Septic arthritis differential diagnosis: Difference between revisions

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{{CMG}};{{AE}}{{VSKP}}
{{CMG}};{{AE}}{{VSKP}}
==Overview==
==Overview==
Septic arthritis should be differentiate from other causes of monoarticular arthritis such as other infectious arthritis, inflmmatory arthritis, non inflammatory arthritis, hemorrhagic arthritis and intra articular derangement that causes acute arthritis. Most cases of acute septic arthritis are caused by bacteria such as [[staphylococcus]] or [[streptococcus]] and it should be differentiated from other causes of arthritis as prompt diagnosis and rapid treatment is required to limit the complications.  
Septic arthritis should be differentiate from other causes of monoarticular arthritis such as other [[infectious arthritis]], [[inflammatory arthritis]], [[Osteoarthritis|non inflammatory arthritis]], [[Coagulopathies|hemorrhagic arthritis]] and intra articular derangement that causes acute arthritis. Most cases of acute septic arthritis are caused by bacteria such as [[staphylococcus]] or [[streptococcus]] and it should be differentiated from other causes of arthritis as prompt diagnosis and rapid initiation of treatment is required to limit the complications.  


==Differential Diagnosis==
==Differential Diagnosis==
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* Female > male
* Female > male
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|
* Patient with history of rheumatoid arthritis or other systemic arthritis
* Patient with history of [[rheumatoid arthritis]] or other systemic arthritis
* Immunocompromised patient  
* [[Immunocompromised]] patient  
* Common in extremes of age such as in newborn or elderly
* Common in extremes of age such as in newborn or elderly
|-
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* Migratory polyarthralgia is common
* Migratory polyarthralgia is common
* Tenosynovitis in majority of patients
* [[Tenosynovitis]] in majority of patients
* Dermatitis in majority of patients
* [[Dermatitis]] in majority of patients
|
|
* Single hot, swollen and painful joint
* Single hot, swollen and painful joint
* Polyarthralgia is very rare
* Polyarthralgia is very rare


