Practical Aspects of septic arthritis in children

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* Concept

* Epidemiology

* Bacteriology

* Predisposing factors

* Pathogenesis

* Pathology

* Location

* Clinical Manifestations

* Diagnosis

* Differential Diagnosis

* Treatment

* Septic arthritis of the newborn

* Reactive Arthritis

* Transient synovitis

* Arthritis, gonococcal and syphilitic

* Conclusions

* References

1. CONCEPT:

“Articulate acute inflammatory process caused by invasion and multiplication of pyogenic organisms.”

Indicates the presence of the infectious organism into the joint and is not associated with adjacent osteomyelitis.

Keywords: arthritis, septic pyogenic infectious, diagnostic, clinical, articular inflammation +, infant, pediatric

2, EPIDEMIOLOGY

* More frequent in childhood than in adulthood

* Increased incidence of 2-6 years.

* In elderly patient due to reduced organic defenses and increased infections in general.

* More common in men than in women (2:1)

* In the male, young adult, gonococcal higher incidence, in the U.S., reaching incidences similar to those produced by Staph.

* More often lower limb joints.

3. Etiology

* More frecuente Staphylococcus (70% to 80%)

* Segundo streptococcus and gonococcus.

* Pneumococcal

*

  • Mainly under 15 months

    * Hips

    * Fluid culture higher diagnostic method.

    * High percentage with decreased susceptibility to penicillin.

    * Diagnosis and treatment precoz good prognosis articular

    * Gram negative

    *

  • E. Coli, Pseudomonas, Proteus, H. influenza, Serratia

    * Less frequent

    * Newborns and infants in sepsis especialmente

    * Patients aged avanzada in urinary infections and systemic.

    4. BACTERIOLOGY

    Newborn, community-acquired infection:

    * 52% Group B Streptococcus (birth canal),

    * Staphylococcus 25%

    * Neisseria gonorrhoeae 17%

    Bacilli * G (-) 5%.

    Newborn nosocomial infections:

    * Staphylococcus 62%

    * Yeast 17%

    * Bacilos G (-) 13%,

    * Streptococcus 13%.

    Children:

    * Before the vaccine and Haemophilus influenza from 1 month to 5 years.

    * As in adults more often staphylococcus.

    Teens: Neisseria gonorrhoeae, Pseudomonas in drug

    5. Predisposing Factors

    * Rheumatoid arthritis

    * Drop

    * Lupus Erythematosus

    * State of immunosuppression, HIV (fungi or mycobacteria) or Deficit complement (C7 and C8)

    * Blood Diseases: Sickle Cell Anemia and hemoglobinopathies

    * Bacteremia transient or persistent

    * Endocarditis.

    * Skin infections.

    * Varicella

    * History of respiratory infection two weeks prior.

    * Trauma or contiguity (osteomyelitis)

    * Joint damage prior

    * Joint prosthesis

    * Joint surgical procedures.

    * Surgery or instrumentation of the urinary tract or bowel.

    * Drug injecting

    * Catheters. Sternoclavicular arthritis (subclavian vein) and arthritis of the hip (femoral)

    6. Pathogenesis

    The germs get into the joint:

    *

  • Hematogenously (the most common).

    * Direct route:

    * Penetrating injury

    * Infected injection

    * Surgical infection.

    * By contiguity:

    *

  • Extension of focus osteomyelitic

    Hip Arthritis child, focus the femoral neck (intracapsular)

    * The remainder of the joints must cross the barrier infection determined by the growth plate and the epiphysis or via periarticular (node).

    Process:

    * Synovium: bacteria multiplican PMN migration

    * Liberation of proteolytic enzymes (metalloproteinases) and proinflammatory cytokines (IL-1, TNFa) bacteria Phagocytosis

    * Increased Proliferation flow membrane sanguneo sinovial

    * Oozing into space articulate and purulent discharge

    * Increased pressure cavity Articulate cartilage degradation

    * Possible loss of joint integrity.

    7. Pathology

    First etapa “Synovitis”

    * Hyperemia, swelling and leukocyte infiltration of synovial

    * Intraarticular serous effusion, seropurulent, purulent.

    Second etapa “phlegmon capsular>>

    * All joint tissues infiltrated by the exudate.

    * Commitment of articular cartilage, irreparable damage.

    Bone involvement

    * Chondrolysis and osteolysis

    * Permanent joint damage and cartilage loss

    * Contact between bone ends or bony ankylosis fusionan

    * Reparativo is interposed fibrous ankylosis fibrous tissue.

