rheuma rounds

1. A Rheumatology & Infectious Joint Conference
by
Gresaneth Claire Lumasag, MD
Jennifer Cabanilla, M.D
20 September 2017
West Visayas State University MedicalCenter
Department of Internal Medicine

3. I.
1. Present a case of a 75 y.o with left knee pain
2. Discuss approach to monoarthritis, specifically
on infection related arthritis as to
 Diagnosis
 Pathophysiology
 Etiologic agents
 Management
 Prognosis
 Prevention
objectives
II.
a. Complications
b. Ethical, Moral Decision-making

4. • 75/ F
• Tubungan, Iloilo
• Roman Catholic

5. Left Knee pain
for 4 days
following a simple
gardening chores

6. CASE
4 days PTC Day of Consult
✓Pain of left
knee,
aggravated by
movement,
VAS 5/10
✓Swelling and
warm to
touch
✓Increasing
severity of
left knee pain,
with
limitation of
ROM, VAS 8-
9/10
✓Fever
A
D
M
I
S
S
I
O
N

7. (+) S/P STROKE WITH RESIDUAL LEFT SIDED
WEAKNESS 4/5
MAINTENANCE:
ASA 80MG/TAB 1 TAB OD
LOSARTAN 50MG/TAB 1 TAB OD
(-) PREVIOUS SURGERY OR ADMISSION
(-) TRAUMA
Past medical history

8. (+) Hypertension-
mother
(-) DM
(-) BA
(-) CA
Family history

9. • Housekeeper
• 10 pack-year smoker
• Non-alcoholic
drinker
• Single parent
Personal & Social History

10. At the emergency room
 wheelchair-borne
 Grimacing in pain
 Not in pulmonary
distress
• VITAL SIGNS
• BP 100/60 MMHG
• CR 106 BP M
• RR 18 CPM
• O2 SAT 98% AT ROOM AIR
• BMI 20

11. Skin:
Fair skin, (+) brownish hyperpigmentation on extremities
HEENT:
Anicteric sclerae, pinkish conjunctiva, pupils 2-3mm equally reactive to light and
accommodation, no cervical lymphadenopathies
Chest and Lungs:
Symmetrical Chest expansion, equal vocal and tactile fremiti, clear breath sounds
Heart:
Adynamic precordium, PMI at 5th left intercostal space MCL, normal cardiac rate and
regular rhythm, no murmurs
Abdomen:
Flat, no striations noted, hypoactive bowel sound, soft abdomen,
(-) organomegaly, (-) ascitic fluid wave, (-) direct tenderness
(-) rebound tenderness
Physical examination

12. Extremities:
•LKJ (+) swelling grade 3
• (+) redness
• (+) warm to touch,
• (+) limitation of
• movement
Physical examination

13. Admitting Impression
ACUTE MONOARTHRITIS, PROBABLY
SEPTIC

14. HOWto APPROACH APATIENT presenting WITH acute
monoarthritis?

15. History and physical examination
Is it articularTrauma/fracture
Soft tissue rheumatism
no
> 6 weeks
yes
Chronic
yes
Acute
Infectious arthritris
Crystal induced
Reactive arthritis
No
Signs of inflammation
Chronic
noninflamatory
arthritis
DIP, CMC1,Hip
,Knee joint
osteoarthritis
yes
Osteonecrosis
Charcots joint
no
yesChronic
inflammatory
arthritis
Joints involved
1-3
Psoriatic symmetrical
>3
Psoriatic
Reactive
no
yes
PCP,MCP/MT
P
yes
Rheumatoid
no
SLE/Scleroderma
no

16. Differential Diagnosis:
Infectious (Septic Arthritis)- a direct invasion of joint
space by various microorganisms, most commonly caused
by bacteria.
Crystal induced- an intensely painful type of arthritis
that occurs mainly in the joints of the big toe. It can also
attack the top of the foot and ankle.
Reactive (Infection-related arthritis)- an infection in
another party of the body – usually the intestines,
genitals or urinary tract – triggers an inflammatory
response in the joints.

