Table 1. Bacteria Which Are Most Commonly Isolated from Synovial Fluid of Patients with Bacterial Arthritis*
Gram-positive strains
Staphylococcus epidermidis, and other coagulase negative staphylococci
Streptococci
Gram-negative strains
* Any strain, including anaerobes, which causes bacteraemia may invade joint tissues and elicit bacterial arthritis
Old age (>80 years)
Rheumatoid arthritis
Immunosuppressive therapy
Prosthetic joint
Previous intra-articular corticosteroid injection
Diabetes mellitus
Osteoarthritis
Low socioeconomic status
Alcoholism
Cutaneous ulcers
Trauma penetrating into the joint
Table 3 Differential Diagnosis for Acute Monoarthritis
___________________________________________________________
Gout
Pseudogout
Rheumatoid arthritis
Apatite-related arthropathy
Reactive arthritis
Transient synovitis of the hip
Pigmented villonodular synovitis
Hemarthrosis
Neuropathic arthropathy
Osteoarthritis
Intra-articular injury (fracture, meniscal tear, osteonecrosis)
Metastatic carcinoma
________________________________________________________
Table 4. Bacterial Infections Associated with the Development of Reactive Arthritis
_____________________________________________________________________________
Enteritis caused by
Salmonella
Various serovars
S. flexneri
S. dysenteriae
S. sonnei
Yersinia
Y. enterocolitica (especially O:3 and O:9)
C. coli
Urethritis caused by
Upper respiratory infection caused by
Group A beta-haemolytic streptococcus**
____________________________________________________________________________
* causes urethritis, but the role in reactive arthritis still discussed;
** typically causes acute rheumatic fever, but has been described to cause ‘reactive-like’ arthritis
Table 5. Clinical Features of Reactive Arthritis in Hospital Series
|
Number of joints, range |
1-24 |
|
Low back pain, range (%) |
2-67 |
|
X-ray sacroilitis, range (%) |
11-20 |
|
Urethritis, mean, range (%) |
4-93 |
|
Conjunctivitis, range (%) |
6-78 |
|
Iritis, range (%) |
6-17 |
|
Skin lesions, range (%) - erythema nodosum - pustules - keratodermia |
4-14 |
|
Duration of arthritis, range, months |
1-30 |
|
Chronic course (>12 months), range (%) |
0-30 |
|
HLA-B27 + , range (%) |
0-94 |
Table 6. Revised Jones Criteria for Acute Rheumatic Fever [8]
|
Major manifestations |
Minor manifestations |
Laboratory findings |
|
Carditis
Polyarthritis |
Fever
Arthralgia |
Elevated acute-phase reactants: a) C-reactive protein (CRP) b) Erythrocyte sedimentation rate (ESR) |
|
Chorea
|
Previous rheumatic fever or rheumatic heart disease |
Prolonged P-R interval in ECG |
|
Erythema marginatum
Subcutaneous nodules |
|
Supporting evidence of preceding streptococcal infection: a) Increased ASO or other streptococcal antibodies b) Positive throat culture for Group A-haemolytic streptococci c) Recent scarlet fever |
Table 7. Musculoskeletal Features of Borreliosis with Respect to Geographical Areas. Adapted from [9]
|
Clinical symptom |
Europe and Asia (B. afzelii, B. garinii, B. burgdorferi ss) |
North America (B. burgdorferi ss) |
|
Arthritis, acute |
Oligoarthritis (less frequent) Less intense joint inflammation
|
Oligoarthritis (more frequent) More intense joint inflammation
|
|
Arthritis, chronic |
Persisting arthritis less frequent |
Treatment-resistant arthritis in about 10% of the patients |
Table 8. Arthritis and Autoimmune Diseases Associated with Parvovirus B19 Infection
|
Type of arthritis |
Other autoimmune features |
Other manifestations |
|
Acute Chronic |
Vasculitis Antiphospholipid syndrome SLE |
Rash, haematological changes, hepatitis, myocarditis, myositis, CNS symptoms |
