Infectious Arthritis Flashcards
Acute Bacterial Arthritis
-medical emergency that warrents rapid, accurate diagnosis w/immediate treatment along with appropriate consultation with additional specialists as needed
Most instances of native joint infection are the result of?
bacteremic seeding
Most frequent microorganism in adult nongonoccal septic arthritis?
staphyloccus aureus
What do you do with infected joint?
- drain, abx course,
- surgical drainage but only if needle aspirations don’t work
Poor prognostic factors in bacterial joint infections?
- old age
- underlying rheumatoid arthritis
- infection in a prosthetic joint
What to do with patients with early prosthetic joint infections?
debridement, abx, implant retention
What to do with late prosthetic joint infections?
- abx directed at isolated microorganism
- complete removal of prosthesis and get rid of infection before new prosthesis
To avoid prosthetic joint infections?
preoperative evaluation, abx abx prophylaxis (for dental procedures)
Clinical Features of Bacterial Arthritis
- monoarticular (knee joint)
- polyarticular occures in 5-8% or pediartic and 10-19% of adult nongonoccal cases
- DDX: trauma, infection, crystal-induced synovitis like gout
What patients is polyarticular arthritis seen in?
- systemic inflammatory disorders
- spondyloarthropathies, RA, SLE other CT diseases or patients with overwhelming sepsis
What is Lyme disease caused by?
-infection with tick-transmitted spirochetes of the genus Borrelia burgdorferi sensu lato and has worldwide distribution
Lyme Disease Begins with?
-expanding macular skin lesion erythema migrans
Early recongniton/treatment of lyme disease has lead to a decrease in?
- Carditis
- Acute Neurologic Disease
- Late disease manifestations
Lyme disease with musculoskeletal manifestations?
- occure in more that 50% of patients and at all stages of infection
- frank arthritis is a sign of late disease and is uncommon (<10%)
Diagnosis of Lyme disease?
-should be suspected when a patient who lives, works, vacay in an endemic area presents with signs & symptoms
Test for Lyme disease?
-two-tiered serologic test (enzyme-linked immunosorbent assay and immunoblot) can be negative with early infection but become positive in most patients with infection of >1month duration
How long to cure Lyme disease?
- most cured in 2-4 weeks of antibiotic therapy
- time to disease resolution may extend beyond the duration of therapy and irreversible tissue damage may occure
Antibiotic-refractory arthritis?
-occurs in less that 10% of patients with Lyme arthritis, responds to disease-modifying antirheumatic drugs, and typically resolves within 4 to 5 years
Post-Lyme disease syndrome
- persistent debilitating complaints of fatigue, mild cognitive dysfunction, and musculoskeletal pain
- antibiotic treatment for Lyme disease occurs in a minority of patients
- B. burgdorferi cannot be detected in these patients, and controlled treatment trials show no benefit of prolonged antibiotic therapy over placebo
TB
global rates have increased due to expanding human immunodeficiency virus pandemic and problem of drug resistance
-increase in TB in response to expanded use of anti-tumor necrosis factor (TNF) agents
Musculoskeletal TB
-typically presents as a chronic localized infection, most commonly involving the spine, less often the hips or knee
Diagnosis for Muscluoskeletal TB
-difficult and often requires biopsy for histopathology and culture of the bone or synovium; rapid diagnostic test techniques have not yet proven reliable in bone and joint specimens
TB skin test
-helpful in identifying latent tuberculosis before treatment with anti-TNF agents, but it is limited by false-positive and false-negative results; the availability of interferon-γ release assays, when available, may be a useful alternative screening procedure
TB Treatment
- multiple agents selected on the basis of susceptibility testing for 6 to 9 months and has been complicated by the increasing incidence of drug resistance
Nontuberculous mycobacteria
-becoming important pathogens to recognize in the face of biologic therapy for rheumatic diseases
Fungal Infections of Joints
- infrequent but clinically important cause of bone and joint infections
- indolent in onset and may masquerades other disorders
- travel has effected it so now may be seen in nonendemic areas
Diagnosis of Fungal Infections of Joints
-be assisted by clinical presentation and serologic testing, examination and culture of infected tissue are critical
Treatment of Fungal Infections of Joints
-new antifungal therapies have broadened the effective options, but choice of drugs, duration of treatment, and combined surgical débridement must be carefully considered to achieve optimal outcomes
Predispose to Fungal Joint Infections
immunocompromise including antiheumatic biologic therapies
- more acute & widely disseminated disease
- screening/prophylactic therapy are not useful so high index of suspicion for acute febrile illness
Rheumatic HIV
-patients live longer b/c of better treatment, challenges of HIP-associated rheumatic manifestations are growing
Diseases particular to HIV infection?
- HIV-associated arthritis
- diffuse infiltrative lymphocytosis syndrome (DILS)
- HIV-associated polymyositis
Diseases that go into remission with HIV infection and flare with antiretroviral treatment?
CD4-mediated diseases
- rheumatoid arthritis
- systemic lupus erythematosus
- **immune reconstitution after antiretroviral therapy, a new spectrum of autoimmune and autoinflammatory disease has emerged requiring special attention
Viral Arthritis
-acute-onset, symmetric polyarthritis can be caused by viral infection, especially when accompanied by rash
Most common viral arthritis in US?
Parvovirus B19
Rash in Parvovirus B19?
-may be subtle or absent
History for Parvovirus B19?
-travel, exposure, occupation, vaccination history
Rubella Arthritis?
- occurs in young adult
- vaccine reduced overall incidence of rubella infection but has shifted the peak age to young adults
Rubella Vaccine
-Arthralgia, arthritis, or neuropathic pain may occur after rubella vaccination; these conditions are usually self-limited in duration
Alphaviruses
-mosquito-borne causes of arthritis and rash. Outbreaks occur in endemic areas associated with rising mosquito populations and should be considered in travelers entering the United States
Hep. B Virus Infection
-presents as an arthritis-urticaria syndrome
Hep. C Virus Infection
- causes cryoglobulinemia and vasculitis. Cryoglobulinemic vasculitis often presents as palpable purpura of the lower legs
- history of risk behaviors associated may be romote
Acute Rheumatic Fever (ARF)
-delayed, nonsuppurative sequel of a pharyngeal infection with group A streptococci. Although a dramatic decline in the severity and the mortality of the disease has been noted, reports have described its resurgence in the United States
Treat Streptococcal Pharyngitis
-markedly reduces the incidence of subsequent ARF. Appropriate antimicrobial prophylaxis prevents recurrence of disease in known patients with ARF
Clinical Presentation of ARF
-lack of a single pathognomonic feature led to the development of the revised Jones criteria, which should be used to establish a diagnosis
migrating/migratory
-often used to describe the polyarthritis of ARF, but these designations do not signify that the inflammation disappears in one joint when it appears in another. Rather, the various localizations usually overlap in time, and the onset, as opposed to the full course of arthritis, “migrates” from joint to joint
Post-strep migratory arthritis in absence of carditis??
may be distinct from ARF
-Although these features may be seen (admittedly rarely), migratory arthritis without evidence of other major Jones criteria but supported by two minor manifestations still should be considered ARF, especially in children
Treatment for ARF
Antibiotic prophylaxis with penicillin should be started immediately after resolution of the acute episode. The optimal regimen consists of oral penicillin VK, 250,000U twice a day, or parenteral penicillin G, 1.2 million U intramuscularly every 4 weeks
