Suppurative tenosynovitis and septic bursitis

Imaging features of soft-tissue infections

Skin and soft tissues are among the most common sites of infections. Infections can involve the superficial epidermis to deep muscles and bones. Most infections spread through contiguous structures, although hematogenous spread can occur in the setting of an immunocompromised state and with atypical infections. While clinical diagnosis of infections is possible, it often lacks specificity, necessitating the use of imaging for confirmation. Cross-sectional imaging with US, CT, and MRI is frequently performed not just for diagnosis, but to delineate the extent of infection and to aid in management. Nonetheless, the imaging features have considerable overlap, and as such, it is essential to integrate imaging features with clinical features for managing soft tissue infections. Radiologists must be aware of the imaging features of different infections and their mimics, as well as the pros and cons of each imaging technique to properly use them for appropriate clinical situations. In this review, we summarize the most recent evidence-based features of key soft tissue infections.

Optimal antibiotics duration following surgical management of septic olecranon bursitis: a 12-year retrospective analysis

Introduction: The absence of a standardized postoperative antibiotic treatment approach for patients with surgically treated septic bursitis results in disparate practices. Methods: We retrospectively reviewed charts of adult patients with surgically treated septic olecranon bursitis at Mayo Clinic sites between 1 January 2000 and 20 August 2022, focusing on their clinical presentation, diagnostics, management, postoperative antibiotic use, and outcomes. Results: A total of 91 surgically treated patients were identified during the study period. Staphylococcus aureus was the most common pathogen (64 %). Following surgery, 92 % (84 of 91 patients) received systemic antibiotics. Excluding initial presentations of bacteremia or osteomyelitis (n = 5 ), the median duration of postoperative antibiotics was 21 d (interquartile range, IQR: 14-29). Postoperative complications were observed in 23 % (21 of 91) of patients, while cure was achieved in 87 % (79 of 91). Active smokers had 4.53 times greater odds of clinical failure compared with nonsmokers (95 % confidence interval, 95 % CI: 1.04-20.50; p = 0.026 ). The highest odds of clinical failure were noted in cases without postoperative antibiotic administration (odds ratio, OR: 7.4). Conversely, each additional day of antibiotic treatment, up to 21 d, was associated with a progressive decrease in the odds of clinical failure (OR: 1 at 21 d). Conclusion: The optimal duration of antibiotics postoperatively in this study was 21 d, which was associated with a 7.4-fold reduction in the odds clinical failure compared with cases without postoperative antibiotics. Further validation through a randomized controlled trial is needed.

Septic retrocalcaneal bursitis in a young soccer player treated with hindfoot endoscopic bursectomy: a case report

Septic retrocalcaneal bursitis (RB) is extremely rare with no reports on surgical treatment. Here, we describe a rare case of septic RB in a 14-year-old male soccer player who was treated with hindfoot endoscopic bursectomy. A 14-year-old male soccer player complained of right heel pain without trauma histories when he was playing a soccer. Based on physical examination, radiological findings and laboratory results, we diagnosed the patient with septic RB and started to treat with conservative treatment including a non-weightbearing splint and intravenous antibiotics therapy. However, his symptoms and laboratory results did not improve at 4 days after starting intravenous antibiotics therapy, and so we applied hindfoot endoscopic bursectomy for him. At 4 weeks after the surgery, he could return to the original sport at preinjury level without symptoms and complications. Septic RB in a 14-year-old male soccer player was successfully treated with hindfoot endoscopic bursectomy.

Utilisation of musculoskeletal ultrasonography for the evaluation of septic arthritis in a patient presenting to the emergency department with fever during the era of COVID-19

Prompt recognition and treatment of septic arthritis are crucial to prevent significant morbidity and mortality in affected patients. During the current COVID-19 pandemic, anchoring bias may make an already challenging diagnosis like septic arthritis more difficult to diagnose quickly and efficiently. Musculoskeletal (MSK) point of care ultrasonography (POCUS) is an imaging modality that can be used to quickly and efficiently obtain objective findings that may help a clinician establish the diagnosis of septic arthritis. We report a case where MSK POCUS was a key element in establishing the diagnosis of glenohumeral joint septic arthritis and subdeltoid septic bursitis for a patient that presented to the emergency department with a fever during the era of the COVID-19 pandemic.

