Infection and Arthritis

Infection and Arthritis Max S Lundberg, MD Objectives be able to define septic arthritis and septic bursitis know what factors predispose to development of joint infection, what bacteria commonly cause joint infections be able to list most common pathogens causing septic arthritis by age and risk factor. be able to distinguish gonococcal arthritis from other forms of bacterial septic arthritis. be familiar with the pathogenesis of “Lyme” arthritis know the common characteristics of viral arthritis and how these differ from bacterial septic arthritis. Recommended Reading •Primer on the Rheumatic Diseases, 12th Edition, pp 259-279. Septic Arthritis Viral Arthritis Lyme Disease Mycobacterial Fungal, and Parasitic Arthritis Rheumatic Fever Microbes & Arthritis Overview and Classification Class Infection Live organism present ? Microbial structures present? Example Infection Yes Yes Yes Septic Arthritis Reactive Yes No Yes Chlamydia, Yersinia, Salmonella, Shigella, Campylobacter Rheumatoid Arthritis Inflammatory No No No Septic Arthritis •Arthritis resulting from infection of one or more joints by a microorganism (usually bacterial) Bacteria found in bone and joint infection Bacteria Staphylococcus aureus Coag negative Staph Hemolytic Streptococcus ++ Acute Septic Arthritis +++ Prosthetic Joint Infection +++ +++ ++ ++ ++ Septic Bursitis +++ Osteomyelitis +++ Other Streptococci Skin anaerobes Gram-negative cocci Hemophylus influenza Gram-negative anaerobes Pseudomonas aeruginosa Salmonella Intestinal anaerobes Mycobacteria + + + + + + + + +++ + + + + ++ + + + + + + + + + + Septic Arthritis Epidemiology Elderly or very young Underlying chronic illness Increased incidence with warmer climates and poorer socioeconomic status 1:10,000 annual incidence in Northern European children Septic Arthritis Risk Factors • • • Age > 80 years Comorbid conditions (especially diabetes) Joint damage from arthritis • • • Prosthetic joint Skin infection Immune suppression (malignancy or treatment) • • • Cirrhosis Chronic renal failure and hemodialysis IV drug abuse Septic Arthritis Predisposing Conditions Host Factor Extra-articular infection Serious chronic illness* Prior antibiotics** Prior immune suppressing therapy Prior arthritis in the infected joint *Cancer, cirrhosis, diabetes **Receiving antibiotic medications for at least 5 days prior to any symptom of septic arthritis # of cases 29 11 12 3 16 Pathogenesis 1. 2. 3. 4. 5. Hematogenous Dissemination from osteomyelitis Spread from adjacent soft tissue infection Diagnostic or therapeutic measures Penetrating damage by puncture or cutting. Septic Arthritis 18 year clinical review • • No previous joint disease or illness in 54% 72% of infections were hematogenous in origin • • • Staph aureus 37% Strep pyogenes 16% Neisseria gonorrhea 12% Morgan DS; Fisher D; Merianos A; Currie BJ; Epidemiol Infect 1996 Dec;117(3):423-8. Septic Arthritis Organism Staph aureus Streptococcus hemolyticus Diplococcus pneumoniae Hemophilus influenza Gram negative bacilli Escherichia coli Proteus mirabalis Pseudomonas aeruginosa Serratia marcescens Salmonella Total 5 4 1 1 2 50* 17 14 5 1 Synovial fluid isolates in Adult Septic Arthritis 1967-1972 Series 1947-1967 Reviews 126 23 14 2 7 2 2 1 177 *Three patients with organism recovered from more than one joint (total 47 patients in series) Septic Arthritis Adults versus Children Adults % Gram positive cocci Staph aureus Strep (pyogenes, pneumonia, viridans) Gram negative cocci Neisseria (meningitidis and gonorrhea) Hemophilus influenzae Gram negative bacilli E. coli, Salmonella and Pseudomonas sp. 5 9 50 <1 8 40 35 10 27 16 Children % Mycobacteria and Fungi <1 <1 Septic Arthritis Joints affected (non-gonococcal) Joint Knee Hip Adults % 55 11 Children % 40 28 Ankle Shoulder Wrist 8 8 7 14 4 3 Elbow Others Multiple joints 6 5 (12) 11 3 (7) Septic Arthritis Organism Staphylococcus aureus < 2 yr 20 Bacteria isolated in Children (n=146) prior to 1980 2-6 yr 10 7-14 yr 21 Total 51 Hemophilus influenza* Streptococcus hemolyticus Gram negative bacilli Diplococcus pneumoniae Others Total 25 5 9 6 3 73 4 14 6 3 3 29 0 0 13 2 1 44 29 19 28 11 7 146 Septic Arthritis •1988-93 •40 Children, age < 24 months - Bacteria isolated review of cases patients (26 male, 14 female) Kingella kingae Haemophilus influenzae Type B Other • • • 19 8 13 Arch Pediatr Adolesc Med 1995 May;149(5):537-40 Septic