovial fluid difficult to obtain
(contain only 10,000-20,000
leukocytes/microliter)
Culture: specimen obtained from
potentially infected mucosal sites
CLINICAL DIAGNOSIS OF DGI
(Disseminated Gonococcal
Infection) if cultures are negative
A dramatic alleviation of
symptoms within 1224 h after
the initiation of appropriate
antibiotic therapy
True Gonococcal Septic
Arthritis
Synovial fluid, which contains

>50,000 leukocytes/L, can

be obtained with ease
the gonococcus is only
occasionally evident in gramstained smears, and
cultures of synovial fluid are
positive in <40% of cases
RADIOGRAPH (and others
Plain radiographs
soft tissue swelling
joint space widening
displacement of tissue planes by
the distended capsule.
Narrowing of the joint space and
bony erosions
indicate advanced infection and
a poor prognosis
Ultrasound: for detecting effusions
in the hip
CT or MRI: demonstrate infections of
the sacroiliac joint, the
sternoclavicular joint, and the spine
very well

By Jhennifer Dianne Borillo

From Harrisons Internal Medicine 18th ed