Septic arthritis laboratory findings: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Septic arthritis}} | {{Septic arthritis}} | ||
{{CMG}}; '''Associate Editor(s)-In-Chief:''' | {{CMG}}; '''Associate Editor(s)-In-Chief:'''{{VSKP}} | ||
==Overview== | ==Overview== | ||
Patients with history of chronic disease with concurrent septic arthritis can be misdiagnosed as acute flareup of underlying chronic disease which often delays the treatment for septic arthritis. So, patients with acute flare of one or two new inflamed joints with underlying chronic joint diseases or with another connective tissue disease, it should be assumed that the joint is septic until proven otherwise, should always rule out concurrent septic arthritis with appropriate diagnostic studies.<ref name="pmid9449882">Goldenberg DL (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9449882 Septic arthritis.] ''Lancet'' 351 (9097):197-202. [http://dx.doi.org/10.1016/S0140-6736(97)09522-6 DOI:10.1016/S0140-6736(97)09522-6] PMID: [https://pubmed.gov/9449882 9449882]</ref> In patients with acute effusion of unknown etiology, might have concurrent crystal-induced arthritis and septic arthritis. So, the synovial fluid should always be cultured and examined for crystals in the evaluation of an acute effusion.<ref name="pmid8823821">{{cite journal| author=Ilahi OA, Swarna U, Hamill RJ, Young EJ, Tullos HS| title=Concomitant crystal and septic arthritis. | journal=Orthopedics | year= 1996 | volume= 19 | issue= 7 | pages= 613-7 | pmid=8823821 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8823821 }} </ref> | Patients with history of chronic disease with concurrent septic arthritis can be misdiagnosed as acute flareup of underlying chronic disease which often delays the treatment for septic arthritis. So, patients with acute flare of one or two new inflamed joints with underlying chronic joint diseases or with another [[connective tissue disease]], it should be assumed that the joint is septic until proven otherwise, should always rule out concurrent septic arthritis with appropriate diagnostic studies.<ref name="pmid9449882">Goldenberg DL (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9449882 Septic arthritis.] ''Lancet'' 351 (9097):197-202. [http://dx.doi.org/10.1016/S0140-6736(97)09522-6 DOI:10.1016/S0140-6736(97)09522-6] PMID: [https://pubmed.gov/9449882 9449882]</ref> In patients with acute effusion of unknown etiology, might have concurrent [[Crystal arthropathies|crystal-induced arthritis]] and septic arthritis. So, the synovial fluid should always be cultured and examined for crystals in the evaluation of an acute effusion.<ref name="pmid8823821">{{cite journal| author=Ilahi OA, Swarna U, Hamill RJ, Young EJ, Tullos HS| title=Concomitant crystal and septic arthritis. | journal=Orthopedics | year= 1996 | volume= 19 | issue= 7 | pages= 613-7 | pmid=8823821 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8823821 }} </ref> | ||
==Laboratory Findings== | ==Laboratory Findings== | ||
=== Serum markers === | === Serum markers === | ||
Serum markers such as peripheral white cell count, erythrocyte sedimentation | Serum markers such as peripheral [[White blood cells|white cell count]], [[erythrocyte sedimentation rate]], [[C-reactive protein (CRP)|C-reactive protein]] are useful to determine infectious or inflammatory response and also useful to monitor therapeutic response. Absence of raise in these parameters may not be good correlate for the diagnosis of septic arthritis, as these tests are neither sensitive nor specific.<ref name="pmid11157138">Gupta MN, Sturrock RD, Field M (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11157138 A prospective 2-year study of 75 patients with adult-onset septic arthritis.] ''Rheumatology (Oxford)'' 40 (1):24-30. PMID: [https://pubmed.gov/11157138 11157138]</ref> | ||
* '''Peripheral WBC count:''' Peripheral WBC count increases in septic arthritis, especially in children where as in adults it varies with severity.<ref name="pmid9375540">Jeng GW, Wang CR, Liu ST, Su CC, Tsai RT, Yeh TS et al. (1997) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9375540 Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis.] ''Am J Emerg Med'' 15 (7):626-9. PMID: [https://pubmed.gov/9375540 9375540]</ref> It is not sensitive or specific to diagnose septic arthritis. | * '''Peripheral WBC count:''' Peripheral [[WBC]] count increases in septic arthritis, especially in children where as in adults it varies with severity.<ref name="pmid9375540">Jeng GW, Wang CR, Liu ST, Su CC, Tsai RT, Yeh TS et al. (1997) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9375540 Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis.] ''Am J Emerg Med'' 15 (7):626-9. PMID: [https://pubmed.gov/9375540 9375540]</ref> It is not sensitive or specific to diagnose septic arthritis. | ||