17. Arthrocentesis!

19. Synovial Fluid Result
Amount 5 cc
Color Yellow with blood tinge
Transparency purulent
Cell count 80448
RBC count 380
Segmenters 82%
Lymphocytes 8%
Gram stain
Many pus cells. Occasional
gram negative bacilli and
gram positive cocci in singles
and in pairs

20. On Admission Result Normal
Hemoglobin 139 g/L 120-160
Hematocrit 0.41 L/L 0.37-0.47
WBC 27.11 4.5-11
Segmenters 0.93 0.50-0.70
Lymphocytes 0.03 0.20-0.40
Platelet 266 150-450
ESR 125 0- 10
A.L.

21. Infectious arthritis,
- direct invasion of joint space by various
microorganisms (bacteria, viruses, mycobacteria
& fungi)
Rheumatologic emergency as joint destruction
occurs rapidly and can lead to significant
morbidity and mortality.
Septic arthritis

22. Infectious Arthritis
Septic
Arthritis
Acute
Monoarticular Polyarticular
Chronic
Monoarticular Polyarticular

23. Etiologic Agents of infectious Arthritis
• Acute
– Monoarticular
• Staphylococcus aureus
• Streptococcus pneumoiae
• Β-Hemolytic streptococci
• Gram Negative bacilli
• Neisseria gonorrhoeae
• Candida spp
– Polyarticular
• Immunologic reaction
(endocarditis, rheumatic fever,
dessiminated nesserial
infection, acute hepatitis B)
• Chronic
– Mycobacterium tuberculosis
– Non tuberculous mycobacteria
– Borrelia burgdoferi
– Treponema pallidum
– Candida spp
– Sporothrix schenckii
– Coccioides immitis
– Blastomyces dermatitidis
– Aspergillus spp
– Cryptococcus neoformans
– Nocardia spp
– Brucella spp

24. Infectious arthritis,
- direct invasion of joint space by various
microorganisms (bacteria, viruses, mycobacteria
& fungi)
Rheumatologic emergency as joint destruction
occurs rapidly and can lead to significant
morbidity and mortality.
Septic arthritis

27. Treatment
Antibiotics + Drainage with Culture
IV VancomycinIV 3rd Gen Cephalosporin MRSA ?
yes
Oxacillin or Nafcillin
Definitive therapy is based on Isolated organism and antibiotic susceptibility
no

28. Treatment
• Staphylococcal – oxacillin, nafcillin, vancomycin (4 weeks)
• Pneumococcal and Streptococcal
– penicillin-susceptible– Penicillin G (2 weeks)
– Penicillin-resistant- Cefotaxime /Ceftriaxone (2 weeks)
• Gram Negative – 2nd or 3rd gen Cephalosporin IV or IV
Flouroquinolone (3-4 weeks)
• Pseudomonas – combination aminoglycoside+ extended
spectrum penicillin or antipseudomonal cephalosporin (4
weeks)
• Gonococcal –IV/IM Ceftriaxone q24H

29. ❖Elderly >60 years
❖Diabetes mellitus
❖Rheumatoid arthritis
❖Prosthetic joint
❖Recent joint surgery
❖Skin infection, cutaneous ulcers
❖IV drug abuse, alcoholism
❖Previous intra-articular injection
PREDISPOSING FACTORS

30. RISK FACTORS
 Age > 60 y.o
 female
 Recent Bacteremia
 Degenerative joint disease
 Rheumatoid Arthritis
 Corticosteroid therapy
 Co-morbidities (DM, Cirrhosis,
Renal Disease)
 Immunocompromised State
(eg. HIV)
Hematogenous
Spread
Direct
Introduction
Extension from
Contiguous site
Of infection
Recent Trauma/
Injury
Bacterial Seeding within the space
Bacterial Adherence and
Colonization

31. • Blood- WBC, CRP, ESR- low specificity;
suggestive but not diagnostic
• WBC>10 000
• ESR>30
• CRP>100
DIAGNOSTICS: What to Request?

32. DIAGNOSIS
• Synovial fluid
usually purulent with increased count (50,000 to
150,000 cells/mm3)
The synovial fluid glucose is often depressed and
lactic acid concentration is elevated.

