septic arthritis lyme disease lecture

JOINT AND BONE INFECTIONSJOINT AND BONE INFECTIONS

IntroductionIntroduction

• Micro-organisms causing joint & bone disease

- Bacteria

- Viruses

- Fungi

- Parasites

IntroductionIntroduction

• Mechanisms which cause disease

- Active infection

- Induced reaction

- Inflammation

These mechanisms are not mutually exclusive

Bacterial InfectionsBacterial Infections

• Factors such as- Source of infection- Age of the patient- Underlying disease

Determine the organism causing infection


• Gram-positive cocci• Staphylococci: Most common in adult

septic arthritis and osteomyelitis• Staphylococcus aureus, epidermidis,

saprophyticus• Staphylococcal toxic shock syndrome


• Streptococci - Group A b-haemolytic:

Streptococcus pyogenes, Strep. Pneumoniae

- Rheumatic fever, experimentally induced arthritis


• Gram-negative cocciGram-negative cocci• Gonococcal arthritisGonococcal arthritis

- UncommonUncommon- Diffuse or migratory arthralgiaDiffuse or migratory arthralgia- Low-grade feverLow-grade fever- Mono-arthritis or oligoarthritisMono-arthritis or oligoarthritis


•Gram-negative bacilli

•Anaerobes

- Bacteroidaceae e.g. Bacteroides fragilis.

•Aerobes and faculative anaerobes

- Enterobacteriaceae e.g. Escherichia coli, particularly in neonates.


• Salmonella and Yersinia spp.

• Shigella spp. Infection is uncommon.

• Klebsiella pneumoniae and Proteus mirabilis.


• Acid-fast bacilli• Tuberculosis: Mycobacterium • Tuberculosis and M. leprae • Joint/Bone

- 10% of cases of extrapulmonary tuberculosis

- 2% of all new cases of tuberculosis


•Mycobacterium tuberculosis and M. leprae

• 5 clinical syndromes- Spondylitis (Pott’s disease)- Peripheral arthritis- Osteomyelitis/dactylitis- Tenosynovitis/bursitis- Reactive arthritis (Poncet’s disease)


• Brucellosis

-Contracted from infected animals• Spirochaetes• B. burgdorferi • Lyme disease


Chlamydia

•C. trachomatis, psittaci, pneumoniae - reactive arthritis

Mycoplasmas

• M. hominis and ureaplasma urealyticum

- genital tract.

Borrelia Burgdorferi Borrelia Burgdorferi SpeciesSpecies

• North American and Europe- B. burgdorferi sensu stricto

• Europe- B. afzelii and B. garinii

Clinical Features of Clinical Features of Lyme BorreliosisLyme Borreliosis

•Stage I: Early localised

•Stage II: Early disseminated

•Stage III: Late Lyme borreliosis

Lyme Borreliosis Lyme Borreliosis

Treatment• Erythema migrans and facial palsy

-Amoxycillin or Doxycycline 21 days

• Acute arthritis

- Increase treatment time to 30 days


Treatment • Neuroborreliosis

- IV antibiotics eg. ceftriaxone 2mg daily 21 days


Prophylaxis

•Avoidance- keep skin covered- insect repellent- examine clothes and skin

•To remove ticks- oil- lift with twisting motion – DO NOT

squeeze!

Lyme DiseaseLyme Disease

• Vaccination- OspA preparation offer oral

protection• Safe and immunogenic LD patients

References J. Infect Dis. 1995, 171: 1368-1370K. Infect Dis. 1995, 1324-1329

Septic ArthritisSeptic Arthritis

Lyme Disease Vaccine• 10,936 individuals received three doses

of either OspA with aluminum hydroxide adjuvant (Lymerix) or placebo upon entry into the study, at 1 month, and 12 months later

• Reports of adverse musculoskeletal and neurologic events following vaccine


Lyme Disease Vaccine• Use of the vaccine decreased

dramatically • 2002, Manufacture stopped • There is no currently licensed

vaccine against Lyme disease

Reference • Steere et al. N Engl J Med 1998; 339:209.• GSK Lymerix. The Pink Sheet, F-D-C Reports, Inc. Chevy Chase, Maryland 2002; 64(9):23.

