septic arthritis

1. CASE CONFERENCE
ORTHOPEDIC
By Poonperm Sucharitpong
Medical student

2. PATIENT PROFILE
• Case ผู้ป่วยหญิงไทย
• อายุ 67 ปี
• ภูมิลาเนา จังหวัด นครราชสีมา
• อาชีพ ค้าขาย

3. CHIEF COMPLAINT
• ปวดสะโพกขวา 2 วัน ก่อนมาโรงพยาบาล

4. PRESENT ILLNESS
2 d PTA
• ผู้ป่วยเริ่มปวดสะโพกด้านขวา ปวดแบบแสบๆ ไม่มีปวดร้าวไป
ตาแหน่งอื่น ปวดจนเดินไม่ได้ ไม่มีแขนขาอ่อนแรง ไม่มีชา ทานยาแก้
ปวดเอง อาการปวดลดลงเล็กน้อย
• มีไข้ต่าๆตลอด ปัสสาวะไม่แสบขัด ไม่ไอ ไม่มีน้ามูก ไม่มีปวดท้อง ไม่มี
คลื่นไส้อาเจียน ไม่มีถ่ายเหลว
• ไม่เคยปวดบริเวณสะโพกขวามาก่อน
• ปฏิเสธประวัติอุบัติเหตุ

5. PAST HISTORY
• Underlying disease – DM , Hypertension
on Amlodipine(5) 1x2 po pc
Hydralazine(50) 1x2 po pc
Glipizide(5) 2x2 po ac
Pioglitazone(30) 1/2x1 po ac
• S/P I&D gluteal abscess Lt.
• No history of accident

6. PERSONAL HISTORY
• No history alcohol drinking and smoking
• No herbal medication
• No drug and food allergy

7. PHYSICAL EXAMINATION
• Vital signs – BT 37.3 C HR 98 /min
RR 16 /min BP 153/72 mmHg
• General appearance – An elderly Thai female,
hypersthenic build, good consciousness, not pale, no
jaundice
• HEENT – not pale conjuctivae, anicteric sclerae
• Cardiovascular – pulse full and regular, normal s1&s2
sound, no murmur

8. PHYSICAL EXAMINATION
• Lungs and chest – clear, equal breath sound
• Abdomen – soft, not tender, no distension
• Extremities – tender and warmth at right hip, no
swelling, no erythema, limit ROM due to pain, Rolling
positive, Anvil negative

9. PROBLEM LIST
• Acute monoarthitis
• Underlying disease – DM , Hypertension

10. MANAGEMENT AT ED
• Septic work-up
CBC
H/C x II
UA
CXR
• Arthrocentesis for fluid profile, gram stain, culture
• Basic lab: BUN/Cr, Electrolyte, Anti-HIV,Coagulogram
• ESR, CRP, Uric level
• Ultrasound Emergency

11. LABORATORY
• CBC
Hb 9.7 g/dL Hct 29.4%
WBC 12,000 /uL Neutrophil 75.8%
Lymphocyte 15.4% Monocyte 8.2%
Eosinophil 0.3% Basophil 0.3%
Platelet 455,000 /uL MCV 82.3 fl
• ESR 117
• CRP 36.3

12. LABORATORY
• Electrolyte
Sodium 133.4 mmol/L
Potassium 3.95 mmol/L
Chloride 97.9 mmol/L
Bicarbonate 23.9 mmol/L
• BUN = 19.2 mg/dL
• Creatinine = 1.89 mg/dL
• Uric level

13. LABORATORY
• Joint fluid profile
Color: slightly red Crystal: not found
Transparency: cloudy Sp.gr. 1.015
RBC: 26,500 cell/mm3
PMN: 97 %
• UA
Y/C Nitrite neg
pH 8.0 RBC neg
Protein trace WBC 0-1
Sugar neg sq.epi 2-3

14. LABORATORY
• Joint fluid culture : pending
• Joint fluid gram stain
Many WBC
Not seen organism
• Ultrasound : x-ray suggest CT

15. DIFFERENTIAL DIAGNOSIS
• Septic arthritis
• Crystal-induced arthritis
• Reactive arthritis
• Rheumatoid arthritis
• Acute traumatic arthritis

16. FILM PELVIS AP

17. CHEST X-RAY

18. PLAN FOR
MANAGEMENT
• Admit
• ATB prophylaxis: cefazolin 1 gm IV q 6 hr
• Pain control : MO 4 mg IV prn q 6 hr,
Paracetamol(500) 1 tab po prn q 4-6 hr