* Tenosynovitis and dermatitis are very rare.
* [[Tenosynovitis]] and [[dermatitis]] are very rare.
|-
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!Polyarticular involvement
!Polyarticular involvement
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!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Key clinical clues}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Key clinical clues}}
|-
|-
! '''Staphylococcus aureus'''
! '''[[Staphylococcus aureus]]'''
|
|
* Rheumatioid arthritis<ref name="pmid769545">Goldenberg DL, Cohen AS (1976) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=769545 Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis).] ''Am J Med'' 60 (3):369-77. PMID: [https://pubmed.gov/769545 769545]</ref>  
* [[Rheumatoid arthritis]]<ref name="pmid769545">Goldenberg DL, Cohen AS (1976) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=769545 Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis).] ''Am J Med'' 60 (3):369-77. PMID: [https://pubmed.gov/769545 769545]</ref>  
* Diabetes mellitus<ref name="pmid8689280">Le Dantec L, Maury F, Flipo RM, Laskri S, Cortet B, Duquesnoy B et al. (1996) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8689280 Peripheral pyogenic arthritis. A study of one hundred seventy-nine cases.] ''Rev Rhum Engl Ed'' 63 (2):103-10. PMID: [https://pubmed.gov/8689280 8689280]</ref>
* [[Diabetes mellitus]]<ref name="pmid8689280">Le Dantec L, Maury F, Flipo RM, Laskri S, Cortet B, Duquesnoy B et al. (1996) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8689280 Peripheral pyogenic arthritis. A study of one hundred seventy-nine cases.] ''Rev Rhum Engl Ed'' 63 (2):103-10. PMID: [https://pubmed.gov/8689280 8689280]</ref>
* HIV patients<ref name="pmid9279334">Vassilopoulos D, Chalasani P, Jurado RL, Workowski K, Agudelo CA (1997) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9279334 Musculoskeletal infections in patients with human immunodeficiency virus infection.] ''Medicine (Baltimore)'' 76 (4):284-94. PMID: [https://pubmed.gov/9279334 9279334]</ref>
* [[Human Immunodeficiency Virus (HIV)|HIV]] patients<ref name="pmid9279334">Vassilopoulos D, Chalasani P, Jurado RL, Workowski K, Agudelo CA (1997) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9279334 Musculoskeletal infections in patients with human immunodeficiency virus infection.] ''Medicine (Baltimore)'' 76 (4):284-94. PMID: [https://pubmed.gov/9279334 9279334]</ref>
|
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* Healthy adult with skin lesions and previously history of damaged joint (e.g, rheumatoid arthritis) or prosthetic joint
* Healthy adult with skin lesions and previously history of damaged joint (e.g, [[rheumatoid arthritis]]) or [[Prosthetic|prosthetic joint]]
|-
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! '''Streptococcus pyogenes'''  
! '''[[Streptococcus pyogenes]]'''  
'''Streptococcal pneumonia'''
'''[[Streptococcal Infection|Streptococcal pneumonia]]'''
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* Autoimmune diseases<ref name="pmid8972665">Morgan DS, Fisher D, Merianos A, Currie BJ (1996) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8972665 An 18 year clinical review of septic arthritis from tropical Australia.] ''Epidemiol Infect'' 117 (3):423-8. PMID: [https://pubmed.gov/8972665 8972665]</ref>
* [[Autoimmune diseases]]<ref name="pmid8972665">Morgan DS, Fisher D, Merianos A, Currie BJ (1996) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8972665 An 18 year clinical review of septic arthritis from tropical Australia.] ''Epidemiol Infect'' 117 (3):423-8. PMID: [https://pubmed.gov/8972665 8972665]</ref>
* Chronic skin infections<ref name="pmid8689280">Le Dantec L, Maury F, Flipo RM, Laskri S, Cortet B, Duquesnoy B et al. (1996) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8689280 Peripheral pyogenic arthritis. A study of one hundred seventy-nine cases.] ''Rev Rhum Engl Ed'' 63 (2):103-10. PMID: [https://pubmed.gov/8689280 8689280]</ref>  
* Chronic skin infections<ref name="pmid8689280">Le Dantec L, Maury F, Flipo RM, Laskri S, Cortet B, Duquesnoy B et al. (1996) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8689280 Peripheral pyogenic arthritis. A study of one hundred seventy-nine cases.] ''Rev Rhum Engl Ed'' 63 (2):103-10. PMID: [https://pubmed.gov/8689280 8689280]</ref>  
* Trauma
* Trauma
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* Healthy adults with spleenic dysfunction
* Healthy adults with spleenic dysfunction
|-
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! '''Groups B Streptococcal infection'''
! '''[[Group B streptococcal infection|Groups B Streptococcal infection]]'''
|
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* Immunocompromised patients<ref name="pmid9556703">Schattner A, Vosti KL (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9556703 Bacterial arthritis due to beta-hemolytic streptococci of serogroups A, B, C, F, and G. Analysis of 23 cases and a review of the literature.] ''Medicine (Baltimore)'' 77 (2):122-39. PMID: [https://pubmed.gov/9556703 9556703]</ref>  
* [[Immunocompromised]] patients<ref name="pmid9556703">Schattner A, Vosti KL (1998) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9556703 Bacterial arthritis due to beta-hemolytic streptococci of serogroups A, B, C, F, and G. Analysis of 23 cases and a review of the literature.] ''Medicine (Baltimore)'' 77 (2):122-39. PMID: [https://pubmed.gov/9556703 9556703]</ref>  
* Diabetes mellitus  
* [[Diabetes mellitus]]
* Malignancy  
* [[Malignancy]]
* Severe genitourinary or gastrointestinal infections
* Severe [[Genitourinary pathology|genitourinary]] or gastrointestinal infections
|
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* Healthy adults with spleenic dysfunction
* Healthy adults with spleenic dysfunction
|-
|-
!'''Neisseria gonorrhoeae'''
!'''[[Neisseria gonorrhoeae]]'''
|
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* Complement deficiency
* [[Complement deficiency]]
* Systemic lupus erythematosus
* [[Systemic lupus erythematosus]]
* Male homosexuality
* Male homosexuality
* low socioeconomic status
* low socioeconomic status
|
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* Healthy young and sexually active adult with
* Healthy young and sexually active adult with
** Tenosynovitis
** [[Tenosynovitis]]
** Skin lesions such as vesicular pustules
** Skin lesions such as [[Pustules|vesicular pustules]]
** Complement deficiency (C5-9 deficiency)  
** [[Complement deficiency]] (C5-9 deficiency)  
** Culture negativity on synovial fluid analysis
** Culture negativity on synovial fluid analysis
|-
|-
| '''Gram-negative bacilli'''
| '''[[Gram-negative bacilli]]'''
* Pseudomonas
* [[Pseudomonas]]


