OSTEOMYELITIS SEPTIC ARTHRITIS
A.C.O.I. BOARD REVIEW 2017 Howard L. Feinberg, D.O., F.A.C.O.I., F.A.C.R. OSTEOMYELITIS Definition: Inflammation of the bone caused by a pathogenic organism ETIOLOGY
Hematogenous Spread –Bacteremia of any etiology (ie pneumonia,abscess, surgery, trauma) Contiguous Spread –cutaneous ulcer –infected joint or joint prosthesis –abscess ORGANISIMS
Staph aureus HIV Coag. Neg. Staph. – Candida – Mycobacterium kansasii Streptococcus – Nocardia asteroides Polymycrobial - Cancer especially in diabetic foot ulscers Immunocompromised host Sickle Cell Disease – histoplasmosis, - 50% salmonella – coccidiomycosis, ???? – blastomycosis Gram negative Tuberculosis CLINICAL MANIFESTATIONS ACUTE CHRONIC – fever – night sweats – point tenderness – low grade fever – muscle spasm – weight loss – vague pain – draining sinus – CHILDREN - – muscle spasm acute onset fever, – point tenderness chills, lethargy, irritability TUBERCULOSIS
Weight bearing joints are most commonly affected Pott’s Disease – TB of spine – Destroys disk – Vertebral collapse – Spinal cord compression LABORATORY ACUTE CHRONIC – Elevated ESR – Elevated ESR – Increased WBC – Normal WBC – Blood cultures - 50% – Negative cultures are positive – Bone culture/biopsy – Bone culture/biopsy – Other phase reactants – Urine cultures RADIOLOGY Plain X-ray – will not be positive for at least 10 days – lytic lesions may not be present for 6 weeks BONE SCAN MRI SPINAL OSTEOMYELITIS TREATMENT
ACUTE - CHRONIC IV antibiotics for – drainage at least 4 - 6 – debridement weeks – vascular assessment – remove prosthesis – amputation SEPTIC ARTHRITIS
MONOARTICULAR POLYARTICULAR – Gonococcal 50% – Gonococcal-variable – Non-gonococcal – Non-gonococcal S. aureus 35% carries a much B-hemolytic strep. worse prognosis 10% often associated Gram negative 2-8% with other polymicrobial 2-10% rheumatic diseases Fungal/atypical >1% or immune suppression GONOCOCCAL ARTHRITIS Migratory polyarthralgias Tenosynovitis Bursitis Arthritis Fever Dermatitis GONOCOCCAL ARTHRITIS Synovial fluid Treatment - based cultures usually on local sensitivity negative – Penicillin Urethral/vaginal – Penicillinase cultures often resistant penicillin positive – ceftriaxone - DOC PCR (polymerase Outcome - rapid chain reaction test response to improves accuracy) treatment 24-48h SEPTIC ARTHRITIS
Knee 40-50% Ankle 6-8% Hip 15 -20% Elbow 3-7% Shoulder 10% Hand/Foot 5% Wrist 5-8% Polyarticular 10-20% SEPTIC ARTHRITIS SEPTIC ARTHRITIS
Outcome Good Prognosis – 5 - 15% mortality – Knees 80% - good – 25 - 60% joint outcome damage – early treatment - (less than 1 week – 22 - 70% full duration) - 66% recovery Poor Prognosis Polyarticular Mortality – delayed treatment (over 2 weeks) - 22% – overall 23% – polyarticular – in RA 56% disease RHEUMATIC FEVER
Major: Arthritis, Plus: Evidence of a Carditis,Chorea, recent Strep Erythema infection ( Elevated ASO, Antistreptococcal marginatum, Antibodies, Group A Strep Nodules on throat culture, Recent Scarlet Fever) Minor: Prior ARF, 2 Major or 1 Major Arthralgias, Fever, and 2 Minor plus ESR>120, CRP, evidence of recent Leukocytosis, Strep infection Prolonged PR LYME DISEASE
Causative Organism – Borelia Burgdorferi – Spirochete 95% of U.S. Vector-borne diseases I scapularis (dammini) – Tick vector – Nymph – white footed mouse – Adult - Deer LYME DISEASE
STAGE I - Early STAGE III - Late – Erythema Migrans – Acrodermatitis chronica – Flu-like Syndrome atrophicans – intermittent/chronic STAGE II - Early oligoarthritis Disseminated – chronic encephalitis – Erythema migrans – sensorimotor – Borrelia lymphocytoma neuropathies – Migratory arthralgia – peripheral neuropathy – Carditis (fluctuating A-V block LYME DISEASE LYME DISEASE Diagnosis is clinical Laboratory tests – Skin culture of Erythema Migrans – ELISA – Western blot – PCR most useful in arthritis – CNS antibody is confirmatory for CNS disease – Elevated ESR – Transient increase in SGOT LYME DISEASE TREATMENT Tick bite Arthritis (30-60 day) – 200mg doxycycline – Doxycycline 100mg bid Early disease – Amoxicillin 500mg tid – 21 day oral doxycycline – Ceftriaxone 2g IV daily 100mg – Penicillin G 3.5 million units – 21 day oral Amoxicillin q4h 500mg tid Carditis (21 day) – 14 day IV ceftriaxone – Ceftriaxone Neurologic (28 day) – Penicillin G – Ceftriaxone 2g IV daily – Amoxicillin – Cefotaxime 2g IV q8h – Doxycycline AIDS
Arthralgia Spondyloarthropathy Infectious Arthritis (undifferentiated) Reiter’s Syndrome AIDS associated arthritis Psoriatic Arthritis Avascular necrosis Sjogren’s Syndrome Myositis Contact Information
Howard Feinberg, D.O., F.A.C.O.I., F.A.C.R. 1310 Club Drive Vallejo, CA 94592