Presumed Septic Arthritis Research Articles

Donor-Derived Disseminated Mycobacterium Tuberculosis Infection in a Lung Transplant Recipient Three Months After Transplant

<h3>Introduction</h3> Reactivation of latent mycobacterium tuberculosis (MTB) infection in lung transplant recipients is common, which is why pre-transplant screening is recommended to guide treatment. However, MTB transmission from a donor organ is much rarer and there is no consistent screening process of donors. We describe a consequence of this, a rare case of donor-derived disseminated MTB infection in a bilateral lung transplant (BLTx) recipient. <h3>Case Report</h3> A 61-year-old female three months post BLTx complicated by post-operative right lung torsion requiring pneumonectomy presented with a swollen and tender right index finger, tender nodules along her occiput, and a recurrent left sided pleural effusion, which was drained on presentation and culture negative. She improved initially with linezolid and ceftriaxone for presumed septic arthritis, however re-presented two weeks later with similar features, which prompted further evaluation. CT and subsequently MRI of the abdomen demonstrated multiple rim-enhancing liver lesions. A finger aspirate and liver biopsy were obtained that were both culture and smear positive for MTB. Sputum acid fast bacilli samples were negative, and she was started on quadruple therapy with rifabutin, isoniazid, pyrazinamide, and ethambutol with clinical improvement, including resolution of her culture-negative pleural effusion. We suspect that this was a donor-derived infection as the donor lived in an endemic region for many years and the recipient was latent TB negative pre-transplant. <h3>Summary</h3> Donor-derived MTB infection can be difficult to diagnosis due to the atypical way it can present, especially in patients who reside in non-endemic areas. As the world becomes more globalized, and access to lung transplant more accessible, we believe that more donor organs will come from individuals who have lived in endemic areas increasing the risk of donor-derived MTB infections making this an important diagnosis to consider.

P100 Acute crystal arthritis: a leading cause of hospital admission, yet poorly recognised and mistreated

Abstract Background/Aims Crystal arthritis is the commonest inflammatory arthritis in adults. A common mimic is septic arthritis. Without appropriate synovial fluid analysis, a mis-diagnosis of sepsis can be made with resultant unnecessary hospitalization, inappropriate intravenous antibiotic therapy and excess cost. Such cases are frequently described as ‘culture-negative’ septic arthritis. We aimed to examine and analyse the cases of acute arthritis requiring acute hospital admission in a tertiary referral centre in Dublin. Methods A retrospective review of database between Jan - Dec 2019 at the Mater Misericordiae University Hospital, Dublin, was carried out. All cases of acute arthritis requiring acute hospital admission were identified. Cases treated at the Emergency Department, Acute Medical Unit or Outpatients which did not require hospital admission were excluded. Results 30 patients were identified during this period, 16 (53%) had an ultimate diagnosis of crystal arthritis, 8 (27%) had confirmed septic arthritis and 6 (20%) had other arthritides (e.g. haemoarthrosis). The median age for crystal arthritis was significantly higher (85.5 y) compared to septic arthritis (47 y). Apart from age, the clinical profile and biomarkers for crystal and septic arthritis were comparable. The majority of crystal arthritis cases were due to pseudogout (69 %), ultimately diagnosed by rheumatology. Septic arthritis led to more days in hospital than crystal arthritis (median 14 vs 5.5 days). All 30 patients received IV antimicrobial therapy for presumed septic arthritis. Conclusion This retrospective study showed crystal arthritis, especially pseudogout, was the commonest cause of hospital admission (53%) with acute arthritis particularly among elderly patients. Accurate diagnosis by synovial fluid analysis with appropriate equipment is extremely useful in the assessment of these cases. More awareness and training among orthopedic, emergency and acute clinicians is needed in order to avoid unnecessary admissions and interventions. Disclosure A. Abdalla: None.

