8. septic arthritis 30th dec 14

Septic Arthritis

By:Pawan KB Agrawal,

Resident MDGP, Year II, IOM,30th December 2014, Tuesday.

Pawan KB Agrawal 2

OUTLINE

• Introduction• Pathophysiology• Clinical features• Diagnosis• Differentials• Treatment• Complications• Prognosis• References30-Dec-14

Pawan KB Agrawal 3

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.

30-Dec-14

Pawan KB Agrawal 4

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.

30-Dec-14

Pawan KB Agrawal 5

INTRODUCTION

Predisposing factors:Elderly >60 yearsDiabetes mellitusRheumatoid arthritisProsthetic jointRecent joint surgerySkin infection, cutaneous ulcersIV drug abuse, alcoholismPrevious intra-articular injection

30-Dec-14

Pawan KB Agrawal 6

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.

30-Dec-14

Pawan KB Agrawal 7

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.

30-Dec-14

Pawan KB Agrawal 8

PATHOPHYSIOLOGY

30-Dec-14

Pawan KB Agrawal 9

PATHOPHYSIOLOGY

30-Dec-14

Pawan KB Agrawal 10

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.

30-Dec-14

Pawan KB Agrawal 11

CLINICAL FEATURES

20 % of septic joint infections are polyarticular3.

30-Dec-14

Pawan KB Agrawal 12

CLINICAL FEATURESJoint affected Attitude

1.Knee Flexion2. Hip Flexion, abduction

& internal rotation.3. Shoulder Adduction &

internal rotation.4. Elbow Flexion & mid

pronation5. Wrist Flexion6. Ankle Planter flexion30-Dec-14

Pawan KB Agrawal 13

DIAGNOSIS

Arthrocentesisusually purulent with

increased count (50,000 to 150,000 cells/mm3)

The synovial fluid glucose is often depressed and lactic acid concentration is elevated.

30-Dec-14

Pawan KB Agrawal 14

DIAGNOSIS

Arthrocentesisusually 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

30-Dec-14

Pawan KB Agrawal 15

DIAGNOSIS

30-Dec-14

Pawan KB Agrawal 16

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.

30-Dec-14

Pawan KB Agrawal 17

DIAGNOSIS

30-Dec-14

Pawan KB Agrawal 18

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.

30-Dec-14

Pawan KB Agrawal 19

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.

30-Dec-14

Pawan KB Agrawal 20

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.

30-Dec-14

Pawan KB Agrawal 21

DIAGNOSIS

Radionuclide bone scans:technetium-99m

methyldiphosphonate increase in isotope

accumulation in areas of osteoblasts and increased vascularity

30-Dec-14

Pawan KB Agrawal 22

DIFFERENTIALS

GoutPseudogoutTransient synovitisRheumatoid arthritisViral arthritisLyme disease

30-Dec-14

Pawan KB Agrawal 23

TREATMENT

Principle:AntibioticsJoint drainage &Joint rest.

30-Dec-14

Pawan KB Agrawal 24

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.

30-Dec-14

Pawan KB Agrawal 25

TREATMENT

30-Dec-14

Pawan KB Agrawal 26

TREATMENT

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

30-Dec-14

Pawan KB Agrawal 27

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.

30-Dec-14

Pawan KB Agrawal 28

TREATMENT

30-Dec-14

Pawan KB Agrawal 29

TREATMENT

30-Dec-14

Pawan KB Agrawal 30

TREATMENT

30-Dec-14

Pawan KB Agrawal 31

TREATMENT

30-Dec-14

Pawan KB Agrawal 32

TREATMENT

30-Dec-14

Pawan KB Agrawal 33

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.

30-Dec-14

Pawan KB Agrawal 34

FOLLOW UP

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

30-Dec-14

Pawan KB Agrawal 35

COMPLICATIONS

Partial or complete destruction of epiphysis.

Retarded growthAnkylosisOsteomyelitis Sepsis

30-Dec-14

Pawan KB Agrawal 36

PROGNOSIS

Poor outcome predictors:Age older than 60 yearsInfection of hip or shoulderUnderlying RAPersistent positive findings.Delay in therapy.

30-Dec-14

Pawan KB Agrawal 37

PROGNOSIS

Irreversible loss of joint function in 25-50%

Mortality ranges from 5-15%6.

30-Dec-14

Pawan KB Agrawal 38

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 limpAffected limb is shorterX-ray shows complete absence

of head and neck of femur.

30-Dec-14

Pawan KB Agrawal 39

REFERENCES1. 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.

30-Dec-14

Pawan KB Agrawal 40

REFERENCES5. 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 .

30-Dec-14

Pawan KB Agrawal 41

• THANK YOU …

30-Dec-14