Name
ARTHRITIS, INFECTIOUS, BACTERIAL
DESCRIPTION
DETAIL
CAUSES β’ Hematogenous invasion by microorganisms (80-90%) β’ Contiguous spread (10-15%) from adjacent osteomyelitis in children β’ Direct penetration of micro-organisms secondary to trauma or joint injection -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS β’ Gout β’ Pseudogout (calcium pyrophosphate deposition disease) β’ Spondyloarthropathy (Reiter syndrome, psoriatic arthritis, ankylosing spondylitis, the arthritis of inflammatory bowel disease) β’ Juvenile rheumatoid arthritis β’ Type IIa hyperlipoproteinemia β’ Foreign body synovitis β’ Rheumatoid arthritis β’ Rheumatic fever β’ AIDS β’ Cellulitis β’ Palindromic rheumatism β’ Neuropathic arthropathy β’ Lyme arthritis β’ Sarcoidosis β’ Granulomatous arthritisOTHER TESTS : * ASPIRATION OF THE SYNOVIAL FLUID FROM THE INVOLVED JOINT FOR MICROSCOPIC & BIOCHEMICAL TESTING & C / S , PCR ETC * HLA- B27 GENE PRESENT IN > 90% OF PTS WITH ANKYLOSING SPONDYLITIS β’ Synovial fluid glucose often more than 40 mg/dL (2.22 mmol/L) less than in a simultaneously obtained serum glucose value (in fasting patient). However, arthrocentesis should not be delayed simply to obtain fasting synovial fluid glucose level. β’ Westergren erythrocyte sedimentation rate - often elevated, but normal in 20% β’ Rheumatoid factor positive in 50% - if endocarditis present and in viral arthritis β’ Anti-teichoic acid antibodies - with Staphylococcus infection β’ Elevated peripheral white blood cell count (in 50-90%) β’ Cryoglobulins β’ Immune complexes β’ Febrile agglutinins (to include Brucella and rickettsialrelated titers) β’ Antistreptolysin O (ASO) titer is usually normal, exclusive of streptococcal infections β’ Depressed synovial fluid and occasionally depressed serum levels of complement β’ Microscopic hematuria in subacute bacterial endocarditis (SBE) β’ Presence of crystals (e.g., urate or calcium pyrophosphate) does not exclude infectious arthritis * SYNOVIAL BIOPSY- biopsy will reveal polymorphonuclear leukocytes and possibly the causative organism - if cultures are negative of fluid β’ Countercurrent immunoelectrophoresis or complement fixation for specific bacterial antigens . X-RAY : . Soft tissue swelling . Juxta-articular osteoporosis . Radiolucent area (gas) in a joint space from gas forming organisms. (Caveat - may also occur normally as a vacuum phenomenon. . Effacement of the obturator fat pad (with hip involvement) . X-ray changes are usually a late phenomenon . Rarefaction of subchondral bone may occur as early as 2-7 days . Joint space loss (secondary to cartilage destruction) may be seen as early as 4-10 days . Erosions . Joint destruction with ankylosis may occur as early as 2 weeks
TYPENOTES
GENERAL MEASURES β’ Repeat arthrocentesis to drain the joint, as fl uid re-accumulates β’ Avoid adding anti-infl ammatory therapy so as not to compromise assessment of therapeutic response to antibiotic β’ If a joint prosthesis is present in an infection, the infection is very difficult to eradicate, without removal of the prosthesis β’ Treatment is continued for 1-2 weeks after total resolution of all signs of infl ammation, 3-4 weeks for gram negative organisms, and 6-8 weeks if the joint was previously diseased (e.g., involved by arthritis) β’ Intra-articular antibiotics are not required and may actually aggravate the arthritis SURGICAL MEASURES: - Arthrotomy indicated only if fl uid accumulated is loculated and/or not amenable to needle drainage, or if antibiotics fail ACTIVITY: Limit activity or splint the joint initially. Continuous passive motion may be used as an alternative approach. DRUG(S) OF CHOICE . Neisserial . Ceftriaxone 1 gm IM or IV every day for 14 days (but at least 7 days after symptoms resolve) . Spectinomycin 2 gm IM every 12 hours for 10 days . Non-Neisserial: . Gram positive cocci in chains or clumps - nafcillin 150 mg/kg/day q 4-6 h IV/IM . Gram positive diplococci - penicillin G 1.4 million units q6h . Gram negative bacilli: In neonates - penicillin and gentamicin; in children age 6 months to 4 years - cefuroxime; in adult - penicillin or cephalosporin plus gentamicin, all at full dose. Add clindamycin, at full dose, in the presence of retroperitoneal or pelvic abscess. . Gram negative pleomorphic organisms - clindamycin at full dose (clindamycin has gram negative activity only against anaerobes) . No bacteria seen on smear - penicillin or cephalosporin plus gentamicin, all at full dose PATIENT MONITORING β’ Recurrent arthrocentesis, as fluid re-accumulates - to verify sterilization of the joint and to verify reversion of inflammatory signs to normal β’ If no defi nitive improvement within 48 hours, re-evaluate completely β’ Complete blood count, liver and kidney function and urinalysis twice a week, while on antibiotics (perhaps with creatinine every other day when gentamicin used) β’ Gentamicin levels β’ It is essential to followup one week and a month after stopping antibiotics to detect any relapse POSSIBLE COMPLICATIONS β’ Death (9-33% in elderly) β’ Limited joint range of motion β’ Flail or fused or dislocated joint β’ Carpal tunnel syndrome β’ Septic necrosis β’ Sinus formation β’ Ankylosis β’ Osteomyelitis β’ Postinfectious synovitis β’ Shortening of the limb (in children) EXPECTED COURSE/PROGNOSIS β’ Early treatment should allow cure β’ Delayed recognition/treatment complicated by morbidity and mortality
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
SERUM URIC ACID, RA FACTOR, ASLO TITER, C-REACTIVE PROTEIN, URINE ROUTINE, COMPLETE BLOOD COUNT, X-RAY
ARTHRITIS - AROMA
[HASTA PARASHVASANA]
[ALFALFA] [BLOOD WORT] [CASTORSEEDS] [CELERY] [CHIRAYATA] [COLCHICUM] [EAST INDIAN ROSEBAY] [EPHEDRA] [GARLIC] [GOKULAKANTA] [INDIAN SARSAPARILLA] [INDIAN SENNA] [INDIAN SQUILL] [INDIANCALYPHA] [INDIANLOE] [ISPAGHULA] [JAUNDICE BERRY] [KANTAKARI] [LEADWART] [LEMON GRASS] [LINSEED] [MADHUCA] [NUTMEG] [PEPPER] [ROSEMARY] [ROUGH CHAFF] [SAFFRON] [SAGE] [TURPETH] [VASAKA] [WINTER CHERRY]