Joint Fluid Cultures Research Articles

Subchondral acute inflammation in severe arthritis: a sterile osteomyelitis?

Although arthritis is often associated with synovial inflammation, the osseous changes in inflammatory and degenerative arthritis are principally reactive, and typically lack an acute inflammatory component. We have recently encountered several osteoarticular specimens removed at the time of large joint arthroplasty that have shown a distinctive pattern of subchondral acute inflammation (SCAI) resembling acute bacterial osteomyelitis. These microscopic findings heretofore have not been recognized as a component of the histopathology of arthritis. To determine the frequency of SCAI, we examined slides (mean four per case) from 164 hip arthroplasties performed at one of our institutions in a single year. A total of 10 cases of SCAI, including the 4 original examples (2 humeral head specimens, 2 femoral head specimens) and 6 identified from the slide review are described in this report. Eight patients were female and two were male (ages 54-86 years, mean 70, median 70). All had severe degenerative joint disease, six had rheumatoid arthritis, and three had osteonecrosis. In none was there a clinical or intraoperative suspicion of infection. Cultures of joint fluid or bone were not performed. In all cases, the inflammation was subchondral (within 1.0 cm of the joint surface), and it was frequently associated with subchondral cysts. In osteonecrotic foci, the suppurative inflammation was diffuse within the marrow space, whereas in viable bone it was nodular and vaguely granulomatous. Special stains for organisms were negative. None of the patients was treated with long-term IV antibiotics. There has been no septic loosening of the prostheses at follow-up intervals ranging from 5 to 36 months (mean: 17 months). Our observations, to the best of our knowledge, are novel. Although we cannot definitively exclude bacterial infection as a cause of SCAI, the histologic and clinical features suggest that SCAI likely represents a noninfectious sterile form of inflammation. Subchondral acute inflammation is possibly secondary to synovial fluid insudation into subchondral cancellous bone in the setting of severe osteoarthritis and/or rheumatoid arthritis.

Bacterial arthritis in the elderly: an overview.

The key to successful treatment of acute bacterial arthritis is early diagnosis and initiation of empirical antibacterial therapy. Treatment includes antimicrobial therapy, debridement of the infected joint and treatment of pain. Empirical antibacterial treatment should be re-evaluated as soon as the causative pathogen is identified from joint fluid and other cultures. Mobilisation with partial weight bearing is encouraged early during treatment. The outcome of properly treated bacterial arthritis in the elderly is generally favourable and at least 50% of patients may recover without developing secondary osteoarthritis.

Lymphatic opacification in the prosthetic hip

A retrospective analysis of 52 patients with hip pain following total hip replacement was made. Each of them was evaluated by plain radiographs, technetium 99m pyrophosphate scans, arthrography with plain film subtraction technique, and culture of joint fluid. In 30 cases there was evidence of prosthetic loosening, and in 21 of these lymphatic opacification during arthrography was seen. In 15 cases with lymphatic opacification the diagnosis of prosthetic loosening was subsequently confirmed by prosthetic revision. In none of the 22 cases in which no evidence of prosthetic loosening was seen was there lymphatic opacification. It is concluded that lymphatic opacification during arthrography for pain following total hip prosthesis is a valuable ancillary sign of loosening.

Intra-articular Amphotericin B Treatment of Sporothrix schenckii Arthritis

Arthritis caused by Sporothrix schenckii may not respond satisfactorily to a full course of intravenous amphotericin B therapy. Left untreated, the fungus continues to be recovered from cultures of joint fluid, and the patient typically has serious joint disability. We have shown in one patient with sporotrichosis of the knee that direct low-dose injections of amphotericin B can be performed safely, resulting in eradication of the fungus. The patient has had continued useful range of motion and weight bearing on the involved knee.

Group F Streptococcus

Bacterial arthritis is a serious infection in children occurring either as the result of direct inoculation of organisms into the joint space, of spreading from a contiguous focus of infection, or of hematogenous seeding of the synovium. Although the etiologic agent can be identified in 60% to 70% of cases, joint fluid cultures may remain negative in a substantial number of patients. The most likely etiologic agent depends both on the route of infection and the age of the child. Overall Staphylococcus aureus, Hemophilus influenzae type b and streptococci are the leading causes of bacterial arthritis. Lancefield groups A, B, C, D, and G have all been implicated. However, septic arthritis due to hematogenous seeding with Group F Streptococcus has not been previously reported. A normal 10-month-old boy presented with acute monoarticular arthritis of the knee and had Group F Streptococcus isolated from the blood. Antimicrobial therapy resulted in complete resolution of the arthritis.

Haemophilus parainfluenzae Septic Arthritis in an Adult

ALTHOUGH serious disease in adults caused by Haemophilus sp is being seen with apparently increasing frequency, septic arthritis from these organisms is rare. The majority of these cases of septic arthritis are due to H influenzae type b. We report here a case of H parainfluenzae , septic arthritis in an adult documented by positive culture of joint fluid. Report of a Case A 95-year-old female nursing home resident was admitted to North Central Bronx Hospital because of deterioration of mental status. She was noted to have a temperature of 38.3 °C four days before admission, then became incontinent of urine and disoriented. One day before admission, she fell on her left side and complained of pain in her left hip and ankle. Medical history included hypertension, an organic brain syndrome, and atherosclerotic heart disease. Her medications were 50 mg of chlorthalidone daily and 250 mg of methyldopa daily. There was

Brodie's Abscess of the Patella

IN 1832, Sir Benjamin C. Brodie described localized chronic osteomyelitis in the tibia. 1 Since then, Brodie's abscess has been most often encountered in the tibial and femoral metaphyses and less commonly in the distal radius, ulna, or vertebrae. 2 To our knowledge, this is the first complete case report of Brodie's abscess of the patella. Report of a Case Three years prior to admission, at 24 years of age, our patient smashed his knee on a pipe with resulting stiffness and swelling that spontaneously resolved, leaving chronic exertional discomfort. After a year of recurrent pain and swelling, neither plain roentgenograms nor an arthrogram demonstrated any abnormalities. Since anti-inflammatory medication could not control symptoms during the next several months, arthroscopy was performed and demonstrated inflamed synovium, confirmed as synovitis by biopsy. Cultures of joint fluid were negative. Although therapeutic doses of aspirin attained partial symptomatic palliation for the following several

HEMOPHILUS INFLUENZAE PYARTHROSIS IN AN ADULT.

Infection due to<i>Hemophilus influenzae</i>is generally considered to be a disease of infancy and early childhood, and its occurrence in an adult is rare. With advancing age, resistance to<i>H influenzae</i>increases, as shown by the bactericidal action of most adults' serum on the organism.^{1, 2}Meningitis due to<i>H influenzae</i>in adults is unusual; Merselis et al³in a review of the medical literature in English collected 44 cases to which they added a series of 11. A much rarer manifestation of disease due to the organism is pyarthrosis with only three cases previously described in adults. Dyer et al⁴described a case which involved a 48-year-old female with multiple articular involvement in whom joint fluid culture was positive for<i>H influenzae</i>; blood cultures were negative. The case of a 59-year-old female with pyarthrosis due to<i>H influenzae</i>was reviewed by Weaver and Sherwood.⁵Meligrano