* '''Erythrocyte sedimentation ratio:''' Patients with septic arthritis may have ESR > 30 mm/hr, but normal ESR may not | * '''Erythrocyte sedimentation ratio:''' Patients with septic arthritis may have [[ESR]] > 30 mm/hr, but normal ESR may not rule out septic arthritis.<ref name="pmid11157138">Gupta MN, Sturrock RD, Field M (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11157138 A prospective 2-year study of 75 patients with adult-onset septic arthritis.] ''Rheumatology (Oxford)'' 40 (1):24-30. PMID: [https://pubmed.gov/11157138 11157138]</ref> | ||
* '''C- reactive protein:''' Elevated CRP of > 100 mg/L increased the likelihood of septic arthritis slightly.<ref name="pmid10225388">Söderquist B, Jones I, Fredlund H, Vikerfors T (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10225388 Bacterial or crystal-associated arthritis? Discriminating ability of serum inflammatory markers.] ''Scand J Infect Dis'' 30 (6):591-6. PMID: [https://pubmed.gov/10225388 10225388]</ref> | * '''C- reactive protein:''' Elevated [[C-reactive protein|CRP]] of > 100 mg/L increased the likelihood of septic arthritis slightly.<ref name="pmid10225388">Söderquist B, Jones I, Fredlund H, Vikerfors T (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10225388 Bacterial or crystal-associated arthritis? Discriminating ability of serum inflammatory markers.] ''Scand J Infect Dis'' 30 (6):591-6. PMID: [https://pubmed.gov/10225388 10225388]</ref> | ||
=== Synovial Fluid Analysis === | === Synovial Fluid Analysis === | ||
Diagnosis of septic arthritis mainly depends on arthrocentesis and isolation of the pathogen from aspirated joint fluid.<ref name="pmid7355135">Bayer AS (1980) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7355135 Gonococcal arthritis syndromes: an update on diagnosis and management.] ''Postgrad Med'' 67 (3):200-4, 207-8. PMID: [https://pubmed.gov/7355135 7355135]</ref> Clinical suspicion of joint sepsis should prompt for immediate synovial fluid aspiration. Septic arthritis should not be excluded even though the patient have low fever and normal WBC. The definitive diagnosis of septic arthritis requires identification of bacteria in the synovial fluid by | Diagnosis of septic arthritis mainly depends on [[arthrocentesis]] and isolation of the pathogen from aspirated joint fluid.<ref name="pmid7355135">Bayer AS (1980) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7355135 Gonococcal arthritis syndromes: an update on diagnosis and management.] ''Postgrad Med'' 67 (3):200-4, 207-8. PMID: [https://pubmed.gov/7355135 7355135]</ref> Clinical suspicion of joint sepsis should prompt for immediate synovial fluid aspiration. Septic arthritis should not be excluded even though the patient have low [[fever]] and normal [[WBC]]. The definitive diagnosis of septic arthritis requires identification of bacteria in the [[synovial fluid]] by [[Gram stain]] or by culture.<ref name="pmid9449882">Goldenberg DL (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9449882 Septic arthritis.] ''Lancet'' 351 (9097):197-202. [http://dx.doi.org/10.1016/S0140-6736(97)09522-6 DOI:10.1016/S0140-6736(97)09522-6] PMID: [https://pubmed.gov/9449882 9449882]</ref> If synovial fluid cannot be obtained with closed needle aspiration, the joint should be aspirated again with imaging guidance such as [[ultrasound]] guidance, [[computed tomography]] or [[Fluoroscopy|fluoroscopic]] guidance.<ref name="pmid9449882">Goldenberg DL (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9449882 Septic arthritis.] ''Lancet'' 351 (9097):197-202. [http://dx.doi.org/10.1016/S0140-6736(97)09522-6 DOI:10.1016/S0140-6736(97)09522-6] PMID: [https://pubmed.gov/9449882 9449882]</ref> Synovial fluid analysis include: | ||
* Synovial WBC count with differential | * Synovial [[White blood cells|WBC]] count with differential | ||
* Crystal analysis | * Crystal analysis | ||
* Gram stain | * [[Gram staining|Gram stain]] | ||
* Culture and sensitivity | * Culture and sensitivity | ||