Kingella kingae septic arthritis

The aim of this study was to determine the extent to which patient demographics, clinical presentation, and blood parameters vary in Kingella kingae septic arthritis when compared with those of other organisms, and whether this difference needs to be considered when assessing children in whom a diagnosis of septic arthritis is suspected. A prospective case series was undertaken at a single UK paediatric institution between October 2012 and November 2018 of all patients referred with suspected septic arthritis. We recorded the clinical, biochemical, and microbiological findings in all patients. A total of 160 patients underwent arthrotomy for a presumed septic arthritis. Of these, no organism was identified in 61 and only 25 of these were both culture- and polymerase chain reaction (PCR)-negative. A total of 36 patients did not undergo PCR analysis. Of the remaining 99 culture- and PCR-positive patients, K. kingae was the most commonly isolated organism (42%, n = 42). The knee (n = 21), shoulder (n = 9), and hip (n = 5) were the three most commonly affected joints. A total of 28 cases (66%) of K. kingae infection were detected only on PCR. The mean age of K. kingae-positive cases (16.1 months) was significantly lower than that of those whose septic arthitis was due to other organisms (49.4 months; p < 0.001). The mean CRP was significantly lower in the K. kingae group than in the other organism group (p < 0.001). The mean ESR/CRP ratio was significantly higher in K. kingae (2.84) than in other infections (1.55; p < 0.008). The mean ESR and ESR/CRP were not significantly different from those in the 'no organism identified' group. K. kingae was the most commonly isolated organism from paediatric culture- and/or PCR-positive confirmed septic arthritis, with only one third of cases detected on routine cultures. It is important to develop and maintain a clinical suspicion for K. kingae infection in young patients presenting atypically. Routine PCR testing is recommended in these patients. Cite this article: Bone Joint J2021;103-B(3):584-588.

16. TB or not TB? A mistaken case of SAPHO in a 65 year old male

IntroductionSAPHO is a rare syndrome of osteoarticular disorders with associated skin manifestations. The classic constellation of symptoms includes synovitis, acne, pustulosis, hyperostosis and osteomyelitis. Estimated prevalence is 1-4/10,000, but the syndrome is underdiagnosed due to its variable presentation and lack of formal diagnostic criteria. SAPHO is a diagnosis of exclusion and conditions such as infectious osteomyelitis and bone tumours must be eliminated first. We present a case of SAPHO, mistaken for spinal tuberculosis (TB).Case descriptionA 67-year-old Caribbean man with a history of type 2 diabetes mellitus and multiple prolapsed discs requiring surgical fixation presented in 2014 with severe back pain, swinging fevers and weight loss. A CT scan showed sclerosis of T9/10 vertebrae with corresponding bone oedema on an MRI spine. He commenced induction treatment for TB based on radiological features and travel history. Two months later, an MRI spine showed progressive inflammation at T10/11. Blood and tissue samples were negative for acid fast bacilli. Mycobacterium cultures, Interferon-gamma release assay (IGRA) and PCR were negative. However, treatment for TB was continued for a further ten months. Three months later, he re-presented with thoracic back pain and night sweats. MRI showed new inflammation at T6/7 and L3/4 reported as probable osteomyelitis. IGRA, blood and tissue cultures remained negative. Meanwhile, the patient suffered nine episodes of synovitis affecting knees and wrists. Knee X-rays showed end-stage hypertrophic osteoarthritic changes with severe osteophytosis. Synovial biopsies showed inflammatory changes but no evidence of TB.The patient re-presented in 2018 with back pain, sternoclavicular (SC) joint tenderness, painful knee swelling, night sweats and weight loss. Blood and synovial fluid cultures were negative, with calcium pyrophosphate crystals detected in synovial fluid. USS scan of the SC joint showed floridly active right-sided synovitis and synovial thickening on the left. CRP was 350 and he was treated with broad spectrum antibiotics for two weeks for presumed septic arthritis. Rheumatology review was requested when he failed to improve. His constellation of symptoms (synovitis, hyperostosis, osteitis and a history of a pustular rash) suggests a diagnosis of SAPHO. He commenced a weaning prednisolone regime and given zoledronic acid to good effect. Recurrence of symptoms occurred at low dose prednisolone, so he was given IM steroids and commenced on methotrexate.DiscussionSAPHO is underdiagnosed due its variable presentation and the need to first exclude infection and malignancy. The patient’s radiological features consistent with spinal TB and risk of TB exposure delayed diagnosis, despite negative serology and cultures.It is important to be aware that the full constellation of symptoms may not be evident at the time of presentation, or indeed at all in the course of the condition; our patient reported a prior history of a pustular rash on the soles of his feet, although there was no clinical evidence of this at the time of review. Involvement of classically affected joints, including anterior chest wall and thoracic spine, or skin involvement should increase clinical suspicion of SAPHO. NSAIDs and corticosteroids are first line therapy, with DMARDs, biological agents and bisphosphonates used to maintain remission. Key learning pointsPractitioners must consider the possibility of SAPHO, particularly in those with symptoms of osteomyelitis but no identifiable pathogen or who do not respond to antibiotic therapy. High inflammatory markers or high fevers do not preclude its diagnosis. As such, it is important to exclude infection, including osteomyelitis and septic arthritis, and malignancy prior to making a diagnosis.Clinicians should also be aware that the patient may not present with the full SAPHO syndrome; close review of past medical history and questioning about unreported episodes of synovitis or rash may be required to make the diagnosis.Conflicts of interestThe authors have declared no conflicts of interest.