Imaging musculoskeletal soft tissue infections

Musculoskeletal soft tissue infections are not uncommonly encountered in both the clinic and Emergency Department setting. The clinical diagnosis is not always evident as these infections can have variable presentations depending on the duration and depth of disease extension through the soft-tissue layers. Imaging often plays an important role in diagnosing the infection, defining the extent of involvement, directing tissue sampling, and in monitoring treatment response. After initial radiographs, ultrasound (US) is often the next modality utilized to evaluate patients with suspected soft tissue infections given its low cost, availability, portability, and potential for real-time guidance of fluid aspiration. The widespread use of cross-sectional imaging with magnetic resonance imaging (MRI) and computed tomography (CT) has greatly increased the radiological diagnosis in conditions where US may be limited. In addition, CT and MRI allow a thorough evaluation of disease extension, including assessment of joint spaces, tendons, and osseous changes indicative of bone involvement. This review will focus on the radiological findings of soft tissue infections on US, CT, and MRI.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT) is a common closed-space infection of the flexor tendon sheaths of the hand, which remains one of the most challenging problems facing hand surgeons. PFT goes by several names including septic or suppurative flexor tenosynovitis. Adequate treatment requires timely diagnosis and often prompt surgical treatment. However, despite prompt treatment, and regardless of the protocol used, complication rates as high as 38% have been reported in the literature. Moreover, even with successful eradication of the infection, a significant proportion of patients will suffer from continuing pain, swelling, stiffness, loss of composite flexion, weakness, and recurrence potentially requiring amputation. This review will focus on current evidence-based antimicrobial and surgical treatment strategies to maximize treatment outcomes.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT)is a potentially devastating closed-space infection of the flexor tendon sheath of the hand that can result in considerable morbidity. Management of PFT, regardless of the pathogen, includes prompt administration of empirical intravenous antibiotics and often surgical treatment. However, currently, there is no standardized treatment algorithm for PFT in regards to the need for, timing, or type of surgical treatment. Many utilize a combination of surgical decompression and sheath irrigation. However, despite prompt treatment, and regardless of the protocol used, complication rates can be high, leading to impaired function and even amputation of the affected digit. Further research is needed to elucidate the role of local antibiotics and corticosteroids in treating this condition and potentially preventing the morbid outcomes that are currently seen. This paper reviews the background, microbiology, and treatment options and controversies surrounding PFT.

Management of septic bursitis

Superficial septic bursitis is common, although accurate incidence data are lacking. The olecranon and prepatellar bursae are the sites most often affected. Whereas the clinical diagnosis of superficial bursitis is readily made, differentiating aseptic from septic bursitis usually requires examination of aspirated bursal fluid. Ultrasonography is useful both for assisting in the diagnosis and for guiding the aspiration. Staphylococcus aureus is responsible for 80% of cases of superficial septic bursitis. Deep septic bursitis is uncommon and often diagnosed late. The management of septic bursitis varies considerably across centers, notably regarding the use of surgery. Controlled trials are needed to establish standardized recommendations regarding antibiotic treatment protocols and the indications of surgery.

Septic Infrapatellar Bursitis in an Immunocompromised Female

Bursitis is a relatively common occurrence that may be caused by traumatic, inflammatory, or infectious processes. Septic bursitis most commonly affects the olecranon and prepatellar bursae. Staphylococcus aureus accounts for 80% of all septic bursitis, and most cases affect men and are associated with preceding trauma. We present a case of an 86-year-old female with an atypical septic bursitis involving the infrapatellar bursa. Not only are there very few reported cases of septic infrapatellar bursitis, but also this patient's case is particularly unusual in that she is a female with no preceding trauma who had Pseudomonas aeruginosa on aspirate. The case also highlights the diagnostic workup of septic bursitis through imaging modalities and aspiration. This patient had full resolution of her septic bursitis with appropriate IV antibiotics.