Normal synovial fluid appears as clear, transparent, thick in viscosity with WBC count less than 200 mm3 and < 25% of PMN, where as in septic arthritis and other arthritis synovial fluid analysis will be as follows:<ref name="pmid3883171">Goldenberg DL, Reed JI (1985) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3883171 Bacterial arthritis.] ''N Engl J Med'' 312 (12):764-71. [http://dx.doi.org/10.1056/NEJM198503213121206 DOI:10.1056/NEJM198503213121206] PMID: [https://pubmed.gov/3883171 3883171]</ref><ref name="pmid6415361">O'Brien JP, Goldenberg DL, Rice PA (1983) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6415361 Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms.] ''Medicine (Baltimore)'' 62 (6):395-406. PMID: [https://pubmed.gov/6415361 6415361]</ref><ref name="pmid2198352">Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE (1990) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2198352 Synovial fluid tests. What should be ordered?] ''JAMA'' 264 (8):1009-14. PMID: [https://pubmed.gov/2198352 2198352]</ref><ref name="pmid7993152">Wise CM, Morris CR, Wasilauskas BL, Salzer WL (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7993152 Gonococcal arthritis in an era of increasing penicillin resistance. Presentations and outcomes in 41 recent cases (1985-1991).] ''Arch Intern Med'' 154 (23):2690-5. PMID: [https://pubmed.gov/7993152 7993152]</ref><ref name="pmid7547108">Goldenberg DL (1995) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7547108 Bacterial arthritis.] ''Curr Opin Rheumatol'' 7 (4):310-4. PMID: [https://pubmed.gov/7547108 7547108]</ref><ref name="pmid18508984">Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M et al. (2008) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18508984 Management of septic arthritis: a systematic review.] ''Postgrad Med J'' 84 (991):265-70. [http://dx.doi.org/10.1136/ard.2006.058909 DOI:10.1136/ard.2006.058909] PMID: [https://pubmed.gov/18508984 18508984]</ref><ref name="pmid11171695">Jalava J, Skurnik M, Toivanen A, Toivanen P, Eerola E (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11171695 Bacterial PCR in the diagnosis of joint infection.] ''Ann Rheum Dis'' 60 (3):287-9. PMID: [https://pubmed.gov/11171695 11171695]</ref><ref name="pmid8185697">Liebling MR, Arkfeld DG, Michelini GA, Nishio MJ, Eng BJ, Jin T et al. (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8185697 Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction.] ''Arthritis Rheum'' 37 (5):702-9. PMID: [https://pubmed.gov/8185697 8185697]</ref> | Normal synovial fluid appears as clear, transparent, thick in viscosity with WBC count less than 200 mm3 and < 25% of [[PMN]], where as in septic arthritis and other arthritis synovial fluid analysis will be as follows:<ref name="pmid3883171">Goldenberg DL, Reed JI (1985) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3883171 Bacterial arthritis.] ''N Engl J Med'' 312 (12):764-71. [http://dx.doi.org/10.1056/NEJM198503213121206 DOI:10.1056/NEJM198503213121206] PMID: [https://pubmed.gov/3883171 3883171]</ref><ref name="pmid6415361">O'Brien JP, Goldenberg DL, Rice PA (1983) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6415361 Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms.] ''Medicine (Baltimore)'' 62 (6):395-406. PMID: [https://pubmed.gov/6415361 6415361]</ref><ref name="pmid2198352">Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE (1990) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2198352 Synovial fluid tests. What should be ordered?] ''JAMA'' 264 (8):1009-14. PMID: [https://pubmed.gov/2198352 2198352]</ref><ref name="pmid7993152">Wise CM, Morris CR, Wasilauskas BL, Salzer WL (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7993152 Gonococcal arthritis in an era of increasing penicillin resistance. Presentations and outcomes in 41 recent cases (1985-1991).] ''Arch Intern Med'' 154 (23):2690-5. PMID: [https://pubmed.gov/7993152 7993152]</ref><ref name="pmid7547108">Goldenberg DL (1995) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7547108 Bacterial arthritis.] ''Curr Opin Rheumatol'' 7 (4):310-4. PMID: [https://pubmed.gov/7547108 7547108]</ref><ref name="pmid18508984">Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M et al. (2008) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18508984 Management of septic arthritis: a systematic review.] ''Postgrad Med J'' 84 (991):265-70. [http://dx.doi.org/10.1136/ard.2006.058909 DOI:10.1136/ard.2006.058909] PMID: [https://pubmed.gov/18508984 18508984]</ref><ref name="pmid11171695">Jalava J, Skurnik M, Toivanen A, Toivanen P, Eerola E (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11171695 Bacterial PCR in the diagnosis of joint infection.] ''Ann Rheum Dis'' 60 (3):287-9. PMID: [https://pubmed.gov/11171695 11171695]</ref><ref name="pmid8185697">Liebling MR, Arkfeld DG, Michelini GA, Nishio MJ, Eng BJ, Jin T et al. (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8185697 Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction.] ''Arthritis Rheum'' 37 (5):702-9. PMID: [https://pubmed.gov/8185697 8185697]</ref> | ||