Viral InfectionsViral Infections

•Few viruses have been unequivocally identified as the direct cause of human

joint inflammation

• AetiopathogenesisDirect toxic effect, immune complex formation, virus or viral antigen persistence, molecular mimicry, superantigen function, modification of the immune response


• Rubella50% of infected women, 6% of men. Uncommon in children. Rubella vaccine is not associated with clinically important acute or chronic joint disease

• Parvovirus B19Acute, benign, self-limiting disease, rheumatoid-like polyarthritis. Rheumatic symptoms occur in 95% of infected children


• HIVAffects 8-10 million individuals. Arthralgia, Reiter’s syndrome, psoriatic arthritis, HIV-associated arthritis, avascular necrosis of bone, septic arthritis and autoimmune rheumatic disease-like syndromes


• Hepatitis Viruses- Acute hepatitis B virus, transient

polyarthritis, in 30% of patients

- Hepatitis C virus type II cryoglobulinaemia. Immunosuppressive agents should be avoided in these patients

Fungal InfectionsFungal Infections

• ImmunosuppressionImmunosuppression- Actinomyces, Aspergillus and Actinomyces, Aspergillus and

CandidaCandida

- Uncommon. One-quarter of all Uncommon. One-quarter of all candidal prosthetic joint candidal prosthetic joint

infections occur in patients with infections occur in patients with rheumatoid arthritisrheumatoid arthritis

Parasitic InfectionParasitic Infection

• ProtozoaProtozoa

• Roundworms (eg. Strongyloides)Roundworms (eg. Strongyloides)

• GiardiaGiardia

• Flatworms (eg. taeniae)Flatworms (eg. taeniae)- Areas endemic for parasitic disease.Areas endemic for parasitic disease.- Symptoms: localization, reaction, Symptoms: localization, reaction, immune-mediated response, immune-mediated response, following treatment.following treatment.


• Most common- Children- Elderly - Immunosuppressed - Damaged joints


• Joints may be held in flexion• Adults may complain of pain• Begin treatment early• 1% septic skeletal infections spinal


Pathogenesis

• Dissemination - Via the bloodstream.- Acute osteomyelitic focus- Spread from an adjacent

infection- Penetrating trauma


• 191 cases of septic arthritis • 72 percent hematogenous • Injection drug use, in dwelling

catheters, immunocompromised state e.g. HIV infection.

• Neonates and the elderly are at highest risk.

References

Morgan et al Epidemiol Infect 1996; 117:423.


Underlying Arthritis

•Bacteremia more likely to localize in a joint with pre-existing arthritis,

particularly if associated with synovitis.

•In 154 patients with bacterial arthritis 40 percent had pre-existing joint

disease, rheumatoid arthritis or osteoarthritis

Reference Kaandorp et al Arthritis Rheum 1997; 40: 884.


PathogenesisPathogenesis • Bacteria enter the jointBacteria enter the joint• Deposit in the synovial membrane Deposit in the synovial membrane • Produce an acute inflammatory Produce an acute inflammatory

cell responsecell response• Synovial tissue has no limiting Synovial tissue has no limiting

basement platebasement plate


Pathogenesis• Organisms may quickly gain

access to the synovial fluid • Creating the characteristic acute

purulent joint inflammation


Pathogenesis• 5 days

- Marked hyperplasia of the lining cells in the synovial membrane

- Inflammatory cells release cytokines and proteases - Cartilage degradation - Inhibit cartilage synthesis.

- Pressure necrosis results in further cartilage and bone loss

OsteomyelitisOsteomyelitis

Acute Osteomyelitis

•Metaphysis- Rich blood supply- Slow circulation time

•Bone- Locally tender - Swelling and warmth

•If treatment within 2-3 days prognosis good

OsteomyelitisOsteomyelitis

Chronic and Subacute Osteomyelitis

• Trauma or surgery- ‘Brodie’s abscess’.

Diagnosing Joint and Diagnosing Joint and Bone InfectionBone Infection

Blood Tests• Acute phase response raised• Immune tests

- e.g. IgM and IgG antibodies to B19 parvovirus.

