Mary E Margaretten, Jeffrey Kohlwes, Dan Moore, Stephen Bent
Does this adult patient have septic arthritis?
JAMA. 2007 Apr 4;297(13):1478-88. doi: 10.1001/jama.297.13.1478.
Abstract/Text
CONTEXT: In patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality.
OBJECTIVE: To review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis.
DATA SOURCES: Structured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity.
STUDY SELECTION: Studies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis.
DATA EXTRACTION: Three authors independently abstracted data from the included studies.
DATA SYNTHESIS: Fourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts <25,000/microL: LR, 0.32; 95% CI, 0.23-0.43; for counts > or =25,000/microL: LR, 2.9; 95% CI, 2.5-3.4; for counts >50,000/microL: LR, 7.7; 95% CI, 5.7-11.0; and for counts >100,000/microL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47).
CONCLUSIONS: Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.
Kaushal Shah, Jeffrey Spear, Larry A Nathanson, Jon McCauley, Jonathan A Edlow
Does the presence of crystal arthritis rule out septic arthritis?
J Emerg Med. 2007 Jan;32(1):23-6. doi: 10.1016/j.jemermed.2006.07.019.
Abstract/Text
The objective of this study was to determine the incidence of septic arthritis in the presence of joint crystals. A retrospective study was conducted at a university tertiary care referral center. The study population included all patients with synovial fluid crystals in the joint aspirate sent to the laboratory during the 7-year study period. Septic arthritis was defined as a positive synovial culture. Of the 265 joint aspirates containing crystals, 183 (69.0%) contained gout crystals, 81 (30.6%) contained pseudogout crystals, and 1 (0.4%) contained both. Four (1.5%) of the aspirates had positive cultures. The mean synovial WBC of the 4 samples with concomitant crystals and septic arthritis was 113,000 (95% confidence interval [CI] 72,700-153,200), which was significantly higher than the entire population at 23,200 (95% CI 19,400-27,000; p < 0.01). Of note, all 4 patients with concomitant disease had significant co-morbidities and synovial WBC counts greater than 50,000. Septic arthritis and acute crystal-induced arthritis can occur simultaneously; there were 4 cases (1.5%) of concomitant disease in our study population. The presence of crystals cannot exclude septic arthritis with certainty.
Ines Colmegna, Noah Alberts-Grill
Parvovirus B19: its role in chronic arthritis.
Rheum Dis Clin North Am. 2009 Feb;35(1):95-110. doi: 10.1016/j.rdc.2009.03.004.
Abstract/Text
B19 infection-associated joint symptoms occur most frequently in adults, usually presenting as a self-limited, acute symmetric polyarthritis affecting the small joints of the hands, wrists, and knees. A small percentage of patients persist with chronic polyarthritis that mimics rheumatoid arthritis raising the question of whether B19 virus may have a role as a concomitant or precipitating factor in the pathogenesis of autoimmune conditions. Comprehensive and updated reviews address different aspects of human parvovirus infection. This article focuses on the evidence supporting the arthritogenic potential of the B19 virus and the proposed mechanisms that underlie it.
M Yamaguchi, A Ohta, T Tsunematsu, R Kasukawa, Y Mizushima, H Kashiwagi, S Kashiwazaki, K Tanimoto, Y Matsumoto, T Ota
Preliminary criteria for classification of adult Still's disease.
J Rheumatol. 1992 Mar;19(3):424-30.
Abstract/Text
We have attempted to design classification criteria for adult Still's disease by analyzing the data obtained through a multicenter survey of 90 Japanese patients with this disease and of 267 control patients. The proposed criteria consisted of fever, arthralgia, typical rash, and leukocytosis as major, and sore throat, lymphadenopathy and/or splenomegaly, liver dysfunction, and the absence of rheumatoid factor and antinuclear antibody as minor criteria. Requiring 5 or more criteria including 2 or more major criteria yielded 96.2% sensitivity and 92.1% specificity. However, an exclusion process will be needed for an accurate classification, since this disease is relatively rare.
Michael R. Liebling MD, et al., Identification of neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction, Arthritis Rheum, 1994 37(5), 702-9.