    8. LOCATION

    Any joint can be involved,

    * The most common sites of infection are:

    * Knee (children and adolescents)

    * Hips (infants and children)

    * Shoulder and Ankle

    * Elbow

    * Doll

    * Pelvis

    * Column (spondylitis in elderly)

    * Most infections affect only one joint.

    9. CLINICAL

    * 80% monoarticular “acute monoarthritis.”

    *

  • Abrupt increase in volume 1 joint with intense pain and local heat.

    * Polyarticular 20%.

    *

  • Patients with pre-existing disease (eg diabetes mellitus) or joints (eg rheumatoid arthritis).

    Clinic:

    * Acute onset (hours or days)

    * Febrile syndrome with prostration and loss of appetite.

    * Commitment articulate spontaneous pain, especially joint mobilization, enlargement, erythema, local heat, functional impotence, antalgic position.

    * Can be clear gateway, skin infection (furuncle, Anthrax, impetigo, scabies infected) or the course of a disease (sepsis, staphylococcal pneumonia or other acute tonsillitis, etc.).

    * If there is no gateway obvious: not changed the diagnostic suspicion

    * When there, we probably guidance on origin and etiology.

    * May or may not be evidence of primary outbreaks of skin infection, urinary tract, respiratory or other.

    Variations.

    * Lactantes general manifestations precede the Local Joint box

    * Adultos more attenuated infectious condition, consult a few days later.

    * Tip Superiore child ceases to move your arm, it remains to be touched and, in attempting movilizrselo, crying with pain.

    * Tip Inferiore similar attitude if infant, older child if you stop walking or does so with great difficulty by local pain.

    * Cadera no swelling, joint is a deep, intense pain especially mobilizing internal and external rotation or abduction, limited. Antalgic position: slight flexion and adduction.

    * Rodilla obvious signs of inflammation and joint effusion, iceberg or sign patellar shock. Antalgic position: mild semiflexion.

    Atypical presentations:

    * Preexisting arthropathy: Rheumatoid Arthritis (RA)

    *

  • It can be difficult to recognize

    * It can be confused with peak activity

    * You can drive by mistake increased immunosuppressive therapy.

    * It can be mono or polyarticular.

    * Presentation polyarticular

    * In old and debilitated patients: with fewer symptoms, sometimes afebrile

    * Locations that may go unnoticed: hips, sternoclavicular, sacroiliac

    10. DIAGNOSIS:

    Synovial fluid studies

    * Mandatory

    * Obtaining usually facilitated by increased amount thereof within the involved joint.

    * Inflammation: turbidity of the liquid, cell growth.

    * Other inflammatory diseases may present turbidity chondrocalcinosis (white-milky arthritis crystals of calcium pyrophosphate), rheumatoid arthritis or gout.

    * Confirms get cloudy fluid or pus.

    * WBC and differential

    * Study of crystals

    * Gram stain

    * Crop

    Puncture technique ARTICULAR

    * Measures aseptic

    * Isolation of the field, surgical scrub hands and use sterile gloves.

    * Insert needle into joint cavity and extract the maximum amount of synovial fluid

    * Puncture of the knee or sperointerno outer quadrant, 1 cm. above and outside or inside the bearing.

    * In hip: 1.5cm. inguinal ligament below 1 cm. outside the femoral artery is identified by palpation of the beating.

    * Normal and colorless liquid.

    * Osteoarthritis: beige and septic arthritis: cream or gray.

    * Mucin clot by adding acetic acid

    *

  • Since the amount of protein bound polysaccharide

    * Average in osteoarthritis; friable rheumatoid arthritis or poor, gout and septic arthritis.

    * Viscosity of liquid

    *

  • Relationship presence of hyaluronate, if placing a drop between thumb and forefinger, are separated over one to several centimeters and liquid is held together, is probably normal.

    * Normal joint fluid of osteoarthritis, normal or high.

    * Rheumatoid arthritis, gout or septic, is decreased

    Cell Review

    *

  • Very useful.

    * Normally around 100 leucocitos/mm2.

    * Tubes with anticoagulant (heparin or EDTA) for cell studies.

    * Processes noninflammatory: 1000-2000 cel/mm2.

    * Inflammatory: on 10.000cel/mm2

    * Septic arthritis: on 100.000/mm2 predominantly polymorphonuclear.

    * Normal protein concentration approx. 30% lower serum concentration.

    * Permeability of the synovial inflammatory increased protein content increases.

    * Glucose infectious processes is decreased <50% of the blood, and is lower in septic processes

    * Confirm etiology, causative.

