Infection and Arthritis

1. Infection and Arthritis Max S Lundberg, MD

2. 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.

3. 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

4. Microbes & ArthritisOverview and Classification

5. Septic Arthritis Arthritis resulting from infection of one or more joints by a microorganism (usually bacterial)

6. Bacteria found in bone and joint infection

7. Septic ArthritisEpidemiology 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

8. Septic ArthritisRisk 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

9. Septic ArthritisPredisposing Conditions

11. Septic Arthritis18 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%

12. Septic ArthritisSynovial fluid isolates in Adult Septic Arthritis

13. Septic ArthritisAdults versus Children

14. Septic ArthritisJoints affected (non-gonococcal)

15. Septic ArthritisBacteria isolated in Children (n=146) prior to 1980

16. Septic ArthritisChildren, age < 24 months - Bacteria isolated 1988-93 review of cases 40 patients (26 male, 14 female) Kingella kingae Haemophilus influenzae Type B Other

17. Septic ArthritisClinical Features Joint swelling and pain Pain with range of motion, immobility Fever Signs of sepsis Distribution usually monoarticular Large joints most often involved

20. Classification of Joint Effusions

21. Septic ArthritisChildren, age < 24 months - Clinical Presentation 1988-93 review of cases 40 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

22. Septic ArthritisDiagnostic Tests Synovial Fluid Analysis WBC count > 50,000 PMNs > 90% Gram stain and culture* Blood culture Radiology

23. Septic ArthritisJoint 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

24. Septic ArthritisNatural History

26. Septic ArthritisTreatment Joint Drainage Repeated needle aspiration Surgical Drainage Antibiotic Therapy Synovial Fluid and Blood Cultures Serial Synovial Fluid Analysis Extended Duration of Treatment (6 weeks)

27. Septic ArthritisOutcome of Treatment by Mode of Drainage

28. Septic ArthritisOutcome of Treatment by Infecting Organism

30. Septic ArthritisInfection 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

31. Gonococcal ArthritisPopulations 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)

32. Gonococcal ArthritisTenosynovitis, dermatitis, polyarthralgia syndrome Acute illness with fever, chills, malaise. Tenosynovitis Generalized arthralgia Dermatitis: pustular or vesicopustular

33. Gonococcal ArthritisPurulent (septic) arthritis Monoarticular or Pauciarticular Large joint involvement (knees, wrists, ankles) Most patients are afebrile Signs of disseminated infection are rare

34. Septic Bursitis Superficial bursae are commonly affected (pre-patellar and olecranon bursae) Underlying joint infection is not common Acute or repetitive Trauma Staph aureus Drainage Antibiotics

36. Osteomyelitis Acute Children and young adults Children < 1 year often have osteomyelitis with septic arthritis and septicemia together. Chronic and Sub-acute Most often follow trauma or surgery Prolonged antibiotic treatment Surgical debridement

38. 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)

39. Viral ArthritisViruses that cause arthritis

40. Viral ArthritisParvovirus B19 Erythema Infectiosum (fifth disease) Children 10% Arthralgia 5% oligoarticular arthritis Adults Up to 80% with joint symptoms Chronic Recurrent Arthritis

41. Viral ArthritisParvovirus 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.

42. Viral ArthritisHepatitis B Sudden onset Symmetric polyarthritis, (hands and knees are most common) Urticarial rash Arthritis usually goes away before onset of jaundice

43. Viral ArthritisHepatitis C Serum transaminases may be normal Essential Mixed Cryoglobulinemia Arthritis Palpable purpura Cryoglobulins Urticarial rash Arthritis usually goes away before onset of jaundice

44. Viral ArthritisRubella Arthritis Post-pubertal females Sudden onset Symmetric polyarthritis Tenosynovitis (carpal tunnel syndrome) May occur with some live attenuated virus vaccines.

45. Viral ArthritisSyndromes 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

46. 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, photo-phobia, 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.

49. 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)

53. Lyme Disease Early Localized Disease Early Disseminated Disease Carditis Neurologic manifestations Late Disease Muculoskeletal complaints Tertiary neuroborreliosis Cutaneous manifestations

54. Lyme Disease Musculoskeletal Manifestations (80% 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.