SUPPURATIVE ARTHRITIS by AYMAN ABU MEHREM, MD, CABP
SUPPURATIVE ARTHRITIS <ul><li>Introduction </li></ul><ul><li>Epidemiology </li></ul><ul><li>Aetiology </li></ul><ul><li>Pa...
INTRODUCTION <ul><li>Suppurative arthritis is a  true clinical emergency </li></ul><ul><li>Before antibiotics </li></ul><u...
EPIDEMIOLOGY <ul><li>Relatively common in infancy & childhood </li></ul><ul><li>Incidence </li></ul><ul><li>Peak: early ye...
ALL PRIMARY CARE PHYSICIANS CARING FOR CHILDREN SHOULD EXPECT TO ENCOUNTER THIS DISEASE
AETIOLOGY <ul><li>Staphylococcus aureus:  the most common organism in all age groups </li></ul><ul><li>Streptococcus pyoge...
AETIOLOGY  …..Cont’d <ul><li>Pseudomonas aeruginosa:  puncture wounds of feet </li></ul><ul><li>Other organisms </li></ul>...
PATHOPHYSIOLOGY <ul><li>Most commonly, pathogenesis is hematogenous </li></ul><ul><li>Contiguous spread from an adjacent c...
Hematogenous septic arthritis <ul><li>Directly through synovial blood vessels </li></ul><ul><li>Spread from an adjacent he...
 
PATHOPHYSIOLOGY, Neonates <ul><li>Immature immune system </li></ul><ul><li>Unusual organisms </li></ul><ul><li>Less capabi...
CLINICAL PRESENTATION <ul><li>Neonates </li></ul><ul><li>Infants </li></ul><ul><li>Older children </li></ul>
THE MOST CONSISTENT SIGN IS PAIN WITH PASSIVE MOTION
CLINICAL PRESENTATION, Neonates <ul><li>Blunted immune response </li></ul><ul><li>Pseudoparalysis </li></ul><ul><li>Irrita...
CLINICAL PRESENTATION, Infants <ul><li>Fever is more prominent </li></ul><ul><li>Irritability, poor feeding, but may appea...
CLINICAL PRESENTATION, Older children <ul><li>Fever, malaise </li></ul><ul><li>Antalgic position: </li></ul><ul><li>Hip: f...
CLINICAL PRESENTATION, Immunocompromised patients <ul><li>Blunted immune response </li></ul><ul><li>Symptoms, signs, & lab...
CLINICAL PRESENTATION, Gonococcal <ul><li>Sexually active teenagers </li></ul><ul><li>Sexual abuse </li></ul><ul><li>Polya...
DIFFERENTIAL DIAGNOSIS <ul><li>Trauma </li></ul><ul><li>Transient synovitis </li></ul><ul><li>Cellulitis </li></ul><ul><li...
WORKUP <ul><li>Indications </li></ul><ul><li>Lab studies </li></ul><ul><li>Imaging studies </li></ul><ul><li>Diagnostic pr...
Indications <ul><li>Aggressive workup is indicated whenever signs and symptoms suggest suppurative arthritis </li></ul>
Lab studies <ul><li>CBC </li></ul><ul><li>ESR </li></ul><ul><li>CRP </li></ul><ul><li>Blood culture </li></ul><ul><li>Othe...
Imaging studies, Plain X-ray <ul><li>To rule out some other conditions </li></ul><ul><li>Neither sensitive nor specific </...
Frontal radiograph of the pelvis shows radiographic signs suggesting right hip joint effusion: lateral displacement of the...
Imaging studies, Ultrasound <ul><li>Highly sensitive </li></ul><ul><li>Confirming a joint effusion in a deeply placed join...
Illustration of correct technique for parasagittal hip US to rule out effusion. The patient is supine and the transducer i...
Parasagittal US image of the hip showing joint effusion Parasagittal US image of the right hip shows the normal juxta-arti...
Imaging studies, CT-Scan <ul><li>Osseous and soft tissue abnormalities </li></ul><ul><li>Ideal for detecting gas in soft t...
Imaging studies, MRI <ul><li>Suppurative arthritis: </li></ul><ul><li>No role in the initial workup </li></ul><ul><li>Use ...