{| border="1" | {| border="1" | ||
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Type of | !colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Type of | ||
| Line 65: | Line 65: | ||
crystalline arthritis | crystalline arthritis | ||
(e.g.Gout, | (e.g.[[Gout]], [[Pseudogout]]) | ||
!Yellow | !Yellow | ||
!Cloudy | !Cloudy | ||
| Line 79: | Line 79: | ||
non-crystalline arthritis | non-crystalline arthritis | ||
(e.g. Rheumatoid arthritis, reactive arthritis) | (e.g. [[Rheumatoid arthritis]], [[reactive arthritis]]) | ||
!Yellow | !Yellow | ||
!Cloudy | !Cloudy | ||
| Line 91: | Line 91: | ||
|- | |- | ||
!Noninflammatory arthritis | !Noninflammatory arthritis | ||
(e.g. Osteoarthritis) | (e.g. [[Osteoarthritis]]) | ||
!Straw | !Straw | ||
!Translucent | !Translucent | ||
| Line 102: | Line 102: | ||
!Negative | !Negative | ||
|- | |- | ||
!Lyme arthritis | ![[Lyme's arthritis]] | ||
!Yellow | !Yellow | ||
!Cloudy | !Cloudy | ||
| Line 114: | Line 114: | ||
!Negative | !Negative | ||
|} | |} | ||
* Synovial fluid glucose level < 40 mg/dl and increased lactate level may represent septic arthritis, but these parameters are very less sensitive.<ref name="pmid485744">Sharp JT, Lidsky MD, Duffy J, Duncan MW (1979) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=485744 Infectious arthritis.] ''Arch Intern Med'' 139 (10):1125-30. PMID: [https://pubmed.gov/485744 485744]</ref><ref name="pmid2198352">Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE (1990) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2198352 Synovial fluid tests. What should be ordered?] ''JAMA'' 264 (8):1009-14. PMID: [https://pubmed.gov/2198352 2198352]</ref> | * Synovial fluid [[glucose]] level < 40 mg/dl and increased [[lactate]] level may represent septic arthritis, but these parameters are very less sensitive.<ref name="pmid485744">Sharp JT, Lidsky MD, Duffy J, Duncan MW (1979) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=485744 Infectious arthritis.] ''Arch Intern Med'' 139 (10):1125-30. PMID: [https://pubmed.gov/485744 485744]</ref><ref name="pmid2198352">Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE (1990) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2198352 Synovial fluid tests. What should be ordered?] ''JAMA'' 264 (8):1009-14. PMID: [https://pubmed.gov/2198352 2198352]</ref> | ||
* Presence of crystals may not exclude septic arthritis, as the | * Presence of [[Crystal|crystals]] may not exclude septic arthritis, as the co-existent infection might be possible along with [[Crystal arthropathies|crystalline disease]].<ref name="pmid2198352">Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE (1990) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2198352 Synovial fluid tests. What should be ordered?] ''JAMA'' 264 (8):1009-14. PMID: [https://pubmed.gov/2198352 2198352]</ref><ref name="pmid3735282">Baer PA, Tenenbaum J, Fam AG, Little H (1986) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3735282 Coexistent septic and crystal arthritis. Report of four cases and literature review.] ''J Rheumatol'' 13 (3):604-7. PMID: [https://pubmed.gov/3735282 3735282]</ref> | ||
* Polymerase chain reaction (PCR) test is useful in diagnosing gonococcal arthritis especially in patients with high suspesion of septic arthritis with negative culture. PCR has high specificity (96%) and high sensitivity (76%) with less low false positivity (<4%).<ref name="pmid8185697">Liebling MR, Arkfeld DG, Michelini GA, Nishio MJ, Eng BJ, Jin T et al. (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8185697 Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction.] ''Arthritis Rheum'' 37 (5):702-9. PMID: [https://pubmed.gov/8185697 8185697]</ref> | * [[Polymerase chain reaction]] (PCR) test is useful in diagnosing gonococcal arthritis especially in patients with high suspesion of septic arthritis with negative culture. [[PCR]] has high specificity (96%) and high sensitivity (76%) with less low false positivity (<4%).<ref name="pmid8185697">Liebling MR, Arkfeld DG, Michelini GA, Nishio MJ, Eng BJ, Jin T et al. (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8185697 Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction.] ''Arthritis Rheum'' 37 (5):702-9. PMID: [https://pubmed.gov/8185697 8185697]</ref> | ||
