In rheumatology, I will take a look at
a septic arthritic condition.
Something that you want to keep in mind is,
what's the difference between
septic arthritis and
you ever heard of reactive arthritis?
So what is septic arthritis?
Now, seriously, this is an emergency.
Acute inflammatory, asymmetric,
monoarticular. You're going to
have this perhaps the knee,
swollen, red, and it's inflammatory.
In other words, it would be purulent,
the synovial fluid will be
when you do arthrocentesis.
But why is it a medical emergency?
Because it may only take hours
for disinfection to completely
destroy the cartilage.
And then once that cartilage
has been damaged,
please note that oftentimes, that this is a
permanent manifestation. Not good.
Now, I mentioned purulent synovial fluid.
So, what does that mean to you?
So here's a condition in which
the synovial fluid…
And you might find the WBC
count to be > 50,000.
Yes, you heard that correctly; 50,000.
A normal WBC count,
well, in your serum should be
between 45 to 11,000.
Here, it could be as high as 50,000.
we call that non-inflammatory
because if you did
an arthrocentesis and the
synovial fluid was < 2000,
then you'd call that non-
Now, apart from the rapid nature of all this,
the associations are important.
Then diabetes, skin infection
secondary to neuropathologic
changes could be present.
In drug users,
obviously here looking at
the site of injection,
and in addition, you're also worried about
endocarditis, aren't you?
For example, tricuspid valve issues.
In a young patient who comes
in with that monoarticular
inflammatory painful, red knee,
you're thinking about gonococcal.
Continue our discussion
of nidus of infection.
If your patient comes in and he
is an African-American boy
and has sickle cell disease,
well, you know that in sickle cell patient,
the common organism that then causes
osteomyelitis will be Salmonella.
And that's what you might be thinking
about here. Keep that in mind, though.
The reason I want you to
keep that in mind is
if your patient has back pain,
and is HLA-B27 positive,
and you find something like Salmonella,
then you might be thinking about
reactive arthritis. But here, this is in
a setting of sickle cell disease,
In trauma, look for Staph epidermidis.
In immunosuppressed patient, and
you're worried about
septic arthritis in general,
from whatever type of bacteria, perhaps.
Patients with underlying disease,
especially rheumatoid arthritis.
Patients with prosthetic joints
are often susceptible.
The 2 main groups of organisms, however,
with septic arthritis, you're going
to focus on the following
in terms of category. Now,
so as I told you earlier, the nidus
of septic arthritis, prior discussion,
if the patient came sickle cell disease,
diabetes, and so forth,
then you might be looking at other
organisms. But, in general,
you'll divide this into gonococcal, non-
gonococcal type of septic arthritis.
This has nothing and may not
have an association with
and does not have an association
As soon as you start hearing about HAL-B27,
then you're thinking about,
"Oh, what type of arthritis
dealing with organisms,"
then you might be thinking about
reactive arthritis, isn't it?
It used to be called Reiter, remember that?
So we'll discuss Reiter in detail,
but it is no longer called Reiter
in current day practice.
It is called reactive arthritis.
Our discussion here is what?
We're dividing this into gonococcal
staph would be common.
Group A beta streptococcus, we're talking
about streptococcus pyogenes.
If it is gonococcal, you think about
that young patient that comes in
and what's my presentation?
inflamed knee, and it feels warm.
And you know it's inflammatory because
that synovial fluid is going to have
> 50,000 WBC. Is that understood?
Signs and symptoms. Here we go again.
Acute monoarticular joint pain,
red, fever, septic.
Mimics gouty, but has nothing to do
with uric acid crystals, correct?
Both are inflammatory type, no doubt,
but this is obviously septic.
Both septic in gouty,
will occur at the same time,
that's a possibility.
And depending on the drug,
the severity of symptoms would be,
well, a little bit different.
So, if you're thinking nongonococcal
and you're thinking about staph
aureus, oh my goodness,
his thing is so aggressive.
Remember, this is an emergency.
If you're not careful,
and if you're not paying attention, and
you're not doing due diligence,
that cartilage is going to be destroyed
and this patient then goes into
think gonococcal if the patient is young,
present as such.
Young sexually active patient,
and here, acute monoarticular type
of pain that you would expect.
And you would assume, as a clinician,
that it's a gonococcal type
of septic arthritis,
unless proven otherwise.
Also keep in mind, in labs,
at times can be rather difficult…
It can be difficult to identify.
So just because it comes
back to be negative,
but the patient is presenting
and a young patient,
you still need to aptly confirm
and rule out gonococcal.
Slower onset of symptoms,
usually, still, days.
So, we're not talking about months here,
we're talking days, so still relatively quick.
Whereas, if you're thinking staph…
The patient may have symptoms of a genital
infection if you're thinking gonococcal.
Asymptomatic, well, here,
if you're thinking about periarthritis-
Now, what that means is the following.
Let's say that your patient has gonococcal-
type of septic arthritis,
but you don't find purulent arthritis.
What does that mean?
You don't find the synovial fluid
to have WBC count < 50,000.
Then you're not going to look
for the following triad
with gonococcal. You're ready?
The triad. Well, periarthritis.
What does that mean?
In the hand, you're thinking
tenosynovitis, number 1.
When you're thinking derm,
you're thinking about issues with pustules.
Keep that in mind.
And there might be joint pain
So we have polyarthralgia,
we have issues with the
hand with tenosynovitis,
and lastly, there might be pustules,
including a derm.
Now, the triad, please, for gonococcal.
If you do not find purulent
arthritis, look for that.
seen in neisseria meningitidis
would be what?
The rash. So, in general,
the rash, as I was telling you
earlier, with the pustules,
could be seen with gonococcal,
but in addition,
may also be seen with the neisseria species
meningitidis, keep that in mind.
So both of these may be taking
With gonococcal arthritis,
positive sexual history, as we talked about.
In a lady, the culture,
cervical, urethral, pharyngeal, rectum,
all different areas in which
there might have been introduction
Gonococcal, hard to culture, as
I was telling you earlier,
and so, therefore, if inappropriately
performed in the laboratory,
it may then give you a false
negative, keep that in mind.
End joint aspiration needs to be done.
As I told you, you could find
that purulent arthritis.
And if you don't find it to be purulent
and you don't find the high WBC count,
you're looking for that triad, of what again?
Tenosynovitis of the hand.
If it's derm, then you're thinking
and you're thinking about polyarthralgia,
which means joint pain in many joints.
Give me the 2 major organisms here.
They included staph, credibly,
The other one might be strep.
So here, you're going to find, once
again, a purulent type of arthritis
and a synovial fluid will have
a WBC count > 50,000.
If you're suspecting to be nongonococcal,
obviously, your staph and strep
will then be Gram stain positive
and gram-positive anything.
If patient received antibiotic
prior to aspiration,
well, then this may give you
a false negative, correct,
in general. Kind of like the same theory
and discussion that you would have
with urinary tract infections, as well.
Blood cultures for nongonococcal.
Management of gonococcal
would be ceftriaxone IV,
followed by oral. It's important
that you attack
and combat the septic arthritis.
If it's a nongonococcal, then
such as vancomycin.
If it's nongonococcal,
require drainage, for sure,
surgery drainage, and ortho
consult, keep that in mind.
You need to be aggressive in
how you manage a patient
with nongonococcal. Remember, with gonococcal,
it may buy a little bit more time,
but we're only talking about, maybe, days more.