Coronal T1W MR image in a 13 yr old boy with septic arthritis showing right hip effusion.
Imaging studies, MRI <ul><li>Osteomyelitis: </li></ul><ul><li>The best radiologic imaging technique for the identification...
Imaging studies, Radionuclide <ul><li>Technetium-99 methylene diphosphonate </li></ul><ul><li>Symmetric uptake on both sid...
Diagnostic procedures:  joint aspiration <ul><li>The single most important diagnostic procedure </li></ul><ul><li>Use larg...
Diagnostic procedures:  joint aspiration, synovial fluid Poor Good Mucin clot 50 - 90 None(<10) Synovial fluid-to-serum gl...
TREATMENT <ul><li>Medical therapy </li></ul><ul><li>Surgical therapy </li></ul><ul><li>Physical therapy </li></ul>
TREATMENT, Medical therapy <ul><li>Neonates: </li></ul><ul><li>Antistaphylococcal penicillin: nafcillin or oxacillin (150-...
TREATMENT, Medical therapy <ul><li>Children 4 yr and younger: </li></ul><ul><li>Antistaphylococcal </li></ul><ul><li>Cover...
TREATMENT, Medical therapy <ul><li>Children older than 4 yr: </li></ul><ul><li>Antistaphylococcal penicillin </li></ul>
TREATMENT, Medical therapy <ul><li>Special situations: </li></ul><ul><li>Penicillin allergy: clindamycin (30-40 mg/kg/d) <...
TREATMENT, Medical therapy <ul><li>If the pathogen is not identified and the patient is not improving: </li></ul><ul><li>R...
TREATMENT, Medical therapy <ul><li>Duration of antibiotic therapy: </li></ul><ul><li>Generally: continue abx until clinica...
TREATMENT, Medical therapy <ul><li>Use of oral antibiotics: </li></ul><ul><li>It may be considered after 1 wk of i.v. ther...
TREATMENT, Surgical therapy <ul><li>Consider a septic joint as closed abscess </li></ul><ul><li>Daily aspiration: peripher...
TREATMENT, Physical therapy <ul><li>Comfort position vs. extension </li></ul><ul><li>Traction </li></ul><ul><li>Splints </...
COMPLICATIONS <ul><li>Osteonecrosis </li></ul><ul><li>Premature osteoarthritis </li></ul><ul><li>Growth arrest </li></ul><...
COMPLICATIONS
COMPLICATIONS
PROGNOSIS & FOLLOW UP <ul><li>Good, if treatment is established within 1 wk of beginning of symptoms </li></ul><ul><li>Del...
CONTROVESIES <ul><li>Differentiation between septic arthritis and transient synovitis </li></ul><ul><li>Duration of antibi...
REFERRANCES <ul><li>e-Medicine.com, Septic Arthritis, Pediatrics, by Edward P Schwentker, MD </li></ul><ul><li>Nelson, Tex...
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Suppurative Arthritis

  1. 1. SUPPURATIVE ARTHRITIS by AYMAN ABU MEHREM, MD, CABP
  2. 2. SUPPURATIVE ARTHRITIS <ul><li>Introduction </li></ul><ul><li>Epidemiology </li></ul><ul><li>Aetiology </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Clinical presentation </li></ul><ul><li>Workup </li></ul><ul><li>Treatment </li></ul><ul><li>Complications </li></ul><ul><li>Prognosis & follow up </li></ul><ul><li>controversies </li></ul>
  3. 3. INTRODUCTION <ul><li>Suppurative arthritis is a true clinical emergency </li></ul><ul><li>Before antibiotics </li></ul><ul><li>After antibiotics </li></ul><ul><li>After Hib vaccine </li></ul>
  4. 4. EPIDEMIOLOGY <ul><li>Relatively common in infancy & childhood </li></ul><ul><li>Incidence </li></ul><ul><li>Peak: early years of the first decade of life, 50% of cases by 2 yr, and 75% of cases by 5 yr of age </li></ul><ul><li>Boys : Girls = 2 :1 </li></ul><ul><li>Twice as common as osteomyelitis in childhood </li></ul>
  5. 5. ALL PRIMARY CARE PHYSICIANS CARING FOR CHILDREN SHOULD EXPECT TO ENCOUNTER THIS DISEASE
  6. 6. AETIOLOGY <ul><li>Staphylococcus aureus: the most common organism in all age groups </li></ul><ul><li>Streptococcus pyogens & Streptococcus pneumoniae: 10-20% of all cases </li></ul><ul><li>Haemophilis influenzae </li></ul><ul><li>Neisseria gonorrheae: in sexually active adolescents </li></ul><ul><li>Salmonella: common in sicklers </li></ul><ul><li>Kingella kingae: fastidious aerobic G-ve microorganism children < 3 yr </li></ul>