Infectious flexor hand tenosynovitis: State of knowledge. A study of 120 cases

INTRODUCTION

Since Kanavel in 1905, knowledge of phlegmon of flexor tendon sheaths of the fingers have evolved over the twentieth century. This serious infection is 20% of infections of the hand and may have adverse consequences for the function of the finger and even beyond, of the hand. Amputation is always a risk. Frequently face this type of infection, we conducted a retrospective study and made an inventory of knowledge in order to consolidate and improve the overall care.

MATERIALS & METHODS

The study was retrospective and cross, focused on 120 patients operated on at Hand Surgery Unit, during 4 years. Inclusion criteria were primary or secondary infection of the sheath of the flexor tendons of the fingers.The evaluation focused on clinical and paraclinical perioperative parameters. At last follow, digital mobility (Total Active Motion), the functional score of QuickDASH and the socio-professional consequences were evaluated.

RESULTS

The mean age was 40 years, with a male predominance. The hospital stay was 17 days on average (3 days to 80 days). From the classification of Michon, as amended by Sokolow, we found 60 Stage I, 48 stage II, 12 stage III. The Total Active Motion was respectively 240 °, 140 °, 40 °. QuickDASH scores were respectively 20, 56 and 90 out of 100. The time for return to work was 1 month for stage I, 4 months for stage II and 12 months for stage III.

DISCUSSION

The long-term functional outcome was generally poor, with stiffness or digital amputation. The poor prognostic factors were: the initial advanced stage of infection, infection beta-haemolytic Streptococcus group A, and delayed surgical management. Smoking was identified as a new risk factor in this disease, as well as diabetes or immunodeficiency. This study confirmed the predominance of Staphylococcus, and scalability of the infection depending on the mode of contamination, and / or type of germ that is to say, scalability schedule for β-hemolytic streptococci group A chronic and scalability for intracellular bacteria (mycobacteria).

CONCLUSION

Any suspicion of flexor hand tenosynovitis should lead to an emergency surgical exploration, not primary antibiotics prescription!

Radiologic Approach to Musculoskeletal Infections

Imaging is often used to establish a diagnosis of musculoskeletal infections and evaluate the full extent and severity of disease. Imaging should always start with radiographs, which provide an important anatomic overview. MRI is the test of choice in most musculoskeletal infections because of its superior soft tissue contrast resolution and high sensitivity for pathologic edema. However, MRI is not always possible. Alternative imaging modalities including ultrasound scan, computed tomography, and radionuclide imaging may be used. This article reviews the individual imaging modalities and discusses how specific musculoskeletal infections should be approached from an imaging perspective.

Infectious tenosynovitis with bloodstream infection caused by Erysipelothrix rhusiopathiae, a case report on an occupational pathogen

Background

Erysipelothrix rhusiopathiae is an established animal pathogen, which may cause infections in humans. It is a gram-positive rod and found in the tonsils or the digestive tracts of animals. The bacterium is occupationally related, as usually only people with frequent animal contacts are infected. We report a case of a patient who was admitted with an infectious tenosynovitis with bloodstream infection due to E. rhusiopathiae, and to our knowledge, this is the first report of a tenosynovitis with systemic manifestation associated with this bacterium.

Case presentation

A 52-year old Norwegian man, who worked with transportation of swine cadavers, was admitted to the local hospital with sepsis and unknown focus of infection. A few days earlier he had an injury to the skin of one of his fingers that later proved to be infected with E. rhusiopathiae. There were no other causes for his symptoms than the infectious tenosynovitis with systemic manifestation. The infection resolved on treatment with antibiotics and surgery. A transoesophageal echocardiogram was performed to exclude endocarditis, which may be associated with this pathogen.