    * Study direct Gram stain morphology without waiting seed crop

    * Positive culture in 90% of nongonococcal bacterial arthritis

    * Growing medium

    *

  • Usual blood agar

    * Neisseria gonorrhea, haemophilus: chocolate agar

    * Fungi Sabouraud

    * Mycobacteria: specific means.

    Radiology

    * Method secondary early diagnosis.

    * Radiographic late, do not help in acute, but after 10 to 15 days.

    * Allows:

    *

  • Knowing joint precondition

    * Pesquisar possibility of other diagnoses

    * Rate after disease progression.

    Radiologic Signs

    * Increased periarticular soft

    * Decreased joint space: commitment cartilage

    * (Chondrolysis)

    * Increase joint fluid increased joint space.

    * Subchondral and epiphyseal bone demineralization

    * Effacement and irregularity of contour articulate and

    * Progressive destruction of articular surfaces.

    * Skeletal scintigraphy: Concentration in coordination abnormal radiopharmaceutical diagnostic value suspect is in initial stages. Technetium 99, increased uptake in affected joint. (+) In 24 hours.

    * Joints difficult to locate and / or to puncture is useful and CT or MRI.

    * MRI. Reveals abnormalities of bone marrow and soft tissues within 24-48 hours. Demonstrates increased infection and edema fluid around. Typically: focal area, well defined with much edema extending to adjacent soft tissues.

    Ultrasound

    * For joint space and can recognize early periosteal elevation.

    * Intraarticular fluid is easily detectable.

    * Can assess edema as areas of high echogenicity.

    * You can not rate structures intraosseous

    Other laboratory tests

    * Blood cultures: (+) in 50% of nongonococcal bacterial arthritis

    * CBC: leukocytosis and increased neutrophil.

    * Elevation of ESR and C-reactive protein

    11. DIFFERENTIAL DIAGNOSIS

    * Active rheumatic disease (migratory arthritis).

    * Arthritis crystals (gout or pseudogout).

    * Mono-articular rheumatoid arthritis.

    * Traumatic arthritis.

    * Infectious processes periarticular soft tissue.

    * Acute osteomyelitis.

    * Toxic synovitis (also called (irritable hip, reactive or transient synovitis)

    * Epiphyseal osteomyelitis.

    * Viral arthritis (varicella zoster, parvovirus B19, rubella and others).

    * Arthritis by fungi and mycobacteria.

    * Traumatic arthritis.

    * Bacterial endocarditis.

    * Villonodular synovitis.

    * Leukemia.

    * Cellulite deep.

    * Serum sickness.

    * Ulcerative colitis.

    * Granulomatous colitis.

    * Schnlein-Henoch.

    * Traumatic arthritis.

    * Fracture.

    * Legg-Calv-Perthes disease.

    * Epiphysiolysis of the femoral head.

    * Metabolic diseases that affect the joints

    12. TREATMENT

    * You must be urgent and early

    * Purulent secretion condroltica has a powerful action will destroy the joint from the functional viewpoint

    * It is a septic focus with the consequences that can derive from it (sepsis).

    * Mandatory bedrest patient to top

    * Rehabilitation to achieve a joint anatomically and functionally normal.

    * Recommended early mobilization to prevent contractures.

    Antibiotic Treatment

    * According to: causative organism, clinical and bacteriology with Gram, culture and sensitivity.

    * Majority: Staph aureus, oxacillin intravenous dose of 150 to 200 mg / kg or 1 gr. every 6 hours in adults.

    * Penicillin G estreptococo Gonococcus or 100-200 mg / kg or 2 million units every 6 hours EV in adults.

    * EV are administered for 14 days followed by oral treatment for another 14 days.

    * No need intrarticulacin, concentrations achieved in synovial intravenously are sufficient.

    Drainage of exudate

    * Arthrotomy, repeated punctures or Arthroscopy articular aspirational.

    * Method of choice: surgical drainage system leaving joint lavage with saline for 5-10 days.

    * Insufficient articular punctures and not indicated in staph infections or arthritis very aggressive.

    * Mandatory and urgent, hip, destruction is imminent for cartilage damage and necrosis of the femoral head vascular damage

    * In the infant, the destruction of the femoral head and neck with distension of the joint capsule can cause dislocation of the hip, bad functional prognosis.

    13. NEWBORN septic arthritis

    * Difficulty of diagnosis: clinical scarcity and nonspecific

    * Etiology: unusual microorganisms

    * May be involved etiological agents Staphylococcus, Streptococcus and Enterobacteriaceae.

    * Also been reported for Candida albicans and gonococcus.

    * Gonococcal: is polyarticular, 1-5 weeks after birth.

    * DX and catastrophic consequences if not early Tto

    * It may affect more than one joint.