Arthritis Clinical Features • • • • • • Joint swelling and pain Pain with range of motion, immobility Fever Signs of sepsis Distribution usually monoarticular Large joints most often involved Classification of Joint Effusions Type Features WBC/mm3 <200 <25% PMNs Normal Clear, colorless, Viscous Non-Inflammatory Clear, Yellow, viscous Cloudy, Yellow, Watery Glucose may be low 200-2000 <25% PMNs 2000-100,000 >50% PMNs Inflammatory Septic Purulent Glucose very low 80,000 >90% PMNs Septic Arthritis •1988-93 •40 Children, age < 24 months - Clinical Presentation review of cases patients (26 male, 14 female) Temp < 38.3 in 14/40 WBC < 15K in 13/38 ESR < 30 in 4/36 Synovial fluid WBC < 50K in 8/22 Arch Pediatr Adolesc Med 1995 May;149(5):537-40 • • • • Septic Arthritis Diagnostic Tests • • • • • • Synovial Fluid Analysis WBC count > 50,000 PMNs > 90% Gram stain and culture* Blood culture Radiology Early changes are non-specific “Diagnostic changes occur later Septic Arthritis Joint tissue damage • Infiltration of joint by bacteria (direct damage) • • • • Aggressive Host Inflammatory Response Proliferation of synovial pannus Anaerobic acidic environment Action of Protease, Collagenase, and Elastase enzymes on cartilage and subchondral bone • Mechanical forces on weakened structures Septic Arthritis Natural History Experimental bacterial arthritis induced Maximal acute arthritis symptoms Chronic or irreversible changes 0 1 2 3 4 Time (days) 5 6 7 8 Septic Arthritis Treatment • • Joint Drainage Repeated needle aspiration • Surgical Drainage Antibiotic Therapy Synovial Fluid and Blood Cultures Serial Synovial Fluid Analysis Extended Duration of Treatment (6 weeks) • • • • Septic Arthritis Outcome of Treatment by Mode of Drainage Open Arthrotomy 16 17 Needle Aspiration Patients Joints infected Results (by joint) Complete Recovery 37 46 37 (80%) 8 (47%) Poor Result† 9 (20%) 9 (53%) †Includes ankylosis, flexion contractures, secondary osteomyelitis, recurrent infection Septic Arthritis Outcome of Treatment by Infecting Organism Gram negative Staphylococcus Streptococcus bacilli aureus hemolyticus # of patients # of deaths 13 2 19 3 16 0 # of joints infected in survivors Complete Recovery Poor Result† 12 4 (33%) 8 18 9 (50%) 9 25 22 (88%) 3 †Includes ankylosis, flexion contractures, secondary osteomyelitis, recurrent infection Septic Arthritis Infection in prosthetic joints • Early onset infections • • • • Usually directly related to surgical wound 75% Staphylococcus and Streptococcus species Symptoms tend to be acute Late onset infections • • Hematogenous spread Symptoms tend to be indolent Gonococcal Arthritis Populations at Risk • • Typically seen in young adults The most common cause of septic arthritis in sexually active populations More common in females (asymptomatic carrier state) • Gonococcal Arthritis • Tenosynovitis, dermatitis, polyarthralgia syndrome Acute illness with fever, chills, malaise. • • • Tenosynovitis Generalized arthralgia Dermatitis: pustular or vesicopustular Gonococcal Arthritis Purulent (septic) arthritis • Monoarticular or Pauciarticular •Large joint involvement (knees, wrists, ankles) • • Most patients are afebrile Signs of disseminated infection are rare Septic Bursitis • Superficial bursae are commonly affected (prepatellar and olecranon bursae) Underlying joint infection is not common Acute or repetitive Trauma • • • • • Staph aureus Drainage Antibiotics Osteomyelitis • Acute §Children §Children and young adults < 1 year often have osteomyelitis with septic arthritis and septicemia together. • Chronic and Sub-acute •Most often follow trauma or surgery antibiotic treatment debridement •Prolonged •Surgical Viral Arthritis • Inflammatory polyarthritis, similar to early RA Duration usually < 1 month, self limited illness Not destructive to joint Prodromal symptoms • • • • • Fever Rash Supportive Treatment (NSAIDs, Analgesics) • Viral Arthritis Viruses that cause arthritis Definite Hepatitis (B & C) Rubella Parvovirus Mumps Arbovirus Variola Possible Vaccinia Varicella Rubeola Echo EBV Adenovirus Viral Arthritis Parvovirus B19 • • • Erythema Infectiosum (fifth disease) Children 10% Arthralgia • 5% oligoarticular arthritis Adults Up to 80% with joint symptoms • • • Chronic Recurrent Arthritis Viral Arthritis Parvovirus B19 • • • Diagnosis Usually seronegative for RF RF, ANA and anti-Lymphocyte antibodies can be seen anti-B19 IgM antibodies may be