Conclusions

This case report highlights the importance of clinicians being aware of this bacterium, and we describe risk factors for infection, differences in the clinical manifestations of the disease, challenges with diagnosing the bacterium and adverse effects of immunosuppressive drugs. Recommended treatment is appropriate antibiotic therapy and adequate debridement and surgical drainage of the tendon sheath.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-2102-1) contains supplementary material, which is available to authorized users.

Role of Diffusion Weighted Imaging in Musculoskeletal Infections: Current Perspectives

Accurate diagnosis and prompt therapy of musculoskeletal infections are important prognostic factors. In most cases, clinical history, examination and laboratory findings help one make the diagnosis, and routine magnetic resonance imaging (MRI) is useful to identify the extent of the disease process. However, in many situations, a routine MRI may not be specific enough especially if the patient cannot receive contrast intravenously, thereby delaying the appropriate treatment. Diffusion-weighted imaging (DWI) can help in many such situations by providing additional information, accurate characterization and defining the extent of the disease, so that prompt treatment can be initiated. In this article, we illustrate the imaging findings of the spectrum of musculoskeletal infections, emphasizing the role of DWI in this domain.

KEY POINTS

• Abscess in background cellulitis is detected on DWI. • Infectious tenosynovitis shows diffusion restriction as compared to mechanical tenosynovitis. • Pyomyositis with abscess can be differentiated from diabetic myonecrosis on DWI. • Intraosseous abscess is bright on DWI versus devitalized tissue, sequestrum and air. • DWI can be used to differentiate spine infection from simple Modic changes.

Bedside ultrasound identification of infectious flexor tenosynovitis in the emergency department

Infectious flexor tenosynovitis (FTS) is a serious infection of the hand and wrist that can lead to necrosis and amputation without prompt diagnosis and surgical debridement. Despite the growing use of point-of-care ultrasound (POCUS) by emergency physicians there is only one reported case of the use of POCUS for the diagnosis of infectious FTS in the emergency department setting. We present a case of a 58 year-old man where POCUS identified tissue necrosis and fluid along the flexor tendon sheath of the hand. Subsequent surgical pathology confirmed the diagnosis of infectious FTS.

Magnetic resonance imaging of musculoskeletal infections: systematic diagnostic assessment and key points

Prompt diagnosis and treatment are essential in preventing the complications of musculoskeletal infection. In this context, imaging is often used to confirm clinically suspected diagnoses, define the extent of infection, and ensure appropriate management. Because of its superior soft-tissue contrast resolution, magnetic resonance imaging (MRI) is the modality of choice for evaluating musculoskeletal infections. This article describes the MRI features along the full spectrum of musculoskeletal infections and provides several illustrative case examples.

Flexor tendon sheath infections of the hand

Flexor tendon sheath infections of the hand must be diagnosed and treated expeditiously to avoid poor clinical outcomes. Knowledge of the sheath's anatomy is essential for diagnosis and to help to guide treatment. The Kanavel cardinal signs are useful for differentiating conditions with similar presentations. Management of all but the earliest cases of pyogenic flexor tenosynovitis consists of intravenous antibiotics and surgical drainage of the sheath with open or closed irrigation. Closed irrigation may be continued postoperatively. Experimental data from an animal study have shown that local administration of antibiotics and/or corticosteroids can help lessen morbidity from the infection; however, additional research is required. Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. Patients with medical comorbidities or those who present late with advanced infection can expect poorer outcomes, including severe digital stiffness or amputation.