* Escherichia coli
* [[Escherichia coli]]
|
|
* History of intravenous drug abuse<ref name="pmid2283490">Deesomchok U, Tumrasvin T (1990) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2283490 Clinical study of culture-proven cases of non-gonococcal arthritis.] ''J Med Assoc Thai'' 73 (11):615-23. PMID: [https://pubmed.gov/2283490 2283490]</ref>  
* History of intravenous drug abuse<ref name="pmid2283490">Deesomchok U, Tumrasvin T (1990) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2283490 Clinical study of culture-proven cases of non-gonococcal arthritis.] ''J Med Assoc Thai'' 73 (11):615-23. PMID: [https://pubmed.gov/2283490 2283490]</ref>  
* Extremes of age  
* Extremes of age  
* Immunocompromised patients
* [[Immunocompromised host|Immunocompromised patients]]
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|
* Immunocompromised patients
* [[Immunocompromised host|Immunocompromised patients]]
* Recent history gastrointestinal infections such as infectious diarrhea caused by Shigella, Salmonella, Campylobacter, or Yersinia
* Recent history gastrointestinal infections such as [[infectious diarrhea]] caused by [[Shigella]], [[Salmonella]], [[Campylobacter]], or [[Yersinia]]
|-
|-
!'''Haemophilus influenzae'''
!'''[[Haemophilus influenzae]]'''
|
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* Unimmunized children<ref name="pmid7497542">De Jonghe M, Glaesener G (1995) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7497542 [Type B Haemophilus influenzae infections. Experience at the Pediatric Hospital of Luxembourg].] ''Bull Soc Sci Med Grand Duche Luxemb'' 132 (2):17-20. PMID: [https://pubmed.gov/7497542 7497542]</ref>
* Unimmunized children<ref name="pmid7497542">De Jonghe M, Glaesener G (1995) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7497542 [Type B Haemophilus influenzae infections. Experience at the Pediatric Hospital of Luxembourg].] ''Bull Soc Sci Med Grand Duche Luxemb'' 132 (2):17-20. PMID: [https://pubmed.gov/7497542 7497542]</ref>
|
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|-
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!'''Anaerobes'''
!'''[[Anaerobes]]'''
|
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* Diabetes mellitus   
* [[Diabetes mellitus]]    
* Patients with prosthetic joints
* Patients with [[Prosthetic|prosthetic joints]]
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* Immunocompromised hosts
* [[Immunocompromised host|Immunocompromised hosts]]
* Recent history of gastrointestinal infection
* Recent history of gastrointestinal infection
|-
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!'''Mycobacterium spp.'''
!'''[[Mycobacterium|Mycobacterium spp.]]'''
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* Recent history of travel to endemic areas
* Recent history of travel to endemic areas
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* Immunocompromised patients
* [[Immunocompromised host|Immunocompromised patients]]
* Recent history of travel to endemic areas (e.g. India, South Africa, Mexico etc.)
* Recent history of travel to endemic areas (e.g. India, South Africa, Mexico etc.)
* Incidious onset of monoarthritis
* Incidious onset of monoarthritis
|-
|-
|'''Fungal infection''' such as  
|'''Fungal infection''' such as  
* Blastomycosis  
* [[Blastomycosis]]
* Cryptococcus  
* [[Cryptococcus]]
* Coccidioidomycosis
* [[Coccidioidomycosis]]
* Sporotrichosis
* [[Sporotrichosis]]
|
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* Immunocompromised patients
* [[Immunocompromised host|Immunocompromised patients]]
|
|
* Immunocompromised patients
* [[Immunocompromised host|Immunocompromised patients]]
* Incidious onset of monoarthritis
* Incidious onset of monoarthritis
|-
|-
!'''Mycoplasma hominis'''
!'''[[Mycoplasma hominis]]'''
|
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* Recent history of urinary tract procedure  
* Recent history of urinary tract procedure  
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* Immunocompromised patients
* [[Immunocompromised host|Immunocompromised patients]]
* Recent history of urinary tract procedure<ref name="pmid7888535">Luttrell LM, Kanj SS, Corey GR, Lins RE, Spinner RJ, Mallon WJ et al. (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7888535 Mycoplasma hominis septic arthritis: two case reports and review.] ''Clin Infect Dis'' 19 (6):1067-70. PMID: [https://pubmed.gov/7888535 7888535]</ref>
* Recent history of urinary tract procedure<ref name="pmid7888535">Luttrell LM, Kanj SS, Corey GR, Lins RE, Spinner RJ, Mallon WJ et al. (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7888535 Mycoplasma hominis septic arthritis: two case reports and review.] ''Clin Infect Dis'' 19 (6):1067-70. PMID: [https://pubmed.gov/7888535 7888535]</ref>
|-
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!Viral arthritis
!Viral arthritis
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* Immunocompromised patient
* [[Immunocompromised host|Immunocompromised patient]]
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* Polyarthritis
* Polyarthritis
* Fever
* [[Fever]]
* Rash
* [[Rash]]
|-
|-
!HIV infection
![[Human Immunodeficiency Virus (HIV)|HIV infection]]
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* History of multiple sexual partners
* History of multiple sexual partners
* History of IVDA
* History of IVDA
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* Sterile, acute synovitis or reactive arthritis
* Sterile, acute [[synovitis]] or [[reactive arthritis]]
|-
|-
!Lyme disease
![[Lyme disease]]
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* History of recent visit to endemic Lyme area
* History of recent visit to endemic Lyme area
|
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* History of erythema Serology migrans
* History of [[Erythema chronicum migrans|erythema migrans]]
* History of recent visit to endemic Lyme area
* History of recent visit to endemic Lyme area
|-
|-
!Reactive arthritis
![[Reactive arthritis]]
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* Recent gastrointestinal/  genitourinary infection
* Recent gastrointestinal/  genitourinary infection
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* Recent gastrointestinal/  genitourinary infection
* Recent gastrointestinal/  genitourinary infection
* Enthesopathy
* [[Enthesopathy]]
* Skin lesions  
* Skin lesions  
* Uveitis
* [[Uveitis]]
* Conjunctivitis
* [[Conjunctivitis]]
|-
|-
!Endocarditis
![[Endocarditis]]
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* History of endocarditis
* History of [[endocarditis]]
* Damaged heart valves
* Damaged heart valves
* Congenital heart diseases
* [[Congenital heart diseases]]
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* Fever
* [[Fever]]
* New onset of heart murmur
* New onset of heart [[Heart murmur|murmur]]
* Septic and sterile synovitis
* Septic and sterile [[synovitis]]
** Septic joint more common in IVDA
** Septic joint more common in IVDA
|}
|}