  7. 7. AETIOLOGY …..Cont’d <ul><li>Pseudomonas aeruginosa: puncture wounds of feet </li></ul><ul><li>Other organisms </li></ul><ul><li>Neonates: </li></ul><ul><li>Staphylococcus aureus </li></ul><ul><li>GBS </li></ul><ul><li>G-negative bacteria: 15% in NICU settings </li></ul><ul><li>Candida albicans: multisystems </li></ul><ul><li>indwelling catheters </li></ul>
  8. 8. PATHOPHYSIOLOGY <ul><li>Most commonly, pathogenesis is hematogenous </li></ul><ul><li>Contiguous spread from an adjacent cellulitis </li></ul><ul><li>Penetrating wound: uncommon </li></ul><ul><li>After a procedure </li></ul>
  9. 9. Hematogenous septic arthritis <ul><li>Directly through synovial blood vessels </li></ul><ul><li>Spread from an adjacent hematogenous metaphysial osteomyelitis </li></ul>
  10. 11. PATHOPHYSIOLOGY, Neonates <ul><li>Immature immune system </li></ul><ul><li>Unusual organisms </li></ul><ul><li>Less capability of mounting an inflammatory response to infection </li></ul><ul><li>Premature in the NICU’s </li></ul><ul><li>Commonly involve multiple sites </li></ul>
  11. 12. CLINICAL PRESENTATION <ul><li>Neonates </li></ul><ul><li>Infants </li></ul><ul><li>Older children </li></ul>
  12. 13. THE MOST CONSISTENT SIGN IS PAIN WITH PASSIVE MOTION
  13. 14. CLINICAL PRESENTATION, Neonates <ul><li>Blunted immune response </li></ul><ul><li>Pseudoparalysis </li></ul><ul><li>Irritability, poor feeding </li></ul><ul><li>Lock for other joints & bones </li></ul>
  14. 15. CLINICAL PRESENTATION, Infants <ul><li>Fever is more prominent </li></ul><ul><li>Irritability, poor feeding, but may appear completely comfortable </li></ul><ul><li>Pseudoparalysis </li></ul><ul><li>Localizing signs </li></ul>
  15. 16. CLINICAL PRESENTATION, Older children <ul><li>Fever, malaise </li></ul><ul><li>Antalgic position: </li></ul><ul><li>Hip: flexion, abduction, and external rotation </li></ul><ul><li>Knee & ankle: partial flexion </li></ul><ul><li>Shoulder: adduction, and internal rotation </li></ul><ul><li>Elbow: midflexion </li></ul><ul><li>Limp: antalgic gait, inability to bear weight </li></ul><ul><li>Localizing signs </li></ul>
  16. 17. CLINICAL PRESENTATION, Immunocompromised patients <ul><li>Blunted immune response </li></ul><ul><li>Symptoms, signs, & lab parameters may appear deceptively benign </li></ul>
  17. 18. CLINICAL PRESENTATION, Gonococcal <ul><li>Sexually active teenagers </li></ul><ul><li>Sexual abuse </li></ul><ul><li>Polyarticular: 80% </li></ul><ul><li>Rash </li></ul><ul><li>Tenosynovitis </li></ul>
  18. 19. DIFFERENTIAL DIAGNOSIS <ul><li>Trauma </li></ul><ul><li>Transient synovitis </li></ul><ul><li>Cellulitis </li></ul><ul><li>Bursitis </li></ul><ul><li>JRA </li></ul><ul><li>Rheumatic fever </li></ul><ul><li>Legg-Calv é-Perthes disease </li></ul><ul><li>Lyme disease </li></ul><ul><li>Malignancy </li></ul>
  19. 20. WORKUP <ul><li>Indications </li></ul><ul><li>Lab studies </li></ul><ul><li>Imaging studies </li></ul><ul><li>Diagnostic procedures </li></ul>
  20. 21. Indications <ul><li>Aggressive workup is indicated whenever signs and symptoms suggest suppurative arthritis </li></ul>
  21. 22. Lab studies <ul><li>CBC </li></ul><ul><li>ESR </li></ul><ul><li>CRP </li></ul><ul><li>Blood culture </li></ul><ul><li>Other cultures </li></ul>
  22. 23. Imaging studies, Plain X-ray <ul><li>To rule out some other conditions </li></ul><ul><li>Neither sensitive nor specific </li></ul>
  23. 24. Frontal radiograph of the pelvis shows radiographic signs suggesting right hip joint effusion: lateral displacement of the femoral epiphysis, subtle bulging of the fat planes
  24. 25. Imaging studies, Ultrasound <ul><li>Highly sensitive </li></ul><ul><li>Confirming a joint effusion in a deeply placed joint </li></ul><ul><li>Guiding joint aspiration </li></ul>
  25. 26. Illustration of correct technique for parasagittal hip US to rule out effusion. The patient is supine and the transducer is held perpendicular to the bed just lateral to the common femoral artery and vein.
