Infection and Arthritis

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Infection and Arthritis

• Max S Lundberg, MD

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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.

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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

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Microbes ArthritisOverview and Classification
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Septic Arthritis

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

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Bacteria found in bone and joint infection
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Septic ArthritisEpidemiology

• Elderly or very young
• Underlying chronic illness
• Increased incidence with warmer climates and
  poorer socioeconomic status
• 110,000 annual incidence in Northern European
  children

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Septic ArthritisRisk Factors

• Age gt 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

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Septic ArthritisPredisposing Conditions
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Pathogenesis
1. Hematogenous 2. Dissemination from
osteomyelitis 3. Spread from adjacent soft tissue
infection 4. Diagnostic or therapeutic
measures 5. Penetrating damage by puncture or
cutting.
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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

Morgan DS Fisher D Merianos A Currie BJ
Epidemiol Infect 1996 Dec117(3)423-8.
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Septic ArthritisSynovial fluid isolates in Adult
Septic Arthritis
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Septic ArthritisAdults versus Children
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Septic ArthritisJoints affected (non-gonococcal)
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Septic ArthritisBacteria isolated in Children
(n146) prior to 1980
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Septic ArthritisChildren, age lt 24 months -
Bacteria isolated

• 1988-93 review of cases
• 40 patients (26 male, 14 female)
• Kingella kingae
• Haemophilus influenzae Type B
• Other

19 8 13
Arch Pediatr Adolesc Med 1995 May149(5)537-40
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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

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Classification of Joint Effusions
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Septic ArthritisChildren, age lt 24 months -
Clinical Presentation

• 1988-93 review of cases
• 40 patients (26 male, 14 female)
• Temp lt 38.3 in 14/40
• WBC lt 15K in 13/38
• ESR lt 30 in 4/36
• Synovial fluid WBC lt 50K in 8/22

Arch Pediatr Adolesc Med 1995 May149(5)537-40
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Septic ArthritisDiagnostic Tests

• Synovial Fluid Analysis
• WBC count gt 50,000
• PMNs gt 90
• Gram stain and culture
• Blood culture
• Radiology

Early changes are non-specific
Diagnostic changes occur later
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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

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Septic ArthritisNatural History
Experimental bacterial arthritis induced
Maximal acute arthritis symptoms
Chronic or irreversible changes
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Time (days)
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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)

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Septic ArthritisOutcome of Treatment by Mode of
Drainage
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Septic ArthritisOutcome of Treatment by
Infecting Organism
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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

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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)

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Gonococcal ArthritisTenosynovitis, dermatitis,
polyarthralgia syndrome

• Acute illness with fever, chills, malaise.
• Tenosynovitis
• Generalized arthralgia
• Dermatitis pustular or vesicopustular

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Gonococcal ArthritisPurulent (septic) arthritis

• Monoarticular or Pauciarticular
• Large joint involvement (knees, wrists, ankles)
• Most patients are afebrile
• Signs of disseminated infection are rare

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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

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Osteomyelitis

• Acute
• Children and young adults
• Children lt 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

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Viral Arthritis

• Inflammatory polyarthritis, similar to early RA
• Duration usually lt 1 month, self limited illness
• Not destructive to joint
• Prodromal symptoms
• Fever
• Rash
• Supportive Treatment (NSAIDs, Analgesics)

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Viral ArthritisViruses that cause arthritis
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Viral ArthritisParvovirus B19

• Erythema Infectiosum (fifth disease)
• Children
• 10 Arthralgia
• 5 oligoarticular arthritis
• Adults
• Up to 80 with joint symptoms
• Chronic Recurrent Arthritis

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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.

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Viral ArthritisHepatitis B

• Sudden onset
• Symmetric polyarthritis, (hands and knees are
  most common)
• Urticarial rash
• Arthritis usually goes away before onset of
  jaundice

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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

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Viral ArthritisRubella Arthritis

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

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Viral ArthritisSyndromes observed with HIV
infection

• Arthralgia
• Reiters Syndrome
• Psoriatic Arthritis
• Undifferentiated Spondyloarthropathy
• Idiopathic or HIV associated arthritis
• Aseptic Necrosis
• Septic Arthritis
• Sjogrens-like Syndrome
• Inflammatory and non-inflammatory myopathy
• Systemic Vasculitis
• Lupus-like Syndrome

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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).
• Onyong-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.

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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-Feb20(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.
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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)

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Lyme Disease

• Early Localized Disease
• Early Disseminated Disease
• Carditis
• Neurologic manifestations
• Late Disease
• Muculoskeletal complaints
• Tertiary neuroborreliosis
• Cutaneous manifestations

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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.