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Acute supurative arthritis

- Causal organism:
a) Staphylococcus aureus
b) 1-4 yrs: haemophilus influenza (unless vaccinated)
c) Occasional microbes: streptococcus, Escherichia coli, proteus
- Predisposing conditions:
a) RA
b) AIDS
c) IV drug abuse
d) Immunosuppressive drug therapy
e) Chronic debilitating d/os
- An infected jt by (mode of infection)
a) Direct invasion through a penetrating wound, intra-articular injection, arthroscopy
b) Direct spread from an adjacent bone abscess
c) Blood spread from a distant site
- Infants: initial infection in metaphysis spread to jt or vice-versa is difficult to elicit
- Clinical practice: no need to differentiate between OM & SA in infants as they often occur
together; assume entire jt & adjacent bone ends infected in advanced cases
- Pathology:
a) Usual trigger: haematogenous infection settling in synovial membrane
b) An acute inflammatory reaction with serous or seropurulent exudates & an increase in SF
c) Pus appears in jt: destroyed & eroded articular cartilage by
1) Bacterial enzymes &
2) Proteolytic enzymes (released from synovial cells, inflammatory cells & pus)
d) Severely damaged largely cartilaginous entire epiphysis in infants
e) Vascular occlusion leading to epiphyseal bone necrosis in older children
f) Confined effects to articular cartilage in adults; late stage: extensive erosion d/t synovial
proliferation & ingrowth
g) Untreated infection: spread to underlying bone or burst out of jt to form abscesses &
sinuses
h) Results of healing:
1) Complete resolution & return to normal
2) Partial loss of articular cartilage & fibrosis of jt
3) Loss of articular cartilage & bony ankylosis
4) Bone destruction & permanent deformity of jt
- Clinical features
a) Differ as per age
b) New-born infants: focus on septicaemia than jt pain; irritable baby; refuse to feed; rapid
pulse; fever; suspected infection anywhere; carefully feel jts & move to elicit local signs of
warmth, tenderness & resistance to movement; examine umbilical cord for source of
infection; an inflamed iv infusion site (suscpicion); carefully examine babys chest, spine &
abdomen to exclude other sites of infection; Special care not to miss concomitant om in
adjacent bone end
c) Children: acute pain in single large jt hip/knee; reluctance to move limb (pseudoparesis); ill
child; rapid pulse; swinging fever; overlying skin in sup jt: swollen, red, local warmth, marked
tenderness; all movements restricted & often completely abolished by pain & spasm; look
for source of infection (a septic toe, a boil, an ear discharge)
d) Adults: often sup jt (knee, wrist, finger, ankle, toe): painful, swollen, inflamed, warmth,
marked local tenderness, restricted movements; examine & question for gonococcal
infection/drug abuse; RA on corticosteroid t/t: silent jt infection; unexplained deterioration
of pts general condition; carefully examine every jt
- Imaging
a) Usg: jt effusion (early case; most reliable); comparison of both hips; widening of space between
capsule & bone >2mm: effusion may be echo-free (transient synovitis) or +vely echogenic (SA)
b) X-ray examn: normal (early); soft-t/s swelling, loss of t/s planes, widening of radiographic jt
space & slight subluxation (becoz of jt fluid);E.coli.: gas in jt; late features: narrowing &
irregularity of jt space
c) MRI & Radionuclide scanning/imaging: helpful in diagnosing arthritis in obscure sites (sacroiliac
& sternoclavicular jts)
- Investigations:
a) White cell count & ESR: raised
b) Blood culture: may be +ve
c) Jt aspiration & fluid examination (quicker, more reliable than time taking special
investigations): frankly purulent/ clear(early stage)
d) Immediate white cell count & gram stain:
1) Normal SF leucocyte count: <300 per ml
2) Non-infective inflammatory d/os: >10,000 per ml
3) Highly suggestive of sepsis: >50,000 per ml
4) Gm +ve cocci: S.aureus
5) Gm ve cocci: H. influenza or Kingella kingae (in children); Gonococcus (adults)
e) Samples of fluid sent for full microbiological examination & tests for antibiotic sensitivity
- DD:
a) Acute osteomyelitis: young children: OM indistinguishable from SA; often assume both +nt
b) Other types of infection: psoas abscess; local infection of pelvis; similar systemic features as
in SA
c) Trauma: traumatic synovitis or haemarthrosis associated with acute pain & swelling;
doubtful diagnosis until jt aspiration; injury doesnt r/o infection
d) Irritable jt: at onset: painful jt lacking some movement; not really ill child; no signs of
infection; USG to diff SA from Transient synovitis
e) Haemophilic bleed: an acute haemarthrosis resembles SA; conclusive h/o; doubt resolved by
aspiration
f) Rheumatic fever: pain flits from jt to jt (typical); onset: one jt misleadingly inflamed; no signs
of septicaemia
g) Juvenile RA: start with pain & swelling of a single jt; onset: usually more gradual; systemic
symptoms: less severe than SA
h) Sickle-cell d/s: closely SA resembling clinical picture; indeed nearby bone actually infected;
r/o in communities where its common
i) Gauchers d/s: rare condition; acute jt pain & fever w/o any org found(pseudo-osteitis);
antibiotics given d/t predisposition to true infection
j) Gout & pseudogout: adults: acutecrystal-induced synovitis closely resembling infection; on
aspiration: often turbid jt fluid with high white cell count; microscopic examination by
polarized light: show characteristic crystals
- T/t
a) First priority: aspirate jt & examine fluid
b) t/t: started imm w/o delay; same as for acute OM
c) blood & t/s samples obtained: no need to wait for results to give antibiotics
d) purulent looking aspirate: drain jt w/o waiting for lab results
e) steps:
1) General supportive care: analgesics for pain; IV fluids for dehydration
2) Splintage: rest jt; light splintage for neonates & infants; hip infection: jt held abducted &
30 degrees flexed, on traction to prevent dislocation
3) Antibiotics: t/t follows same guidelines as for AH OM; initial choice: based on most likely
pathogen; neonates & infants upto 6 months age: protected against staphylococcus &
Gm-ve streptococci (penicillanse-resistant penicillin ie flucloxacillin + 3rd-generation
cephalosporin); children from 6 months to puberty: similar antibiotics (if vaccinated with
Haemophilus influenza); older teenagers & adults: flucloxacillin + fusidic acid; 3rd-
generation cephalosporin added if initial examn shows Gm-ve org; more appropriate
drugs substituted after full microbiological inv; IV antibiotics for 4-7 days & orally for
another 3 weeks
4) Drainage: under anaesthesia; open jt thru a small incision ; drain & wash out with
physiological saline; a small catheter left in place & wound closed; suction-irrigation
continued for another 2 or 3 days; safest policy & advisable
a) In very young infants
b) When hip is involved
c) If aspirated pus is very thick