===Arthrocentesis=== | |||
For a detailed approach on performing arthrocentesis watch the video below: | |||
{{#ev:youtube|fZ2dcZhoGP8}} | |||
=== Culture From Other Sites === | === Culture From Other Sites === | ||
Culture | Culture from sites other than synovial fluid is useful in the diagnosis of [[Gonococcal infection|gonococcal]] arthritis or [[disseminated gonococcal infection]] [[gram stain]] and culture of synovial fluid for [[Neisseria gonorrhoeae]] is less reliable.<ref name="pmid6415361">O'Brien JP, Goldenberg DL, Rice PA (1983) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6415361 Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms.] ''Medicine (Baltimore)'' 62 (6):395-406. PMID: [https://pubmed.gov/6415361 6415361]</ref><ref name="pmid7993152">Wise CM, Morris CR, Wasilauskas BL, Salzer WL (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7993152 Gonococcal arthritis in an era of increasing penicillin resistance. Presentations and outcomes in 41 recent cases (1985-1991).] ''Arch Intern Med'' 154 (23):2690-5. PMID: [https://pubmed.gov/7993152 7993152]</ref> | ||
{| border="3" | {| border="3" | ||
! Site of Culture !! Positivity | ! Site of Culture !! Positivity | ||
|- | |- | ||
|alingn=center| Endocervix | |alingn=center| [[Endocervix]] | ||
|alingn=center| ~90% of women | |alingn=center| ~90% of women | ||
|- | |- | ||
|alingn=center| Urethral | |alingn=center| [[Urethral]] | ||
|alingn=center|50-75% | |alingn=center|50-75% | ||
|- | |- | ||
|alingn=center| Pharyngeal | |alingn=center| [[Pharyngeal]] | ||
|alingn=center| 20% | |alingn=center| 20% | ||
|- | |- | ||
|alingn=center| Rectal mucosa | |alingn=center| [[Rectal|Rectal mucosa]] | ||
|alingn=center|15% | |alingn=center|15% | ||
|} | |} | ||
| Line 140: | Line 143: | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
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[[Category:Needs overview]] | [[Category:Needs overview]] | ||
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[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Rheumatology]] | [[Category:Rheumatology]] | ||
[[Category:Emergency medicine]] | |||
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[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | [[Category:Infectious disease]] | ||
[[Category: | [[Category:Orthopedics]] | ||
Latest revision as of 00:08, 30 July 2020
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Septic arthritis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Septic arthritis laboratory findings On the Web |
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American Roentgen Ray Society Images of Septic arthritis laboratory findings |
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Risk calculators and risk factors for Septic arthritis laboratory findings |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief:Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]
Overview
Patients with history of chronic disease with concurrent septic arthritis can be misdiagnosed as acute flareup of underlying chronic disease which often delays the treatment for septic arthritis. So, patients with acute flare of one or two new inflamed joints with underlying chronic joint diseases or with another connective tissue disease, it should be assumed that the joint is septic until proven otherwise, should always rule out concurrent septic arthritis with appropriate diagnostic studies.[1] In patients with acute effusion of unknown etiology, might have concurrent crystal-induced arthritis and septic arthritis. So, the synovial fluid should always be cultured and examined for crystals in the evaluation of an acute effusion.[2]
Laboratory Findings
Serum markers
Serum markers such as peripheral white cell count, erythrocyte sedimentation rate, C-reactive protein are useful to determine infectious or inflammatory response and also useful to monitor therapeutic response. Absence of raise in these parameters may not be good correlate for the diagnosis of septic arthritis, as these tests are neither sensitive nor specific.[3]
- Peripheral WBC count: Peripheral WBC count increases in septic arthritis, especially in children where as in adults it varies with severity.[4] It is not sensitive or specific to diagnose septic arthritis.