  26. 27. Parasagittal US image of the hip showing joint effusion Parasagittal US image of the right hip shows the normal juxta-articular soft tissue planes
  27. 28. Imaging studies, CT-Scan <ul><li>Osseous and soft tissue abnormalities </li></ul><ul><li>Ideal for detecting gas in soft tissues </li></ul>
  28. 29. Imaging studies, MRI <ul><li>Suppurative arthritis: </li></ul><ul><li>No role in the initial workup </li></ul><ul><li>Use when other simpler diagnostic measures fail </li></ul>
  29. 30. Coronal T1W MR image in a 13 yr old boy with septic arthritis showing right hip effusion.
  30. 31. Imaging studies, MRI <ul><li>Osteomyelitis: </li></ul><ul><li>The best radiologic imaging technique for the identification of abscesses & for differentiation between bone and soft tissue infection </li></ul><ul><li>Comparable positive predictive value to radionuclide imaging </li></ul><ul><li>Vertebral osteomyelitis, deskitis </li></ul>
  31. 32. Imaging studies, Radionuclide <ul><li>Technetium-99 methylene diphosphonate </li></ul><ul><li>Symmetric uptake on both sides of the joint, limited to the bony structures adjacent to the joint </li></ul><ul><li>Concomitant osteomyelitis </li></ul>
  32. 33. Diagnostic procedures: joint aspiration <ul><li>The single most important diagnostic procedure </li></ul><ul><li>Use large-bore needle before administering Abx </li></ul><ul><li>Peripheral joints: tapped in a clinic setting </li></ul><ul><li>Deep joints: ultrasonic guided,  sedation or GA </li></ul><ul><li>Of vital importance is ensuring that the joint was entered </li></ul>
  33. 34. Diagnostic procedures: joint aspiration, synovial fluid Poor Good Mucin clot 50 - 90 None(<10) Synovial fluid-to-serum glucose diff. (mg/dL) 90 <10 PMN % 10,000 - 250,000 (80,000) 0 - 200 WBC( / μL) Very turbid, white gray Clear-straw color, yellow Appearance Septic arthritis Normal
  34. 35. TREATMENT <ul><li>Medical therapy </li></ul><ul><li>Surgical therapy </li></ul><ul><li>Physical therapy </li></ul>
  35. 36. TREATMENT, Medical therapy <ul><li>Neonates: </li></ul><ul><li>Antistaphylococcal penicillin: nafcillin or oxacillin (150-200 mg/kg/d ÷ q6h) + 3 rd gener. Cephalosporin, cefotaxime (150-200 mg/kg/d) </li></ul><ul><li>Aminoglycosides </li></ul><ul><li>Premature, central lines: </li></ul><ul><li>P. aerugenosa </li></ul><ul><li>CONS </li></ul><ul><li>Fungi </li></ul>
  36. 37. TREATMENT, Medical therapy <ul><li>Children 4 yr and younger: </li></ul><ul><li>Antistaphylococcal </li></ul><ul><li>Cover for Hib </li></ul><ul><li>Cefuroxime </li></ul>
  37. 38. TREATMENT, Medical therapy <ul><li>Children older than 4 yr: </li></ul><ul><li>Antistaphylococcal penicillin </li></ul>
  38. 39. TREATMENT, Medical therapy <ul><li>Special situations: </li></ul><ul><li>Penicillin allergy: clindamycin (30-40 mg/kg/d) </li></ul><ul><li>Penetrating injuries: clindamycin </li></ul><ul><li>SCD: antistaph. + 3 rd gener. Cephalosporin </li></ul><ul><li>Kingella kingae: ampicillin, 1 st , 3 rd gener. Ceph. </li></ul><ul><li>Gonococcal: 3 rd gener. Cephalosporin </li></ul><ul><li>Immunocompromised patients: vancomycin + ceftazidime, or pipercillin-clavulanate + amingly. </li></ul>
