SEPTIC ARTHRITIS

ESSENTIAL OF DIAGNOSIS

Joint paint
Limitation of motion
Joint swelling, effusion, warmth, and tenderness
Pus and organisms in aspirate of synovial fluid

General Considerations

Septic arthritis is an inflammatory joint disease caused by bacteria or

fungi. Primary infection is caused by direct inoculation of the joint by trauma,
including surgery. Secondary infection occurs hematogenously or by
extension from adjacent osteomyelitis. Septic arthritis characteristically
involves a single joint. This disease must always be considered in the
differential diagnosis of monarticular arthritis.

Occasionally, septic arthritis will develop in a joint already involved by

another from of arthritis. This possibility must be considered whenever an
arthritic joint flares or an arthritic patient becomes systemically ill. Septic
arthritis is more common in children and debilitated elderly individuals
except when gonococci are the cause.

Septic arthritis destroys articular cartilage. The initial reaction to joint

infection is acute synovitis, with effusion that develops an increasing
concentration of PMNs. The fluid tends to coagulate, producing loculations
within the joint cavity. Inflammatory cells infiltrate the synovium, and the
overlying tissues become edematous. With continuing infection, the cartilage
matrix is destroyed, collagen is lost, and chondrocytes are killed. The
damaged cartilage is susceptible to mechanical trauma and is eroded at
points of loading. Continued infection may destroy synovial and capsular
components as well as cartilage and bone. Spread to adjacent bone produces
osteomyelitis. Following successful treatment of early infections, there may

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be no permanent sequelae, but extensive tissue destruction rarely resolves
completely. Fibrous or complete bone ankylosis may result, as well as painful
postinfectious degenerative arthritis.

Gonococci are probably the commonest cause of septic arthritis at

present, at least in sexually active individuals, and must be considered
whenever a seemingly sterile pyarthrosis is encountered. Staphylococcus
aureus is by far the next most common pathogen. Septic joints in children 6
months to 2 years of age are often due to Haemophilus influenzae. Gram-
negative bacilli have recently become a more frequent cause of septic joints,
especially in adults with chronic debilitating illness. How ever, almost every
bacterial pathogen has been reported to cause septic arthritis, and the
clinical presentation is not helpful for determining the causative organism.

Clinical Findings

A. Symptoms And Signs

In acute hematogenous arthritis, the larger joints (knee, hip, elbow,

shoulder, and ankle) are more commonly involved. Infections of other
organ systems (skin, respiratory tract, genitourinary tract, etc) are
possible sources of blood-borne infections. Although infections in adults
usually involve only one joint, multiple joint involvement occurs
occasionally in children. Any joint may be involved secondarily by spread
of a nearby acute or chronic infection. Systemic disease or another
serious infection may divert attention from the infected joint. Systemic
symptoms usually include fever, chills, and malaise-and, occasionally,
misleading migratory polyarthralgia. Pain is progressive and accentuated
by joint motion. Local tenderness and warmth are accompanied by soft
tissue swelling, and an effusion is palpable if the joint is superficial.

B. Laboratory Findings

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 Examination of joint fluid is crucial. By the time infection is clinically
apparent, the fluid is usually turbid or purulent. The white cell count is
often over 50.000/L, with more than 90% PMNs. Synovial fluid glucose is
decreased, usually to 50 mg/dL below a simultaneously obtained blood
glucose level. Gram-stained smears and cultures are essential. The stain
will often dictate the choice of first antibiotic pending sensitivity
confirmation. Pyarthrosis without visible organisms on a Gram-stained
smear is usually gonococcal in origin. Culture specimens for this fastidious
organism must be conveyed promptly to the bacteriology laboratory for
proper plating on a selective medium and incubation in 5% carbon
dioxide. The erythrocyte sedimentation rate is almost always elevated,
and the white count may be. Blood cultures are sometimes positive even
when organisms are not recovered from joint fluid.