elevated for up to 2 months after acute infection. • Viral Arthritis Hepatitis B • • Sudden onset Symmetric polyarthritis, (hands and knees are most common) Urticarial rash Arthritis usually goes away before onset of jaundice • • Viral Arthritis Hepatitis C • • • Serum transaminases may be normal Essential Mixed Cryoglobulinemia Arthritis • • Palpable purpura Cryoglobulins Urticarial rash Arthritis usually goes away before onset of jaundice • • Viral Arthritis Rubella Arthritis • • • Post-pubertal females Sudden onset Symmetric polyarthritis • • Tenosynovitis (carpal tunnel syndrome) May occur with some live attenuated virus vaccines. Viral Arthritis • Syndromes observed with HIV infection • • • • • • • • • • Arthralgia Reiter’s Syndrome Psoriatic Arthritis Undifferentiated Spondyloarthropathy Idiopathic or HIV associated arthritis Aseptic Necrosis Septic Arthritis Sjogren’s-like Syndrome Inflammatory and non-inflammatory myopathy Systemic Vasculitis Lupus-like Syndrome Alphaviruses • • Sindbis – epidemic arthralgia and rash in South Africa and Australia Okelbo disease in Sweden, Pogosta disease in Finland, Karelian fever in Russia Chikungunya – (Swahili for “that which bends up”) febrile arthritis in South Africa, west-central Africa, Thailand, Vietnam, India. High grade fever for 2-4 days, headache, myalgia, nausea/vomiting, coryza, lymphadenopathy, conjunctivitis, photophobia, eye pain, sudden joint pain (wrists and ankles most common). O’nyong-nyong virus (“joint breaker” in Ugandan Acholi dialect) central Africa, epidemic Sudden onset headache, eye pain, chills and symmetric severe polyarthralgia, rash, conjunctivitis, lymph node enlargement, mild fever Ross river virus (South Pacific, Australia, New Zealand), endemic Sudden onset chills, arthralgia, myalgia and mild fever, rash. Mayaro virus (Bolivia, Brazil, Peru) sporadic epidemic Sudden onset fever, headache, dizziness, chills, arthralgia (20% with joint swelling), rash, lymph node enlargement. • • • • • • • • Lyme arthritis: an epidemic of oligo-articular arthritis in children and adults in three Connecticut communities. Steere AC; Malawista SE; Snydman DR; Shope RE; Andiman WA; Ross MR; Steele FM; Arthritis Rheum 1977 Jan-Feb;20(1):7-17. In November 1975, a resident of Old Lyme, Connecticut, informed the Connecticut State Health Department that 12 children from that rural community of 5000 residents had been diagnosed to have juvenile rheumatoid arthritis. Almost concurrently, a second mother from Old Lyme informed physicians at the Yale Rheumatology Clinic that she, her husband, two of their children and several neighbors all had developed arthritis. A surveillance system organized by Drs Steere, Malawista and others revealed that 51 individuals (39 children and 12 adults) in three contiguous, rural communities had developed arthritis between July 1972 and May 1976. Most had recurrent brief attacks of pain and swelling (median 1 week) involving one to a few large joints, predominantly the knee. In 55%, the first attack of arthritis occurred between June and September, and 13 (25%) had noted a peculiar, expanding, erythematous skin lesion a median of 4 weeks prior to the onset of arthritis. One recalled being bitten by a tick at the site of the skin lesion. The skin lesion was suspected to be erythema chronicum migrans (ECM), described by Afzelius in 1910 and known to occur in Europe, where it had been associated with the bite of the sheep tick, Ixodes ricinus, and was suspected to be caused by infection with a transmissible agent. Lyme Disease • Endemic (New York, New Jersey, Connecticut, Rhode Island, Massachusetts, Pennsylvania, Wisconsin, Minnesota) • • • • Infecting organism: Borrelia burgdorferi Vectors Ixodes dammini (NorthEast and North Central US) Ixodes pacificus (Western US • • Ixodes ricinus (Europe) Ixodes persulcatus (Asia) Lyme Disease • • • • • • • • Early Localized Disease Early Disseminated Disease Carditis Neurologic manifestations Late Disease Muculoskeletal complaints Tertiary neuroborreliosis Cutaneous manifestations Lyme Disease •Musculoskeletal •(80% Manifestations of 55 patient cohort) • • Arthralgia (18%) Intermittent inflammatory joint disease (51%) • • • • Chronic Lyme Arthritis (11%) Large Joint Effusions, usually knees Aggressive joint damage is uncommon Clinical picture of “septic joint” is uncommon Attacks lasting weeks to months can occur on and off for several years. •