Acute arthritis: predictive factors and current practice in the approach to diagnosis and management across two hospitals in Sydney

Synovial microflora of large joints in patients of a multidisciplinary hospital

Relevance. There is no doubt that microorganisms participate in occurrence and development of septic process in joints. However, the issue of etiological significance of each agent remains controversial, because, in spite of the general trends, indicating the participation of numerous microorganisms in the development of articular pathology, each result of microbiological analysis concerns only a specific case in the territorial and clinical aspects. The aim of the study - microbiological research of synovial fluid obtained from knee joint during synovitis after its aspiration in patients of various departments of the Stavropol Regional Clinical Hospital. Materials and Methods . There were studied 198 samples of synovial fluid. Primary inoculation of puncture was performed with subsequent isolation, identification of the cultures by mass spectrometry and assessment of their antibiotic sensitivity by discodiffusion method. Results and Discussion . 11 cultures of bacterial pathogens were isolated. Gram-positive cocci - 82 %, of which 77.8 % - microorganisms of Staphylococcus genus (44.4 % S.aureus , 33.4 % S.epidermidis ), 22.2 % - other gram-positive cocci: one strain of each, Enterococcus faecium and Streptococcus mitis . Gram-negative pathogens are represented by K.neumoniae and P.aeruginosa with a total content of 18 %. Highly virulent microorganisms S.aureus , K.neumoniae and P.aeruginosa are isolated from the synovial fluid of patients of the surgical departments (orthopedotraumatological No. 1, No. 2) and the rheumatological department. Microorganisms with low virulence E.faecium , S.mitis and S.epidermidis are isolated from synovial fluid of patients of various departments. No obvious resistance of isolated pathogens to antimicrobial drugs has been registered. Conclusion . The presence and species affiliation of the microorganisms identified in synovial fluid allows predicting their etiological significance in development of septic process in joints. Their role as causative agents of nosocomial infections typical for a medical institution is not excluded. The presence of articular pathology in each of the examined departments dictates the need for a clear understanding of the importance of timely and high-quality joint aspiration followed by microbiological examination in almost all patients with damage of large joints, including patients without clinical signs of septic arthritis. Such an approach that makes it possible to identify a greater number of causative agents of septic arthritis and quickly evaluate the dynamics of their antimicrobial resistance should become an obligatory part of a comprehensive research and treatment of a patient with arthritis in multi-fi eld hospitals.

Diagnostic values of HNP 1-3 and procalcitonin levels in synovial fluid aspirates in the differential diagnosis between septic arthritis and noninfectious arthritis

INTRODUCTION

Although early diagnosis of septic arthritis may reduce mortality rates, and limit unnecessary surgical interventions, clinical parameters alone are not adequate for making the diagnosis of septic arthritis. Therefore, relevant laboratory parameters are used to enhance diagnostic sensitivity. The aim of our study was to assist in making the diagnosis of septic arthritis, and prevent delays in the diagnosis. For this purpose; we aimed to determine the diagnostic values of human neutrophil peptides 1-3 (HNP 1-3) and procalcitonin (PCT) in synovial fluids of patients with arthritis. By comparing the HNP 1-3 and procalcitonin levels, as well as CRP, in synovial fluid aspirates, we evaluated the significance of these data in the differential diagnosis of septic arthritis from noninfectious arthritis.

METHODS

A total of 67 adults consisting of 37 septic arthritis and 30 noninfectious arthritis patients were included in our study. As bioindicators; levels of HNP 1-3, PCT, synovial and serum CRP levels were found to have significant ROC areas in discriminating septic arthritis patients from noninfectious arthritis patients.

RESULTS

As a result, synovial fluid HNP 1-3 levels were significantly higher in septic arthritis patients compared to noninfectious arthritis patients (p < 0.001). The sensitivity, specificity, and accuracy of HNP 1-3 levels in the diagnosis of septic and noninfectious arthritis were found as 86%, 87%, and 87%, respectively (AUC of the ROC curve = 0.828).

CONCLUSIONS

It was decided that the level of HNP 1-3 in the synovial fluid can be used as an alternative indicator in the diagnosis of septic arthritis.

