Septic arthititis

• Inflammation of a joint
• Infection may follow
–penetrating injuries(direct inoculation)
-Hematogenous
-contagious
 Etiology
• Haemophilus influenzae type b- accounted for more than half of all cases
of bacterial arthritis in infants and young children
• Staphylococcus aureus-the most common infection in all age groups
• Group A streptococcus
• Streptococcus pneumoniae (pneumococcus) is most likely in the first 2
years of life
• Kingella kingae is recognized as a relatively common etiology with
improved culture and polymerase chain reaction (PCR) methods in
children <5 yr old
• In sexually active adolescents, gonococcus
• Group B streptococcus is an important cause of septic arthritis in
neonates
• Chronic arthritis- Fungal infections ,tuberculosis
 Pathogenesis
• Septic arthritis primarily occurs as a result of
hematogenous seeding of the synovial space
• Less often, organisms enter the joint space by direct
inoculation or extension from a contiguous focus.
• The synovial membrane has a rich vascular supply and lacks
a basement membrane, providing an ideal environment for
hematogenous seeding
• The presence of bacterial products (endotoxin or other
toxins) within the joint space stimulates cytokine
production (tumor necrosis factor-α, interleukin-1) within
the joint, triggering an inflammatory cascade
 Phatogenesis…
• The cytokines stimulate chemotaxis of neutrophils into the joint
space, where proteolytic enzymes and elastases are released by
neutrophils, damaging the cartilage.
• Proteolytic enzymes released from the synovial cells and
chondrocytes also contribute to destruction of cartilage and
synovium.
• Bacterial hyaluronidase breaks down the hyaluronic acid in the
synovial fluid, making the fluid less viscous and diminishing its
ability to lubricate and protect the joint cartilage.
• Damage to the cartilage can occur through increased friction,
especially for weight-bearing joints.
 Phatogenesis
• The increased pressure within the joint space from
accumulation of purulent material can compromise the
vascular supply and induce pressure necrosis of the cartilage.
• Synovial and cartilage destruction results from a
combination of proteolytic enzymes and mechanical factors
• Synovial inflammation - increased vascular permeability -
increased fluid production-fluid collected under pressure -
compression/thrombosis of intra articular joint vesseles -
avascular necrosis
• Extension of infection to bone may occur.
 Clinical Manifestations
• fever and pain, with localizing signs such as swelling, erythema, and
warmth of the affected joint.
• Decreased the range of motion
• With involvement of joints of the pelvis and lower extremities,
limp or refusal to walk is often seen
• Septic arthritis in neonates and young infants is often associated
with adjacent osteomyelitis caused by transphyseal spread of
infection, although osteomyelitis contiguous with an infected joint
can be seen at any age
• In neonates irritability, poor feeding , pseudoparalysis
• Multiple joint involvement and contigous osteomyelitis common in
infants
 Diagnosis
• Blood cultures
• Aspiration of the joint fluid for Gram stain and culture- the definitive
diagnostic.
• A microbial etiology is confirmed in about 65% of cases of septic arthritis
• Synovial fluid analysis for cell count, differential, protein, and glucose has
limited usefulness because noninfectious inflammatory diseases, such as
rheumatic fever and rheumatoid arthritis, can also cause exuberant
reaction with increased cells and protein and decreased glucose.
• Nevertheless, cell counts >50,000-100,000 cells/mm3 generally indicate
an infectious process.
 Diagnosis ..
• The white blood cell count and differential, erythrocyte
sedimentation rate (ESR), and C-reactive protein (CRP) are
generally elevated in children with joint infections but are
nonspecific and might not be helpful in distinguishing
between infection and other inflammatory processes.
• The leukocyte count and ESR may be normal during the
first few days of infection, and normal test results do not
preclude the diagnosis of septic arthritis.
• Monitoring elevated ESR and CRP may be of value in
assessing response to therapy or identifying complications.
• Plain Radiographs shows widening of the joint
capsule, soft-tissue edema, and obliteration of
normal fat lines
• Ultrasonography
• Ultrasonography is particularly helpful in detecting
joint effusion and fluid collection in the soft tissue
and subperiosteal regions. Ultrasonography is highly
sensitive in detecting joint effusion, particularly for
the hip joint, where plain radiographs are normal in
>50% of cases of septic arthritis of the hip.
• Computed Tomography and Magnetic
Resonance Imaging
• Radionuclide Imaging
• Radionuclide imaging compared to
radiographs is more sensitive in providing
supportive evidence of the diagnosis of septic
arthritis; a scan may be positive within 2 days
of the onset of symptoms.
 Differential Diagnosis
• For the hip, toxic synovitis, Legg-Calve-Perthes disease, slipped capital
femoral epiphysis, psoas abscess, and proximal femoral, pelvic, or vertebral
osteomyelitis as well as diskitis should be considered.
• For the knee, distal femoral or proximal tibial osteomyelitis, pauciarticular
rheumatoid arthritis, and referred pain from the hip should be considered.
• Other conditions such as trauma, cellulitis, pyomyositis, sickle cell disease,
hemophilia, and Henoch-Schonlein purpura can mimic purulent arthritis.
• When several joints are involved, serum sickness, collagen vascular disease,
rheumatic fever, and Henoch-Schonlein purpura should be considered.
• Arthritis is one of the extraintestinal manifestations of inflammatory bowel
disease. Reactive arthritis following a variety of bacterial (gastrointestinal or
genital) and parasitic infections, streptococcal pharyngitis, or viral hepatitis
can resemble acute septic arthritis (Chapter 151).
 Treatment
• Antibiotic Therapy-
• In neonates, an antistaphylococcal penicillin, such as nafcillin or oxacillin
(150-200 mg/kg/24 hr divided q6h IV), and a broad-spectrum
cephalosporin, such as cefotaxime (150-225 mg/kg/24 hr divided q8h IV),
provide coverage for the S. aureus, group B streptococcus, and gram-
negative bacilli. If MRSA is a concern, vancomycin is selected in favor of
nafcillin or oxacillin. If the neonate is a small premature infant or has a
central vascular catheter, the possibility of nosocomial bacteria
(Pseudomonas aeruginosa or coagulase-negative staphylococci) or fungi
(Candida) should be considered.
• In older infants and children with septic arthritis, empirical therapy to
cover for S. aureus, streptococci, and K. kingae includes cefazolin (100-150
mg/kg/24 hr divided q8h) or nafcillin (150-200 mg/kg/24 hr divided q6h).
 Surgical Therapy

• Infection of the hip is generally considered a

surgical emergency because of the vulnerability
of the blood supply to the head of the femur.
For joints other than the hip, daily aspirations
of synovial fluid may be required.
• Generally, one or two subsequent aspirations
suffice. If fluid continues to accumulate after 4-
5 days, arthrotomy or video assisted
arthroscopy is needed.