______________________________________________________________________________
SLE, systemic lupus erythematosus; CNS, central nervous system
Table 9. Alphaviruses Related to Articular Symptoms. Adapted from [11]
|
Virus |
Clinical features |
Epidemiological area |
|
Fever, arthralgia/arthritis, rash, myalgia, chronic joint pain, haemorrhagic symptoms, paresthesias |
Africa, India, South East Asia, Philippines |
|
|
Mayaro |
Fever, arthralgia/arthritis, chronic joint pain, rash, myalgia, haemorrhagic symptoms |
Trinidad, Surinam, Brazil, Colombia, Bolivia |
|
O’nyong-nyong |
Fever, arthralgia/arthritis, chronic joint pain, rash, myalgia, haemorrhagic symptoms, paresthesias |
Uganda, Kenya, Tanzania, Malawi, Senegal |
|
Barmah Forest |
Fever, arthralgia/arthritis, rash, myalgia |
Australia |
|
Igbo Ora |
Fever, arthralgia, rash, myalgia |
Ivory Coast |
|
Ross River |
Fever, polyarthritis, chronic arthralgia, rash, paresthesias, glomerulonephritis |
Australia, New Guinea, Fiji, The Solomon Islands, American Samoa, South pacific Islands |
|
Sindbis |
Fever, rash, arthralgia/arthritis, paresthesias |
Europe, Africa, Australia, Asia, Philippines |
|
Ockelbo |
Fever, arthralgia/arthritis, rash, chronic joint pain, paresthesias |
Sweden, Norway
|
|
Pogosta |
Fever, arthralgia/arthritis, chronic arthritis, rash, |
Finland
|
|
Karelian fever |
Fever, arthralgia, rash |
Russia |
Table 10. Antibiotic Treatment of Septic Arthritis. Adapted from [4,16]
|
Patient group |
Antibiotic choice |
|
No risk factors for atypical organism |
Staphylococcal penicillin (e.g. cloxacillin or flucloxacillin) 2 g four times a day i.v. Fusidic acid 500 mg three times a day p.o, or gentamicin i.v. may be added. In the case of penicillin allergy, clindamycin 450-600 mg for times a day, or 2nd or 3rd generation cephalosporin may be given |
|
High risk of Gram negative sepsis |
2nd or 3rd generation cephalosporin (e.g. cefuroxime 1.5 g three times a day). |
|
MRSA (methicillin resistant Staphylococcus aureus) risk |
Vancomycin plus 2nd or 3rd generation cephalosporin |
|
Suspected gonococcus or meningococcus |
Ceftriaxone 1 g once a day (im. or iv) or similar drugs, depending on local policy/resistance |
|
I.V. drug users |
Discuss with microbiologist |
|
Intensive therapy unit patients, known colonization of other organs |
Discuss with microbiologist |
Figure 1: Septic Arthritis
Figure 2: A Pustule at Early Phase of Disseminated Gonococcal Infection
Figure 3: A Pustule With Necrotic Centre In A Patient With
Disseminated Gonococcal Infection
Figure 4: Fulminant Knee Synovitis In A Patient With Reactive Arthritis
Figure 5: Dactylitis Of Left 2. Toe And Right 4. Toe
In A Patient With Reactive Arthritis
Figure 6: Skin Lesions In A Patient With Reactive
Arthritis Due To Salmonella Infection
Figure 7: A Patient With Acute Gouty Arthritis In The Foot
Figure 8. Erythema Nodosum
Figure 9: Bilateral Hilar Lymphadenopathy In A Patient With Acute Sarcoidosis
Figure 10:. Clinical Approach In A patient Who PresentsWith Fever and Acute Arthritis (A),
and With Fever, Arthritis, and Extra-Articular (B) Symptoms.
ReA=Reactive Arthritis; HIV=Human Immunodeficiency Virus; Gc=Gonococcal; EN=Erythema Nodosum; EM=Erythema Migrans.
Figure 11: Radiology Of The Ankle In A Patient With Septic Arthritis (Same Patient As In Fig. 1)
Figure 12: Radiology Of Left Knee In A Patient Rheumatoid Arthritis With
Septic Arthritis In A Knee With Prosthesis
Figure 13: Indium-111 Labeled Leucocyte Scan In A Patient With
Septic Arthritis (Same Patient As In Fig. 12)
Figure 14: Three-Phase Bone Scan With Technetium-99m Labeled
Diphosphonates In A Patient With Septic Arthritis (Same Patient As In Fig. 12)