A narrative review of the last decade's literature on the diagnostic accuracy of septic arthritis of the native joint

While septic arthritis can be a straightforward diagnosis, there are many cases when the diagnosis is difficult to make. The aim of this study was to review the last decade’s literature on the diagnosis of septic arthritis of the native joint in adults and summarize that data in an easy to follow algorithm to clarify how the last decade’s data may be applied to the diagnosis of septic arthritis. A search of PubMed and CINAHL databases was performed to identify studies that compared results diagnostic tests for septic arthritis. We cross referenced this search with searches of additional databases (including Cochrane Library and Scopus) to confirm similar search results. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used by two independent reviewers to determine study quality and risk of bias. After applying inclusion and exclusion criteria to the initial search, 15 papers total were included for analysis. All 15 papers were of high quality methodology as determined by the QUADAS tool. There were 26 different diagnostics tests used across the 15 papers included for review. Three of those diagnostic tests had specificity and sensitivity greater than 80%. Eight tests had a positive likelihood ratio of ≥10. Three tests had a negative likelihood ratio < 0.1, indicating that they may help to rule out septic arthritis. A flowchart was created to summarize the findings of our review, so that physicians may reference this visual in making the appropriate diagnosis when the commonly held standards of cell count, gram stain, and culture aren’t enough to make the diagnosis.

Chronic seronegative spondyloarthropathy following acute Mycoplasma pneumoniae infection in a human leukocyte antigen B27-positive patient: a case report

Background

We report a case of a 30-year-old patient who presented with acute Mycoplasma pneumoniae infection that was complicated by reactive arthritis and asymmetric proximal myopathy and progressed to chronic spondyloarthropathy. Reactive arthritis and sacroiliitis are unusual extrapulmonary manifestations of M. pneumoniae infection, which is a common condition.

Case presentation

A 30-year-old Greek previously healthy man presented to our emergency department with fever, progressively worsening bilateral lower limb weakness, and asymmetric oligoarthritis. Our diagnosis was based on a positive polymerase chain reaction test for M. pneumoniae using blood and cerebrospinal fluid and magnetic resonance imaging findings that suggested sacroiliitis. Our patient was also found to be human leukocyte antigen B27 positive. His infection was successfully treated with a 14-day course of doxycycline; the arthritis was treated with naproxen and corticosteroids. His arthritis, which restricted his mobility, improved progressively, and he was discharged without any neurological symptoms.

Conclusions

In our case, an acute M. pneumoniae infection eventually progressed to chronic spondyloarthropathy. In our patient, M. pneumoniae infection may represent a random event, or it might be a necessary factor for the development of reactive arthritis, asymmetric proximal myopathy, and sacroiliitis, always in combination with the appropriate genetic background. Extrapulmonary manifestations of M. pneumoniae may occur even in the complete absence of respiratory symptoms, and the diagnosis of unusual complications, such as reactive arthritis, requires high clinical suspicion and extensive investigation.

Performance of a new rapid diagnostic test the lactate/glucose ratio of synovial fluid for the diagnosis of septic arthritis

OBJECTIVE

To evaluate the diagnostic performance of the synovial lactate, glucose and lactate/glucose ratio assay for the diagnosis of septic arthritis.

METHODS

In this monocentric cross-sectional study, synovial fluids were prospectively obtained from patients with acute joint effusion (<30 days) on native joint. Septic arthritis was defined using Newman's criteria. To evaluate diagnostic performance, Receiver Operating Characteristic (ROC) curves with Area under the curve (AUC), Sensitivities (Se), Specificities (Sp), LR+ their 95% confidence intervals were calculated. Synovial fluid cultures with gram staining, crystal analyses, synovial fluid white blood cell counts (WBC), lactate and glucose assays were performed.

RESULTS

A total of 233 synovial fluids were included. 25 patients had septic arthritis and 208 had non-septic arthritis (104 crystal-induced arthritis, 15 RA, 8 SpA, 6 reactive arthritis, and 75 acute arthritis of undifferentiated origin). Synovial lactate/glucose ratio performed higher than the synovial lactate or glucose assay separately (AUC: 0.859 [0.772-0.945]). Best synovial lactate/glucose ratio threshold to differentiate septic arthritis from non-septic arthritis was 5 Se 52% [0.34-0.7], Sp 98.1% [0.95-0.99], LR+ 27.0[9.50-76.00]).

CONCLUSION

The diagnostic performance of synovial lactate/glucose allows septic arthritis to be effectively and very quickly distinguished from other types of arthritis.