Septic arthritis differential diagnosis: Difference between revisions

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=== Microorganism Involved Based on The Clinical History and Symptoms ===
=== Microorganism Involved Based on The Clinical History and Symptoms ===
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!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Clinical history}}  
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Clinical history}}  
!!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Joints involved}}  
!!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Joints involved}}  
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|align=center|[[Mycobacterium marinum]]
|align=center|[[Mycobacterium marinum]]
|}
|}
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 14:35, 26 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, Pseudogout)

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

Microorganism Involved Based on The Clinical History and Symptoms

Clinical history Joints involved Most likely microorganism
Intravenous drug use[14][6] Involvement of axial joints

(e.g. sternoclavicular or sacroiliac joint)

Pseudomonas aeruginosa

Staphylococcus aureus

Sexual activity Tenosynovial involvement in hands, wrists, or ankles Neisseria gonorrhoeae
Terminal complement deficiency[14] Tenosynovial involvement in hands, wrists, or ankles Neisseria gonorrhoeae
Dog or cat bite Small joints involvement Capnocytophaga species

Pasteurella multocida

Ingestion of unpasteurized dairy products[14] Monoarticular involvement, in specific sacroiliac joint Brucella sps
Nail through shoe Foot Pseudomonas aeruginosa
Soil exposure/gardening Monoarticular involvement: knee, hand, or wrist Nocardia sps

Sporothrix schenckii

Soil or dust exposure containing decomposed wood

(north-central and southern United States)[15]

Monoarticular: knee, ankle, or elbow Blastomyces dermatitidis
Southwestern United States, Central and South America

(primary respiratory illness)

Knee Coccidioides immitis
Cleaning fish tank[14][16] Small joints involvement (e.g. fingers, wrists) Mycobacterium marinum

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. 6.0 6.1 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
  14. 14.0 14.1 14.2 14.3 Margaretten ME, Kohlwes J, Moore D, Bent S (2007) Does this adult patient have septic arthritis? JAMA 297 (13):1478-88. DOI:10.1001/jama.297.13.1478 PMID: 17405973
  15. Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML (2011). "Approach to septic arthritis". Am Fam Physician. 84 (6): 653–60. PMID 21916390.
  16. Gardam M, Lim S (2005). "Mycobacterial osteomyelitis and arthritis". Infect Dis Clin North Am. 19 (4): 819–30. doi:10.1016/j.idc.2005.07.008. PMID 16297734.


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