Revision as of 20:56, 25 January 2017

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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

Septic arthritis should be differentiate from other causes of monoarticular arthritis such as other infectious arthritis, inflammatory arthritis, non inflammatory arthritis, hemorrhagic arthritis and intra articular derangement that causes acute arthritis. Most cases of acute septic arthritis are caused by bacteria such as staphylococcus or streptococcus and it should be differentiated from other causes of arthritis as prompt diagnosis and rapid initiation of treatment is required to limit the complications.

Differential Diagnosis

Differentiating gonococcal arthritis from non-gonococcal arthritis
Characteristic Gonococcal arthritis Non gonococcal arthritis
Patient profile
  • Mostly sexually active young adult
  • Female > male
Initial presentation
  • Single hot, swollen and painful joint
  • Polyarthralgia is very rare
Polyarticular involvement
  • Common (~40–70% of patients)
  • Usually involves 2-3 joints
  • Rare (~10–20% of patients).
  • Mostly monoarticular involvement (>85%)
Recovery of bacteria
  • Positive blood culture <10%
  • Positive synovial fluid culture <50%
  • Positive blood culture 50%
  • Positive synovial fluid culture >90%
Response to antibiotics
  • Within a few days outcome excellent
  • Takes weeks
  • Joint drainage must be adequate
  • Outcome often poor


Infectious Differential for Bacterial arthritis

Microorganism or other infectious disease Associated risk factors Key clinical clues
Staphylococcus aureus
Streptococcus pyogenes