Diagnosing Joint andDiagnosing Joint and Bone Infection Bone Infection

Imaging• Radiographic • Infection has been present for > 2

weeks- CT and MRI- In-labelled leucocytes- Scintigraphy (99mTc phosphate)

Diagnosing Joint andDiagnosing Joint and Bone Infection Bone Infection

Microbiology• Synovial fluid culture• Blood and urine cultures• Suspected infectious foci• Tissue biopsy• Mantoux test

Management of Joint and Management of Joint and Bone InfectionsBone Infections

The Principles are:

• Prompt diagnosis

• Early therapy with appropriate antibiotics


Antibiotic Regimen

• Specific bacterial resistance

• Physician’s preference

• Switch culture results known


AntibioticsAntibiotics• Staph. Aureus/Gram-positive cocciStaph. Aureus/Gram-positive cocci

- Adults: flucloxacillin and fusidic Adults: flucloxacillin and fusidic

acid or clindamycinacid or clindamycin

Septic ArthritisSeptic ArthritisAntibiotic Therapy • Choice based upon the Gram stain and/or the

clinical presentation.• Gram positive cocci

- Cefazolin (1 to 2 g IV q8h) community acquired infections

- Vancomycin (30 mg/kg daily IV in two divided doses) hospital/nursing home acquired infection


• H. InfluenzaeH. Influenzae- Children under 3 years of ageChildren under 3 years of age- Ampicillin or a cephalosporin-Ampicillin or a cephalosporin-

cefotaxamine or ceftrioxone).cefotaxamine or ceftrioxone).


• Gram-negative organisms- Elderly/predisposing e.g. RA - Cephalosporine - cefotaxime or

ceftrioxone


• Gram negative bacilli- Third generation cephalosporin e.g.

Certazidime (1 to 2 g IV q8h)- Aminoglycoside e.g. Gentamicin

when Pseudomonas aeruginosa is considered to be a likely pathogen (e.g. in patients who inject illicit drugs).


• Gram negative bacilli- Ceftriaxone (2 g IV q24h),Ceftriaxone (2 g IV q24h),- Cefotaxime (2 g IV q8h) Ceftazidime Cefotaxime (2 g IV q8h) Ceftazidime

should be given should be given

• Modifications made when the culture Modifications made when the culture and and susceptibility results are availablesusceptibility results are available


Antibiotics• 6 weeks

- Septic arthritis• 2-3 months

- Osteomyelitis


• Duration of antimicrobial - Parenteral antibiotics for at least

14 days followed by oral therapy (if possible) for an additional 14 days


Joint Drainage • Peripheral joints closed needle

aspiration• Daily aspiration may be necessary • Arthroscopy or open drainage maybe

necessary


Prognosis • Not improved significantly in the

past few decades• Outcome is directly related to host

factors• Prior joint damage• Virulence of the infecting organism


Prognosis

•Speed with which adequate treatment begun

•Inflammation and destruction of joints may continue in sterile joints despite effective antimicrobial therapy

•121 adults and 31 children with bacterial arthritis had poor joint outcome


Prognosis• Amputation, arthrodesis, prosthetic

surgery or severe functional deterioration occurred in one-third of the patients

Reference Kaandorp et al Arthritis Rheum 1997; 40: 884.


Mortality • Dependent upon the presence of co-

morbid conditions • Advanced age, coexistent renal or

cardiac disease, and immunosuppression

• Mortality rates range from 10 to 15 percent


Mortality• Polyarticular septic arthritis • Due to S. aureus or with rheumatoid

arthritis• Extremely poor prognosis with

mortality rates as high as 50 percent

ReferenceDubost et al Polyarticular septic arthritis. Medicine (Baltimore) 1993; 72:296.

Chronic Fatigue SyndromeChronic Fatigue Syndrome

• Epidemic or sporadic.• Males = females• Peaks: 25-30 years and 40-45

years..

Chronic Fatigue SyndromeChronic Fatigue Syndrome

• Debilitating fatigue• Muscle aches, pains• Lymph node tenderness• Pyrexia• Exhaustion• Invariable psychiatric symptoms

The Sir Joseph Hotung Centre for Musculoskeletal Diseases

St George’s Hospital & Medical School London SW17 OQT UK

septic arthritis lyme disease lecture

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