- Erythrocyte sedimentation ratio: Patients with septic arthritis may have ESR > 30 mm/hr, but normal ESR may not rule out septic arthritis.[3]
- C- reactive protein: Elevated CRP of > 100 mg/L increased the likelihood of septic arthritis slightly.[5]
Synovial Fluid Analysis
Diagnosis of septic arthritis mainly depends on arthrocentesis and isolation of the pathogen from aspirated joint fluid.[6] Clinical suspicion of joint sepsis should prompt for immediate synovial fluid aspiration. Septic arthritis should not be excluded even though the patient have low fever and normal WBC. The definitive diagnosis of septic arthritis requires identification of bacteria in the synovial fluid by Gram stain or by culture.[1] If synovial fluid cannot be obtained with closed needle aspiration, the joint should be aspirated again with imaging guidance such as ultrasound guidance, computed tomography or fluoroscopic guidance.[1] Synovial fluid analysis include:
- Synovial WBC count with differential
- Crystal analysis
- Gram stain
- Culture and sensitivity
Normal synovial fluid appears as clear, transparent, thick in viscosity with WBC count less than 200 mm3 and < 25% of PMN, where as in septic arthritis and other arthritis synovial fluid analysis will be as follows:[7][8][9][10][11][12][13][14]
| Type of
Arthritis |
Color | Transparency | Viscosity | WBC count
(per mm3) |
PMN
cellcount (%) |
Gram stain | Gram Culture | polymerase chain reaction
(PCR) test |
Crystals |
|---|---|---|---|---|---|---|---|---|---|
| Normal | Clear | Transparent | High/thick | < 200 | < 25 | Negative | Negative | Negative | Negative |
| Gonococcal arthritis | Yellow | Cloudy-opaque | Low | 34,000 to 68,000 | > 75 | Variable (< 50 percent) | Positive (25 to 70 percent) | Positive (> 75 percent) | Negative |
| Non-gonococcal arthritis | Yellowish-green | Opaque | Very low | > 50,000 (> 100,000 is
more specific) |
> 75 | Positive (60 to
80 percent) |
Positive (> 90 percent) | -- | Negative |
| Inflammatory:
crystalline arthritis (e.g.Gout, Pseudogout) |
Yellow | Cloudy | Low/thin | 2,000 to 100,000 | > 50 | Negative | Negative | Negative | Positive |
| Inflammatory:
non-crystalline arthritis |
Yellow | Cloudy | Low/thin | 2,000 to 100,000 | > 50 | Negative | Negative | Negative | Negative |
| Noninflammatory arthritis
(e.g. Osteoarthritis) |
Straw | Translucent | High/thick | 200 to 2,000 | < 25 | Negative | Negative | Negative | Negative |
| Lyme's arthritis | Yellow | Cloudy | Low | 3,000 to 100,000
(mean: 25,000) |
> 50 | Negative | Negative | Positive (85 percent) | Negative |
- Synovial fluid glucose level < 40 mg/dl and increased lactate level may represent septic arthritis, but these parameters are very less sensitive.[15][9]
- Presence of crystals may not exclude septic arthritis, as the co-existent infection might be possible along with crystalline disease.[9][16]
- Polymerase chain reaction (PCR) test is useful in diagnosing gonococcal arthritis especially in patients with high suspesion of septic arthritis with negative culture. PCR has high specificity (96%) and high sensitivity (76%) with less low false positivity (<4%).[14]
Arthrocentesis
For a detailed approach on performing arthrocentesis watch the video below: {{#ev:youtube|fZ2dcZhoGP8}}
Culture From Other Sites
Culture from sites other than synovial fluid is useful in the diagnosis of gonococcal arthritis or disseminated gonococcal infection gram stain and culture of synovial fluid for Neisseria gonorrhoeae is less reliable.[8][10]
| Site of Culture | Positivity |
|---|---|
| Endocervix | ~90% of women |
| Urethral | 50-75% |
| Pharyngeal | 20% |
| Rectal mucosa | 15% |
- Culture of derivatives from skin lesions and blood are rarely positive.