Streptococcal pneumonia

  • Healthy adults with spleenic dysfunction
Groups B Streptococcal infection
  • Healthy adults with spleenic dysfunction
Neisseria gonorrhoeae
Gram-negative bacilli
Haemophilus influenzae
  • Unimmunized children[7]
Anaerobes
Mycobacterium spp.
  • Recent history of travel to endemic areas
  • Immunocompromised patients
  • Recent history of travel to endemic areas (e.g. India, South Africa, Mexico etc.)
  • Incidious onset of monoarthritis
Fungal infection such as
Mycoplasma hominis
  • Recent history of urinary tract procedure
Viral arthritis
HIV infection
  • History of multiple sexual partners
  • History of IVDA
Lyme disease
  • History of recent visit to endemic Lyme area
Reactive arthritis
  • Recent gastrointestinal/ genitourinary infection
Endocarditis

Differentiatial Diagnsosis for Acute Arthritis

Septic arthritis should be differentiated from other causes of acute arthritis:[9][10][11][12][13]

Type of

Arthritis

Color Transparency Viscosity Volume

(in ml)

WBC count

(per mm3)

PMN

cellcount (%)

Gram stain Gram Culture polymerase chain reaction

(PCR) test

Crystals
Normal Clear Transparent High/thick < 3.5 < 200 < 25 Negative Negative Negative Negative
Gonococcal arthritis Yellow Cloudy-opaque Low Often >3.5 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 Often >3.5 > 50,000 (> 100,000 is

more specific)

> 75 Positive (60 to

80 percent)

Positive (> 90 percent) -- Negative
Inflammatory:

crystalline arthritis

(e.g.Gout, Pseudo gout)

Yellow Cloudy Low/thin Often >3.5 2,000 to 100,000 > 50 Negative Negative Negative Positive
Inflammatory:

non-crystalline arthritis

(e.g. Rheumatoid arthritis, reactive arthritis)

Yellow Cloudy Low/thin Often >3.5 2,000 to 100,000 > 50 Negative Negative Negative Negative
Noninflammatory arthritis

(e.g. Osteoarthritis)

Straw Translucent High/thick Often >3.5 200 to 2,000 < 25 Negative Negative Negative Negative
Hemorrhagic Red Bloody Variable Usually >3.5 Variable 50-75 Negative Negative Negative Negative
Lyme arthritis Yellow Cloudy Low Often >3.5 3,000 to 100,000

(mean: 25,000)

> 50 Negative Negative Positive (85 percent) Negative

References

  1. ↑ Goldenberg DL, Cohen AS (1976) Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med 60 (3):369-77. PMID: 769545
  2. ↑ 2.0 2.1 Le Dantec L, Maury F, Flipo RM, Laskri S, Cortet B, Duquesnoy B et al. (1996) Peripheral pyogenic arthritis. A study of one hundred seventy-nine cases. Rev Rhum Engl Ed 63 (2):103-10. PMID: 8689280
  3. ↑ Vassilopoulos D, Chalasani P, Jurado RL, Workowski K, Agudelo CA (1997) Musculoskeletal infections in patients with human immunodeficiency virus infection. Medicine (Baltimore) 76 (4):284-94. PMID: 9279334
  4. ↑ Morgan DS, Fisher D, Merianos A, Currie BJ (1996) An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect 117 (3):423-8. PMID: 8972665
  5. ↑ Schattner A, Vosti KL (1998) Bacterial arthritis due to beta-hemolytic streptococci of serogroups A, B, C, F, and G. Analysis of 23 cases and a review of the literature. Medicine (Baltimore) 77 (2):122-39. PMID: 9556703
  6. ↑ Deesomchok U, Tumrasvin T (1990) Clinical study of culture-proven cases of non-gonococcal arthritis. J Med Assoc Thai 73 (11):615-23. PMID: 2283490
  7. ↑ De Jonghe M, Glaesener G (1995) [Type B Haemophilus influenzae infections. Experience at the Pediatric Hospital of Luxembourg.] Bull Soc Sci Med Grand Duche Luxemb 132 (2):17-20. PMID: 7497542
  8. ↑ Luttrell LM, Kanj SS, Corey GR, Lins RE, Spinner RJ, Mallon WJ et al. (1994) Mycoplasma hominis septic arthritis: two case reports and review. Clin Infect Dis 19 (6):1067-70. PMID: 7888535
  9. ↑ Goldenberg DL (1995) Bacterial arthritis. Curr Opin Rheumatol 7 (4):310-4. PMID: 7547108
  10. ↑ Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE (1990) Synovial fluid tests. What should be ordered? JAMA 264 (8):1009-14. PMID: 2198352
  11. ↑ 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
  12. ↑ 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
  13. ↑ 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


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