C. Imaging Studies

The appearance of significant x-ray findings depends upon the duration

and virulence of infection. X-ray changes lag behind the clinical and
pathologic process. During the first 2 weeks, the joint capsule may appear
distended, the overlying soft tissues swollen, and fat planes obscured. In
infants especially, increased intra-articular pressure from effusion may
cause widening of the radiologic joint space, with possible progression
to pathologic dislocation. Comparative x-rays of the opposite normal joint
can aid in identification of subtle changes. With persistent hyperemia and
disuse, demineralization of subchondral bone occurs and extends
proximal and distal to the joint. Trabecular detail is progressively lost, and
the compact subchondral bone appears accentuated. Destruction of
cartilage is reflected by narrowing of the width of the joint space until
subchondral bone is in apposition, a finding accentuated by x-rays taken
during weightbearing.

Complications

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 Complications consist of joint destruction, osteomyelitis, and direct or
hematogenous spread to other sites. The risk of complication is increased by
delayed diagnosis.

Differential Diagnosis

Acute pyogenic arthritis must be differentiated from other acute

arthropathies (reactive arthritis, systemic lupus erythematosus, rheumatoid
arthritis, gout, pseudogout, neurogenic arthropathy, etc). Hematogenous
osteomyelitis (especially of the proximal femur), rheumatic fever, and
epiphysial trauma may mimic acute septic arthritis in childhood. Lyme
disease must also be considered.

Acute pyogenic arthritis may complicate almost any type of preexisting

joint disease, especially rheumatoid arthritis and neuropathic arthropaty.
Concomitant or recent treatment with locally injected or systemic
corticosteroids may both predispose to infection and interfere with diagnosis.
Polyarthralgia occurs in systemic viral infections and allergic reactions, but
the other features of septic arthritis are lacking. Acute infections or
inflammations of periarticular structures (eg, septic bursitis and
tenosynovitis, osteomyelitis, cellulitis, and acute calcific tendinitis) may be
especially difficult to differentiate. Aspiration, examination, and culture of
joint fluid are essential to establish or rule out infection of a joint.
Occasionally, synovial biopsy is helpful in diagnosing obscure cases of
synovitis.

Treatment

A. General Measures

Analgesics and splinting of involved joint in the position of maximal

comfort alleviate pain. Other foci of infection and any coexisting medical
conditions must be identified and treated appropriately. Fluid replacement
and nutritional support may be required.

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B. Spesific Measures

Definitive treatment requires drainage of the pyarthrosis and prompt

institution of effective antibiotic therapy. The technique of drainage
depends upon the joint involved, the stage of infection, and the response
of the patient. Although many infected joints can be drained satisfactorily
with repeated needle aspiration, the hip and perhaps other joints that are
difficult to aspirate-will require arthrotomy as soon as possible after
identification of joint sepsis. Other identifications for surgical drainage of
septic arthritis are inability to aspirate loculated pus, lake of prompt
response to nonoperative management, long-standing infection, and joint
infections after surgery or penetrating wounds.

Parenteral antibiotics are indicated for septic arthritis. If

organisms are not seen on Gram-stained smears and the patient is a
previously healthy adult, gonococcal arthritis is an appropriate working
diagnosis, and penicillin should be started as outlined below. Children
under 4 years of age have a significant incidence of H influenzae arthritis.
Preliminary antibiotic treatment in this age group must be effective
against this organism, which also may be difficult to see on Gram-stained
smears. In adults with negative results on Gram-stained smears and a
suspected cause of infection other than gonococci, treatment should be
started with a cephalosporin or a beta-lactamase-resistant penicillin and
an aminoglycoside.

When organisms are seen, initial antibiotic therapy should be

based on the finding. Culture results and clinical response must
subsequently be used to ensure an appropriate antibiotic regimen.
Parenteral antibiotics are continued at high doses until inflammation
resolves significantly. Ten to 14 days of treatment is usually required. An
additional 3-4 weeks of oral antibiotic therapy is often advised after
parenteral treatment. Briefer treatment usually suffices for gonococcal

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 arthritis. Intravenous penicillin G, 10 million units/24 h, should be
continued until significant improvement is achieved. While the response is
often prompt, several days of treatment may be required. Once local signs
resolve, the antibiotic can be changed to oral ampicillin, 500 mg four
times daily, to complete a 7-day course.

Prognosis

Satisfactory results are achieved in 70% or more of patients with septic

arthritis if early diagnosis and treatment are provided. Joint destruction-
especially of the hip in infants-and joint stiffness in the elderly are the
commonest causes of failure. Deaths are rare.