Septic Arthritis of the Elbow in Children: Clinical Presentation and Microbiological Profile.

Septic arthritis of the elbow in children is a rare but important musculoskeletal infection, and there is little published data to guide treating clinicians. The purpose of this study was to describe the clinical presentation and diagnostic findings, associated pathology, and microbiological profile of septic arthritis of the elbow in a pediatric population. We retrospectively analyzed a consecutive series of children who had an elbow arthrocentesis for presumed septic arthritis and whose joint aspirates were positive for microbial growth. Data collected included demographics, presenting signs and symptoms, imaging, and laboratory data, including culture results. Twelve children underwent diagnostic arthrocentesis of the elbow joint for septic arthritis at an average age of 6 years and 9 months (range, 2 mo to 13 y and 7 mo). Every child had pain, localized erythema and edema, and restricted range of motion; 10/12 were febrile. Mean duration of symptoms prior to joint tap was 4 days (range, 1 to 14 d). Concurrent osteomyelitis was found in 7 patients, as confirmed with magnetic resonance imaging (MRI): 5 at initial presentation and 2 after readmission for persistent symptoms. Causative pathogens were MSSA (7), MRSA (2), Group G streptococcus (1), Pseuodomonas aureginosa (1), and Streptococcus pneumonia (1). ESR was >40 mm/h in 8/11 patients, CRP was >2 mg/dL in all patients, and synovial WBC count was >50,000 cells/mm in 8/9 patients. One patient developed fulminant sepsis during hospitalization and 2 children were readmitted within 30 days of discharge for unrecognized osteomyelitis and/or recurrence of septic arthritis of the elbow. In 12 children studied with septic arthritis, S. aureus was the most common pathogen. Diagnosis is often delayed, and in most cases inflammatory markers were elevated (ESR>40 mm/h, CRP>2 mg/dL). Concomitant osteomyelitis is quite common, and therefore magnetic resonance imaging should be considered as part of the diagnostic work-up for this condition. Level IV—Case series.

Preoperative antibiotics for septic arthritis in children: delay in diagnosis.

To review the records of 50 children who underwent open joint washout for septic arthritis with (n=25) or without (n=25) preoperative antibiotics. Records of 50 children who underwent open joint washout for presumed septic arthritis with (n=25) or without (n=25) preoperative antibiotics were reviewed. 17 boys and 8 girls aged 3 weeks to 16 years (median, 1.5 years) who were prescribed preoperative antibiotics before joint washout were compared with 12 boys and 13 girls aged one month to 14 years (median, 2 years) who were not. Following arthrotomy and washout, all patients were commenced on high-dose intravenous antibiotics. Patients were followed up for 6 to 18 months until asymptomatic. Patients who were referred from places other than our emergency department were twice as likely to have been prescribed preoperative antibiotics (p=0.0032). Patients prescribed preoperative antibiotics had a longer median (range) time from symptom onset to joint washout (8 [2-23] vs. 4 [1-29] days, p=0.05) and a higher mean erythrocyte sedimentation rate (93.1 vs. 54.3 mm/h, p=0.023) at presentation. Nonetheless, the 2 groups were comparable for weight bearing status, fever, and positive culture, as well as the mean (range) duration of antibiotic treatment (4.9 [4-7] vs. 4.7 [1-8] weeks, p=0.586). Preoperative antibiotics should be avoided in the management of septic arthritis in children. Their prescription delays diagnosis and definitive surgery, and leads to additional washouts and complications. A high index of suspicion and expedite referral to a specialist paediatric orthopaedic unit is needed if septic arthritis is suspected.

Epidemiology, Diagnosis, and Treatment of Pericapsular Pyomyositis of the Hip in Children