  39. 40. TREATMENT, Medical therapy <ul><li>If the pathogen is not identified and the patient is not improving: </li></ul><ul><li>Re-aspiration or biopsy </li></ul><ul><li>Possibility of noninfectious conditions </li></ul>
  40. 41. TREATMENT, Medical therapy <ul><li>Duration of antibiotic therapy: </li></ul><ul><li>Generally: continue abx until clinical condition, ESR, CRP normalize </li></ul><ul><li>S. aureus, G-neg bacilli: minimum 21 days </li></ul><ul><li>Patient showed prompt resolution (5-7 days) </li></ul><ul><li>ESR has normalized </li></ul><ul><li>Otherwise 4-6 wks </li></ul><ul><li>Strep., pneumococcus, Hib: minimum 10-14 d </li></ul>
  41. 42. TREATMENT, Medical therapy <ul><li>Use of oral antibiotics: </li></ul><ul><li>It may be considered after 1 wk of i.v. therapy </li></ul><ul><li>For oral β -lactam drugs: use dosage 2-3 times that used for other infections </li></ul><ul><li>Serum bactericidal titres: 1:8 is desired </li></ul>
  42. 43. TREATMENT, Surgical therapy <ul><li>Consider a septic joint as closed abscess </li></ul><ul><li>Daily aspiration: peripheral joints </li></ul><ul><li>Open drainage: </li></ul><ul><li>1-Hip & shoulder infection </li></ul><ul><li>2-Peripheral joints: if fluids continue to accumulate after 4-5 days of initiation of abx </li></ul><ul><li>3-Systemically ill patients </li></ul>
  43. 44. TREATMENT, Physical therapy <ul><li>Comfort position vs. extension </li></ul><ul><li>Traction </li></ul><ul><li>Splints </li></ul><ul><li>Casts </li></ul><ul><li>Passive ROM exercises </li></ul>
  44. 45. COMPLICATIONS <ul><li>Osteonecrosis </li></ul><ul><li>Premature osteoarthritis </li></ul><ul><li>Growth arrest </li></ul><ul><li>Dislocation </li></ul><ul><li>Misalignment </li></ul><ul><li>Deformity of the epiphysis, physis, or metaphysis </li></ul><ul><li>Bone or fibrous ankylosis and ambulatory disability </li></ul>
  45. 46. COMPLICATIONS
  46. 47. COMPLICATIONS
  47. 48. PROGNOSIS & FOLLOW UP <ul><li>Good, if treatment is established within 1 wk of beginning of symptoms </li></ul><ul><li>Delayed treatment causes severe complications </li></ul><ul><li>Follow up for 1 yr </li></ul>
  48. 49. CONTROVESIES <ul><li>Differentiation between septic arthritis and transient synovitis </li></ul><ul><li>Duration of antibiotics </li></ul><ul><li>Corticosteroids: Stricker et al, J Pediatr Orthop, 1996 </li></ul>
  49. 50. REFERRANCES <ul><li>e-Medicine.com, Septic Arthritis, Pediatrics, by Edward P Schwentker, MD </li></ul><ul><li>Nelson, Textbook of Pediatrics, 17 th edition, 2004, pages 2297-2302 </li></ul><ul><li>Septic Arthritis & Toxic Synovitis, H Gahunia, P Baby </li></ul>

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