Septic arthritis differential diagnosis

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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

Differential Diagnosis

Differentiating gonococcal arthritis from non-gonococcal arthritis
Characterestic Gonococcal arthritis Non gonococcal arthritis
Patient profile
  • Mostly sexually active young adult
  • Female > male
  • Patient with history of rheumatoid arthritis or other systemic arthritis
  • Immunocompromised patient
  • Common in extremes of age such as in newborn or elderly
Initial presentation
  • Migratory polyarthralgia is common
  • Tenosynovitis in majority of patients
  • Dermatitis in majority of patients
  • Single hot, swollen and painful joint
  • Polyarthralgia is very rare
  • Tenosynovitis and dermatitis are 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

Differentiatial Diagnsosis for Acute Arthritis

Infectious Differential for Bacterial arthritis

Microorganism or other infectious disease Associated risk factors Key clinical clues
Staphylococcus aureus
  • Rheumatioid arthritis[1]
  • Diabetes mellitus[2]
  • HIV patients[3]
  • Healthy adult with skin lesions and previously history of damaged joint (e.g, rheumatoid arthritis) or prosthetic joint
Streptococcus pyogenes

Streptococcal pneumonia

  • Autoimmune diseases[4]
  • Chronic skin infections[2]
  • Trauma
  • Healthy adults with spleenic dysfunction
Groups B Streptococcal infection
  • Immunocompromised patients[5]
  • Diabetes mellitus
  • Malignancy
  • Severe genitourinary or gastrointestinal infections
  • Healthy adults with spleenic dysfunction
Neisseria gonorrhoeae
  • Complement deficiency
  • Systemic lupus erythematosus
  • Male homosexuality
  • low socioeconomic status
  • Healthy young and sexually active adult with
    • Tenosynovitis
    • Skin lesions such as vesicular pustules
    • Complement deficiency (C5-9 deficiency)
    • Culture negativity on synovial fluid analysis
Gram-negative bacilli
  • Pseudomonas
  • Escherichia coli
  • History of intravenous drug abuse[6]
  • Extremes of age
  • Immunocompromised patients
  • Immunocompromised patients
  • Recent history gastrointestinal infections such as infectious diarrhea caused by Shigella, Salmonella, Campylobacter, or Yersinia
Haemophilus influenzae
  • Unimmunized children[7]
Anaerobes
  • Diabetes mellitus
  • Patients with prosthetic joints
  • Immunocompromised hosts
  • Recent history of gastrointestinal infection
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
  • Blastomycosis
  • Cryptococcus
  • Coccidioidomycosis
  • Sporotrichosis
  • Immunocompromised patients
  • Immunocompromised patients
  • Incidious onset of monoarthritis
Mycoplasma hominis
  • Recent history of urinary tract procedure
  • Immunocompromised patients
  • Recent history of urinary tract procedure[8]
Viral arthritis
  • Immunocompromised patient
  • Polyarthritis
  • Fever
  • Rash
HIV infection
  • History of multiple sexual partners
  • History of IVDA
  • Sterile, acute synovitis or reactive arthritis
Lyme disease
  • History of recent visit to endemic Lyme area
  • History of erythema Serology migrans
  • History of recent visit to endemic Lyme area
Reactive arthritis
  • Recent gastrointestinal/ genitourinary infection
  • Recent gastrointestinal/ genitourinary infection
  • Enthesopathy
  • Skin lesions
  • Uveitis
  • Conjunctivitis
Endocarditis
  • History of endocarditis
  • Damaged heart valves
  • Congenital heart diseases
  • Fever
  • New onset of heart murmur
  • Septic and sterile synovitis
    • Septic joint more common in IVDA

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


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