20. Arthritis that caused by any infectious organism
DEFINITION

21. EPIDEMIOLOGY
Incidence (per 100,000/year)
0 10 20 30 40 50
Prosthetic
joint
Rheumatoid
arthritis
Children
General
population

22. • Age : elderly>60 yr , Newborn
• Systemic disorders: DM ,RA ,H/D, immunosuppressive
drug , HIV infect
• Local factors : Prosthetic joint, OA ,RA ,recent joint
surgery, direct joint trauma
PREDISPOSING FACTOR

23. ORGANISM
60% - S.aureous
20% - Streptococcus spp.
13% - Gram – negative bacilli
4% - Polymicrobial
3% - Anaerobes

24. ORGANISM
Age Organism
1 Neonates Streptococcus
Gram-negative organisms
2 Infants Staphylococcus aureus
Hemophilus influenza
3 Children Staphylococcus aureus
Salmonella
4 Adolescent Staphylococcus aureus
Neisseria gonorrhea
5 Adults Staphylococcus aureus
Streptococcus
Gram-negative organisms
6 IV drug abusers Suspect Pseudomonas and
atypical organisms

25. • Route of infection
• Hematogenous spreading
• Direct inoculation
• Adjacent focal infection
PATHOGENESIS

27. • Onset of the joint pain
• monoarticular or polyarticular
• The presence of extra-articular symptoms
• Previous history of joint disease or trauma, accidental or
iatrogenic
• STD
• Intravenous drug abuse
HISTORY

28. CLINICAL FEATURES
• Fever (high grade fever ~ 50%)
• Acute monoarticular arthritis (~80-90%)
Abrupt onset of hot, painful, and swollen joint
Obvious joint effusion
Limitation of passive and active motion
• Polyarticular (~10-20% :- IVDU, DM, RA)

29. DIFFERENTIAL
DIAGNOSIS OF ACUTE
MONOARTHRITIS
• Soft tissue infection
• Crystal-induced arthritis
• Traumatic arthritis/hemarthrosis
• Reactive arthritis

30. NEWMAN’S CRITERIA FOR
DIAGNOSIS OF SEPTIC ARTHRITIS
A. Organism isolated from joint
B. Organism isolated from elsewhere
C. No organism isolated but
(i) histological or radiological evidence of infection
(ii) turbid fluid aspirated from joint

31. Normal
synovial fluid
Septic
(Type 3)
Transparent, colorless or pale straw-
colored
Purulent or opaque
WBC < 200 WBC > 60,000
PMN < 25% PMN > 80%
Sugar = Blood Sugar <50% blood
Gram stain: (-) May be (+) in septic arthritis
Culture: (-) (+) in septic arthritis
Wet prep : (-) Crystals
Normal synovial
fluid
Crystal – induced arthritis, Bacterial arthritis

32. SYNOVIAL FLUID ANALYSIS
• Macroscopic finding
• Turbid, decreased viscosity
• WBC count
• > 60,000 mm3, PMN > 80%
• Glucose < 50-75% of serum value

33. • Blood
-CBC
-ESR,CRP
-Hemoculture
• Imaging
-plain film
-ultrasound
-CT
-MRI
• Synovial fluid
analysis
-color,
transparency
-G/S, C/S
-Cell diff/cell
count
-crystal
-glucose

34. RADIOLOGICAL
INVESTIGATIONS

35. TREATMENT
Antibiotics
Aspiration
Rehabilitation

36. ANTIBIOTICS
• Start as soon as all specimens are obtained for C/S
• Intravenous antibiotic at least 2 weeks
S. Aureus : cloxacillin,1st 2nd gen cephalosporin
MRSA : vancomycin
Strep gr.A , H. influenza : cefuroxime
Pseudomonas aeruginosa : ceftazidime + gentamycin
• Oral antibiotic for the following 2 – 6 weeks

37. • Surgical debridement
serial joint aspiration in 24-36 Hr.
arthrotomy, arthroscopic technique
JOINT ASPIRATION

38. REHABILITATION
• Rest in optimal joint position
• Continuous passive motion device
• Muscle strengthening exercise
• Active ROM and weight-bearing as pain resolves

39. • Difficult to drain or to assess the adequacy of drainage
• Inability to adequate drainage by needle aspiration
• Unresponsive to medical treatment
• Vertebral osteomyelitis with spinal cord compression
• Coexistent osteomyelitis
• Prosthesis septic joint
• Foreign body in joint
INDICATION FOR
ORTHOPEDIC CONSULTATION

40. OUTCOME
• Complete resolution
• Partial loss articular cartilage and fibrosis of joint
• Loss of articular cartilage and bony ankylosis
• Bone destruction and permanent deformity of the joint

42. THANK YOU