    * Hip: clinic 1-28 days after venipuncture (differentiate femoral thrombosis). Fever and leukocytosis septic appearance. Progression of localized infection spontaneous drainage path along the inner shutter and giving rise to a mass above the inguinal canal.

    * Treatment and antibiotics to cover S. aureus, Enterobacteriaceae, Streptococcus group B and gonorrhea Neiserria the following treatment regimens according to age:

    – Under 7 days: antipenicilinasa penicillin (cloxacillin + cefotaxime).

    – From 7 days to 28 days: cloxacillin + cefotaxime

    – Over 28 days: cloxacillin + cefotaxime

    * Duration: 3 to 4 weeks

    * Will parenteral, or oral and supplemented parenteral start.

    * Perform radiography before stopping treatment because up to two thirds of patients have been observed in addition to arthritis, bone involvement.

    14. Reactive arthritis

    * Caused by an immune mechanism,

    * Have been described in connection with Shigella infections, Chlamydia trachomatis, Salmonella and Yersinia.

    * Joint swelling postinfectious more often in people with HLA-B27 (+).

    * Symptoms: from days to weeks after infection, resolved in 7 to 10 days regardless of the use of antimicrobials

    15. Transient synovitis

    * Characterized: fever, pain and loss of function of the joint.

    * Probable viral

    * Regression spontaneously within a few days.

    * Differential diagnosis with pyogenic arthritis.

    * Facing Dudae hip arthrotomy before leaving evolve pyogenic arthritis

    * Once drained the joint should be immobilized in a cast, brace or be a pelvipedio if the knee or hip respectively.

    16. Gonococcal arthritis

    * More common in young adults

    * Days a few weeks after gonococcal urethritis treated improperly.

    * Oligoarticular or monoarticular.

    * Characteristics of acute pyogenic arthritis.

    * Gram can show Gram negative diplococcus

    * Growing difficult.

    * Antibiotic of choice is penicillin

    * It is conservatively without surgical drainage.

    * Immobilization in functional position is imperative.

    Syphilitic arthritis

    * Exceptional.

    * View syphilitic mother newborns.

    * Tertiary syphilis can cause Charcot arthropathy in adults.

    17. CONCLUSIONS:

    * Increased incidence of 2-6 years and more common in men than in women (2:1)

    * Most common etiologic agent is Staphylococcus (70% to 80%)

    * In a newborn, community-acquired infection: 52% Group B Streptococcus (birth canal) but it is a nosocomial infections: Staphylococcus 62%,

    * The germs get into the joint: hematogenously (the most common).

    * Pathology: First stage: “Synovitis” Stage “capsular phlegmon” Then commitment articular cartilage damage by ltino irreparable.y: bone involvement: chondrolysis and osteolysis with definitive joint damage and cartilage loss.

    * The most common sites of infection are: Knee (children and adolescents) and Hip (infants and children)

    * Presented as monoarticular 80%

    * In Infants general manifestations precede the local joint box Adults differences where it occurs as an infection more attenuated.

    * The study is mandatory synovial fluid confirms the diagnosis established etiology and guides to specific treatment.

    * Plain radiography is a method for early diagnosis secondary radiographic signs are late, and do not help in acute, but after 10 to 15 days.

    * Treatment should be urgent and early include: antibiotics, analgesics, anti-inflammatory, joint exudate drainage, physiotherapy and rest then.

    REFERENCES

    * Tiddia F, Cherchi GB, Pacific L. (1994) Yersinia enterocolitica Causing suppurative arthritis of the shoulder.J Clin Pathol 47 (8): 760,

    * The-Gabalawy HS, Duray P, Goldbach-Mansky R. (2000) Evaluating patients with arthritis of recent onset: studies in pathogenesis and prognosis. JAMA, 284: 2368-2373.

    * Perlman MH, MJ Patzakis, Kurmar PJ. (2000) The Incidence of joint Involvement with adjacent osteomyelitis in pediatric patients. J Pediatr Orthop, 20: 40-43.

    * Perry CR. Septic arthritis. (1999) Am J Orthop; 28:168-178.

    * Cardinal, E., Bureau, N., Aubin, b., Chhem, R., (2001) Role of Ultrasound in Musculoskeletal Infections, Radiol Clin North Am; 39:191201.

    * Roldn-Valadez E, Lima-Davalos R, Shangri-Pinto G, Solorzano-Morales S, Hernandez-Ortiz J (2004) Imaging of acute septic arthritis of the hip. Gac Med Mex, 140 (1): 93-96

    * Goldenberg D. Septic arthritis. (1998) Lancet, 351: 197-202