The yield of synovial fluid cultures in patients meeting clinical criteria for septic hip arthritis remains low. In the presence of positive blood cultures, these patients are diagnosed and treated as "presumed septic arthritis." We hypothesized that some of these patients may instead have an extra-articular infection, such as pericapsular pyomyositis. An IRB-approved prospective study of children with suspected septic hip arthritis at a tertiary care children's hospital over a 2-year time period was conducted. Children were evaluated with a previously published clinical algorithm with the addition of magnetic resonance imaging (MRI). Of the 53 patients presenting with an acutely irritable hip, 32% were found to have pericapsular pyomyositis, whereas 15% were diagnosed with septic arthritis. Although C-reactive protein (CRP, ≥33.1 mg/L) performed well at predicting infection, there were no significant differences in CRP, erythrocyte sedimentation rate, white blood cell count, temperature, or weight-bearing status in children with septic arthritis compared with pericapsular pyomyositis. In addition to MRI, there was a difference in the size of hip effusion on ultrasound, which was significantly smaller in cases of pericapsular pyomyositis. CRP (≥74.3 mg/L) was found to be predictive of need for surgical intervention in children with pericapsular pyomyositis. Correct anatomic diagnosis of the site of infection is essential for the efficient care of the child. Herein, we found that pericapsular pyomyositis is twice as common as septic arthritis in children presenting with an acutely irritable hip. Clinical algorithms are incapable of differentiating these pathologies suggesting that both be considered under the current diagnosis previously referred to as "presumed septic arthritis." Incorrect diagnosis of a septic arthritis in the presence of a pericapsular pyomyositis could potentially lead to unnecessary debridement of the joint in the presence of extra-articular infection, thus contaminating the joint. Conversely, debriding the joint instead of the epicenter of the infection can prolong the infectious process. For these reasons, we conclude that MRI has the potential to improve the clinical care of children by providing a more precise diagnosis. Level II-"Diagnostic" [Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference "gold" standard)].

Reply to the Letter to the Editor: Another Look: Is There a Flaw to Current Hip Septic Arthritis Diagnostic Algorithms?

Reply to the Letter to the Editor: Another Look: Is There a Flaw to Current Hip Septic Arthritis Diagnostic Algorithms?

Comparison of Bacteriologically Proven Septic Arthritis of the Hip and Knee in Children, a Preliminary Study

The hip and knee are the commonest joints affected by septic arthritis in the pediatric age group. Both can present as a limping, unwell child and can be difficult to diagnose. The primary aim of this study is to review and compare characteristics of pediatric patients with culture positive septic arthritis of the hip to those with culture positive septic arthritis of the knee. We retrospectively reviewed all patients who were clinically diagnosed with acute septic arthritis of either hip or knee in a tertiary pediatric hospital for a period of 3 years. Twelve of 29 patients who underwent arthrotomy for presumed septic arthritis of the hip and 7 of 37 patients who underwent arthrotomy for presumed septic arthritis of the knee had positive joint cultures. Patients with septic arthritis of the knee were much younger than that with septic arthritis of the hip. Patients with presumed septic arthritis of the knee based on clinical picture were less likely to have a positive synovial fluid culture. Children with septic arthritis of the knee did not follow Kocher criteria in the same way that children with septic arthritis of the hip did.

Lyme Arthritis Presenting as Acute Septic Arthritis in Children

There is considerable overlap in the initial clinical and laboratory presentations of acute septic arthritis and Lyme arthritis. The authors present a consecutive case series of 10 children with acute arthritis consistent with septic arthritis who ultimately were diagnosed with Lyme disease. Fifty percent presented with a fever of 38 degrees C or higher. The peripheral white blood cell count and differential were not elevated, but the erythrocyte sedimentation rate and the C-reactive protein were significantly elevated. The joint fluid cell count was elevated, with 91% neutrophils. Seven patients in this series underwent emergent joint irrigation and debridement for presumed septic arthritis. The authors suggest that in regions where Lyme disease is endemic, children who present with presumed septic arthritis should also be evaluated for Lyme disease. The authors also present a protocol for evaluation and management of these diagnostically challenging cases.

Childhood Lyme arthritis: Experience in an endemic area

We report 25 children with oligoarticular arthritis associated with Lyme disease. There were 16 boys (male/female ratio 1.8:1); ages ranged from 2 to 15 years. Thirteen (52%) children had no history of erythema chronicum migrans or other rash. Thirteen had temperatures as high as 41 degrees C for up to 2 months before the onset of arthritis. Twelve recalled definite tick bites. Ten (40%) children, of whom seven had no history of rash, were hospitalized for presumed septic arthritis. Another four had diagnoses of pauciarticular juvenile rheumatoid arthritis for as long as 3 years. Seven patients had less acute, recurrent episodes of synovitis. Two children had seventh nerve palsies 2 months before onset of arthritis. All patients had antibodies to the Lyme spirochete. In 14 patients, synovial fluid white blood cell counts ranged from 180 to 97,700/mm3 (greater than or equal to 76% polymorphonuclear leukocytes). Antibiotic therapy was effective in all patients; in 13, orally administered therapy alone resulted in elimination of synovitis and recurrent attacks. Lyme arthritis may be confused with acute bacterial septic arthritis or recurrent "pauciarticular juvenile rheumatoid arthritis," particularly when there is no history of erythema chronicum migrans.