33. DIAGNOSIS

34. OTHER DIAGNOSTIC
MODALITIES
• X-ray, CT, MRI: less helpful in diagnosis
The earliest findings are soft tissue swelling
around the joint and a widened joint space
from joint effusion.
Can demonstrate: joint effusion
Synovial thickening
Perisynovial edema
Cartilage destruction
Bone destruction
Bursitis, tenosynovitis

35. DIAGNOSIS
 Blood cultures are
positive in about 50
percent of cases.
Blood culture: NO GROWTH

36. TREATMENT
The first priority is to aspirate
the joint and the fluid. Treatment
is then started without further
delay!

37. TREATMENT
• Principle:
Antibiotics
Joint drainage
Joint rest.

39. Duration of Treatment
• No controlled trials
• Usually IV antibiotics at least 2 weeks in
duration followed by at least two weeks oral
therapy
• May need longer for particular organisms- P.
aeruginosa, Enterobacter spp. or S. Aureus
with septicaemia

40. TREATMENT
• Principle:
Antibiotics
Joint drainage
Joint rest.

41. Joint Drainage
• Aim to remove pus from joint space- i.e. drain
abscess
– Surgical: arthroscopy or arthrotomy
– Closed needle aspiration

42. Indication of Surgical Drainage
1. Joints that do not respond to antimicrobial
therapy and daily arthrocentesis
2. Any joint with limited accessibility, including the
sternoclavicular joint or the hip joint
3. Patients with underlying disease, including DM,
RA, immunosuppression, or other systemic
symptoms, should be treated aggressively with
earlier surgical intervention

43. 2nd Hospital Day
(+) abdominal pain
(+) vomiting
(+) cold clammy extremities
Rpt ECG: ST elevation high lateral wall
Trop I: 27

44. • ECG:
• Assessment: Acute Coronary Syndrome- ST
Elevation MI- lateral wall

45. Arthrotomy: risks and benefits

46. TREATMENT
• Principle:
Antibiotics
Joint drainage
Joint rest

47. JOINT REST
General support:
analgesics, antipyretics and joint splintage
for first few days.

48. GUIDELINES

49. Are intra-articular antibiotics preferred
over systemic antibiotics?
Intra-articular antibiotics are not
recommended because effective parenteral
or oral therapy produces adequate levels of
antimicrobial agents in joint fluid.
In addition, direct instillation of antibiotics
into a joint may cause an inflammatory
response

50. How can the risk of septic arthritis be decreased
in hospitalized patients?
• 1. Prompt treatment of local skin infections
• 2. Prompt identification and control of bacteremia.
• 3. Removal of intravenous catheters as soon as
possible, and only placing such catheters when
needed.
• 4. Exercising discretion regarding the use of intra-
articular corticosteroid injections and invasive
orthopedic procedures in patients at high risk for septic
arthritis.

51. What can be done to alter morbidity and
mortality associated with septic arthritis?
• 1. Joint aspiration for a synovial fluid sample before
initiation of antibiotics.
• 2. Initiation of empiric antibiotic therapy as soon as
possible
• 3. Adjustment of antibiotic therapy as soon as synovial
fluid culture and susceptibility results are available.

52. 4. Prompt drainage of the infected joint
5. Monitoring response to therapy with serial
synovial fluid analyses with or without serum
inflammatory markers (ESR, CRP).
6. Treatment with antibiotics for at least 3 to 4
weeks, with initial parental therapy.

53. COMPLICATIONS
Partial or complete destruction of
epiphysis.
Retarded growth
Ankylosis
Osteomyelitis
Sepsis

54. PATHOPHYSIOLOGY

55. PROGNOSIS
Poor outcome predictors:
Age older than 60 years
Infection of hip or shoulder
Underlying RA
Persistent positive findings.
Delay in therapy.

56. PROGNOSIS
Irreversible loss of joint function in 25-
50%
Mortality ranges from 5-15%6.

57. KEYPOINTS
• Acute monoarthritis – EMERGENCY!
• Untreated septic arthritis  rapid joint
destruction

58. • Consider septic arthritis in patients with
underlying inflammatory arthritis if one joint
is more acutely inflamed than the others
• Aspiration of the involved joint is critical to
identifying the organism
KEYPOINTS

59. • Thank you