Imaging of musculoskeletal soft tissue infections

Prompt and appropriate imaging work-up of the various musculoskeletal soft tissue infections aids early diagnosis and treatment and decreases the risk of complications resulting from misdiagnosis or delayed diagnosis. The signs and symptoms of musculoskeletal soft tissue infections can be nonspecific, making it clinically difficult to distinguish between disease processes and the extent of disease. Magnetic resonance imaging (MRI) is the imaging modality of choice in the evaluation of soft tissue infections. Computed tomography (CT), ultrasound, radiography and nuclear medicine studies are considered ancillary. This manuscript illustrates representative images of superficial and deep soft tissue infections such as infectious cellulitis, superficial and deep fasciitis, including the necrotizing fasciitis, pyomyositis/soft tissue abscess, septic bursitis and tenosynovitis on different imaging modalities, with emphasis on MRI. Typical histopathologic findings of soft tissue infections are also presented. The imaging approach described in the manuscript is based on relevant literature and authors' personal experience and everyday practice.

[Isolated gonococcal tenosynovitis. Case report and review of literature]

Isolated gonococcal tenosynovitis is rare, and is part of disseminated gonococcal infection. It is due to blood-borne contamination of the flexor tendon sheath. One to 3% of gonococcal mucosal infections develop disseminated infections. Tenosynovitis is present in two-thirds of cases, sometimes in association with arthritis and skin rash. We report a case of a 26-year-old man with isolated gonococcal tenosynovitis of the thumb, with no other medical history, occurring 15 days after unprotected sex. Except local inflammatory signs of the thumb extending to the wrist, and a biological inflammatory syndrome, the patient had no arthritis, skin or mucosa symptoms. Immediate surgical drainage was performed under antibiotic cover with 3rd generation cephalosporin. All bacteriological samples were negative, except for one blood culture positive for Neisseria gonorrhoeae. Thus, in case of an asymptomatic patient with suspected gonococcal infection through a mucus portal, a precise examination, including geographical and sexual history, and a review of screening are recommended. Although the pathophysiology of gonococcal tenosynovitis is still obscure, the best prevention remains that of sexually transmitted diseases.

Prepatellar bursitis due to Brucella abortus: case report and analysis of the local immune response

A case of prepatellar bursitis in a man with chronic brucellosis is presented. Brucella abortus biotype 1 was isolated from the abundant yellowish fluid obtained from the bursa. Clinical and epidemiological data did not suggest a direct inoculation of the agent in the bursa. However, the patient mentioned occasional local trauma due to recreational sports, which may have constituted a predisposing factor. As determined by ELISA, there were higher levels of IgG against Brucella LPS and cytosolic proteins detected in the patient's bursal synovial fluid when compared with serum. Levels of proinflammatory cytokines (tumour necrosis factor alpha, interleukin 1 beta, gamma interferon, interleukin 8 and MCP-1) were higher than in synovial fluids obtained from patients with rheumatoid arthritis and a patient with septic arthritis, and a zymographic analysis revealed a gelatinase of about 92 kDa. These findings indicate that it may be possible to diagnose brucellar bursitis by measuring specific antibodies in the bursal synovial fluid. In addition, our findings suggest a role of increased local levels of proinflammatory cytokines and gelatinases in the inflammatory manifestations of brucellar bursitis.

Q fever osteoarticular infection: four new cases and a review of the literature

Q fever is a worldwide-occurring zoonosis caused by Coxiella burnetii. Better knowledge of the disease and of evolving diagnostics can enable recognition of unusual manifestations. Reported here are four cases of Q fever osteoarticular infections in adults: two cases of Q fever tenosynovitis, which represent the first two reports of this infection, and two cases of Q fever spondylodiscitis complicated by paravertebral abscess. In addition, the literature is reviewed on the 15 previously reported cases of Q fever osteoarticular infection, six of which were vertebral infections. Osteomyelitis is the usual manifestation Q fever osteoarticular infection. Because its onset is frequently insidious, diagnosis is usually delayed. The main differential diagnosis is mycobacterial infection, based on the histological granulomatous presentation of lesions. Whereas serology is the reference diagnostic method for Q fever, detection of C. burnetii in tissue specimens by PCR and cell culture provides useful additional evidence of infection. Culture-negative osteoarticular samples with granulomatous presentation upon histological examination should raise suspicion of Q fever.