Knee: arthroscopic debridement & copious irrigation equally effective;older children with early SA
(symptoms <3days) involving any jt except hip: treated successfully by repeated closed aspiration of jt &
open drainage (if no improvement within 48 hrs)

5) Aftercare: satisfactory general condn + jt no longer painful/warm: unlikely further


damage; preserved articular cartilage: encourage gentle & gradual increasing active
movements; destroyed articular cartilage: aim is to keep jt immobile while ankylosis is
awaited; continuosly maintain splintage in optimum position usually by plaster until
sound ankylosis
- Complications:
a) Highest incidence of complication mostly affecting hip: infants <6months
b) Most obvious risk factors: delay in diagnosis & t/t (>4days); concomitant OM of proximal
femur
c) Subluxation & dislocation of hip; or knee instability: prevented by appropriate posturing or
splintage
d) Most serious complication: damage to cartilaginous physis or epiphysis in growing child;
sequelae: retarded growth, partial or complete destruction of epiphysis, jt deformity,
epiphyseal osteonecrosis, acetabular dysplasia, pseudarthrosis of hip
e) Older pt: articular cartilage erosion (chondrolysis) resulting in restricted movement or
complete jt ankylosis

Gonoccal arthritis
- Commonest cause of SA in sexually active adults (esp among poorer popn): Neisseria
gonorrhoeae
- Increased STDs incidence in affluent commn d/t increased use of non-barrier contraception with
risk of gonococcal & syphilitic bone & jt d/s & their sequelae
- Infection acquired by direct mucosal contact with an infected person (risk >50% after a single
contact)
- c/fs:
a) 2 types of clinical d/os:
1) Disseminated gonococcal infection: triad of polyarthritis, tenosynovitis, dermatitis
2) SA of single jt (usually knee, ankle, shoulder, wrist, or hand)
b) Both syndromes may occur in same pt
c) Slight pyrexia; raised ESR & WBC count
d) Suspected condition: pt questioned about possible contacts during previous days/weeks;
examined for other signs of genitourinary infection (eg: urethral discharge or cervicitis)
e) Jt aspiration: high white cell count; typical gm-ve orgs; disappointing bacteriological inv;
samples from various mucosal surfaces & tests for other STIs (VDRL, HIV, HBSAg)
- T/t
a) Similar to pyogenic arthritis
b) IV/IM 3rd-generation cephalosporins; penicillins(ampicillin or amoxicillin; org sensitive to
penicillin & pt not allergic) & clavulanic acid
c) Gonococcal infection + chlamydial infection: resistant to cephalosporins; both sensitive to
quinolones (ofloxacin & ciprofloxacin)

SA and HIV-1 arthritis

- SA encountered freq in HIV-positive IV drug users, HIV-positive heamophiliacs, other pts with
AIDS
- Usual orgs: Staphylococcus aureus, streptococcus; opportunistic infection by unusual orgs
- c/fs:
a) acutely painful
b) inflamed jt
c) marked systemic features of bacteraemia or sepicaemia
d) some cases: infection confined to a single, unusual site (sacroiliac jt); others: several jts
affected simultaneously
e) opportunistic infection by unusual orgs: produce a more indolent clinical picture
- t/t:
a) follows general principle earlier outlined
b) pts with staphylococcal & streptococcal infection: respond well to antibiotic t/t & jt drainage
c) opportunistic infection: more difficult to control