References
- ↑ 1.0 1.1 1.2 Goldenberg DL (1998) Septic arthritis. Lancet 351 (9097):197-202. DOI:10.1016/S0140-6736(97)09522-6 PMID: 9449882
- ↑ Ilahi OA, Swarna U, Hamill RJ, Young EJ, Tullos HS (1996). "Concomitant crystal and septic arthritis". Orthopedics. 19 (7): 613–7. PMID 8823821.
- ↑ 3.0 3.1 Gupta MN, Sturrock RD, Field M (2001) A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 40 (1):24-30. PMID: 11157138
- ↑ Jeng GW, Wang CR, Liu ST, Su CC, Tsai RT, Yeh TS et al. (1997) Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis. Am J Emerg Med 15 (7):626-9. PMID: 9375540
- ↑ Söderquist B, Jones I, Fredlund H, Vikerfors T (1998) Bacterial or crystal-associated arthritis? Discriminating ability of serum inflammatory markers. Scand J Infect Dis 30 (6):591-6. PMID: 10225388
- ↑ Bayer AS (1980) Gonococcal arthritis syndromes: an update on diagnosis and management. Postgrad Med 67 (3):200-4, 207-8. PMID: 7355135
- ↑ Goldenberg DL, Reed JI (1985) Bacterial arthritis. N Engl J Med 312 (12):764-71. DOI:10.1056/NEJM198503213121206 PMID: 3883171
- ↑ 8.0 8.1 O'Brien JP, Goldenberg DL, Rice PA (1983) Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. Medicine (Baltimore) 62 (6):395-406. PMID: 6415361
- ↑ 9.0 9.1 9.2 Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE (1990) Synovial fluid tests. What should be ordered? JAMA 264 (8):1009-14. PMID: 2198352
- ↑ 10.0 10.1 Wise CM, Morris CR, Wasilauskas BL, Salzer WL (1994) Gonococcal arthritis in an era of increasing penicillin resistance. Presentations and outcomes in 41 recent cases (1985-1991). Arch Intern Med 154 (23):2690-5. PMID: 7993152
- ↑ Goldenberg DL (1995) Bacterial arthritis. Curr Opin Rheumatol 7 (4):310-4. PMID: 7547108
- ↑ Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M et al. (2008) Management of septic arthritis: a systematic review. Postgrad Med J 84 (991):265-70. DOI:10.1136/ard.2006.058909 PMID: 18508984
- ↑ Jalava J, Skurnik M, Toivanen A, Toivanen P, Eerola E (2001) Bacterial PCR in the diagnosis of joint infection. Ann Rheum Dis 60 (3):287-9. PMID: 11171695
- ↑ 14.0 14.1 Liebling MR, Arkfeld DG, Michelini GA, Nishio MJ, Eng BJ, Jin T et al. (1994) Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction. Arthritis Rheum 37 (5):702-9. PMID: 8185697
- ↑ Sharp JT, Lidsky MD, Duffy J, Duncan MW (1979) Infectious arthritis. Arch Intern Med 139 (10):1125-30. PMID: 485744
- ↑ Baer PA, Tenenbaum J, Fam AG, Little H (1986) Coexistent septic and crystal arthritis. Report of four cases and literature review. J Rheumatol 13 (3):604-7. PMID: 3735282