History
The following symptoms are consistent with SA [2, 8, 9, 20, 21, 24, 25, 26] :
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Acuteness of onset of the joint pain
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Whether the pain is superimposed on chronic pain
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Previous history of joint disease or trauma, whether accidental or iatrogenic (eg, infection complicates 0.4% of arthrocenteses)
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Whether the process is monoarticular or polyarticular, and which joints are involved
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The presence of extra-articular symptoms
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History regarding the possible presence of sexually transmitted infections (STIs); exposure to ticks (Lyme disease) and drug abuse should be elicited.
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Conditions that adversely affect the host's defenses (eg, liver disease, diabetes mellitus, lymphoma, solid tumors, complement deficiencies [C7, C8], immunosuppressive drugs, hypogammaglobulinemia) are increasingly involved in cases of SA.The most important historical factor is the existence of underlying joint disease, especially rheumatoid arthritis, and the possibility of recent injury to the joint, needle aspiration, or injections into the joint.
Symptoms
Patients with an infected joint typically present with the triad of fever (40-60% of cases), pain (75% of cases), and impaired range of motion. These symptoms may evolve over a few days to a few weeks. Fever is usually less than 102°F. Rigors are present in only 20% of cases. Somewhat surprisingly, spiking fevers and chills are much more common with crystalline arthritis.
Lyme disease
Months after infection onset, 60% of patients with untreated Lyme disease develop swelling and pain, chiefly affecting the large joints. Usually, Lyme disease affects one to two joints at a time, with the knee most commonly involved. The distinguishing pattern is attacks extending from a few weeks to months and separated by periods of complete remission. The rate of recurrence lessens by about 15% per year. A small percentage of individuals develop chronic arthritis (ie, inflammation of a joint lasting ≥ 1 y). This type of relapsing course almost always precedes the chronic stage of Lyme arthritis.
Prosthetic joint infection
Compared with patients with infections of native joints, most patients with PJI exhibit a prolonged low-grade course with gradually increasing pain. PJI due to Gram-negative organisms may present much more acutely.
Generally, no significant fever or swelling occurs in delayed prosthetic joint infections. However, individuals with early prosthetic joint infection may present with an acute illness characterized by high-grade fever, focal swelling, and redness. Cellulitis and draining sinus tracts often develop. Because late prosthetic joint infection usually is secondary to bacteremia, the clinical picture often is dominated by the source of the bloodstream infection.
The nature of the invading organism, the type of tissue infected, and the route of infection determine presentation. A high index of suspicion is needed for identification of bacteremic and delayed prosthetic joint infection. Because of its many pathogenic mechanisms, S aureus usually is associated with a fulminant course, as opposed to the indolent course of coagulase-negative S aureus (CoNS) that dominates delayed prosthetic joint infection. Relatively devitalized tissues (eg, wound hematomas) are conducive to rapid bacterial replication and a more acute course. Bacteremic spread allows infection with fewer organisms and leads to a more muted course.
Reactive and tuberculous arthritides
Reactive arthritis usually begins several weeks after the underlying infection has resolved. [21] Few concurrent systemic symptoms occur.
Symptoms of tuberculous arthritis are quite indolent; the diagnosis may be delayed for several years. Usually, the purified protein derivative (PPD) results are negative, and no signs, past or present, of pulmonary tuberculous exist.
Viral septic arthritis
Table 1, below, provides a summary of the clinical features of arthritis caused by various viral organisms.
Table 1. Clinical Features of Viral Disease–Associated Arthritis (Open Table in a new window)
Virus |
Clinical Features of Viral Disease–Associated Arthritis |
Parvovirus B19 |
Occurs in adult women with erythema infectiosum; often an itchy rash |
Hepatitis A |
Muscle aches and rash in 10% of cases |
Hepatitis B |
Onset in the preicteric phase; usually resolves as jaundice develops; chronic arthritis possible in patients with chronic hepatitis B infection |
Hepatitis C |
History similar to hepatitis B joint infection; usually associated with cryoglobulinemia |
Rubella (natural infection and vaccine related) |
Onset is possible before, during, or after the appearance of the rash; usually resolves in a few weeks; may recur and, more commonly, may persist |
Human immunodeficiency virus [HIV] (2 types occur, both with noninflammatory, sterile joint fluid) |
Develops over several days, and severe knee or ankle pain is characteristic; excellent response to nonsteroidal anti-inflammatory agents (NSAIDS) |
Sudden onset of severe pain in the shoulders and elbows, closely resembling an acute gouty attack; opiates often necessary to control pain |
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Mumps |
Occurs in adult men 2 weeks after the presentation of parotitis |
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Physical Examination
The most commonly involved joint in septic arthritis is the knee (50% of cases), followed by the hip (20%), shoulder (8%), ankle (7%), and wrists (7%). The elbow, interphalangeal, sternoclavicular, and sacroiliac joints each make up 1-4% of cases.
A thorough inspection of all joints for signs of erythema, swelling (90% of cases), warmth, and tenderness is essential for diagnosing infection. Infected joints usually exhibit an obvious effusion, which is associated with marked limitation of both active and passive ranges of motion. Frequently, these findings may be diminished or poorly localized in cases of infection of the spine, hip, and shoulder joints. [19]
Signs and symptoms of infection may be muted in people who are elderly; who are immunocompromised (especially those with rheumatoid arthritis); and in those who inject drugs.
Pattern of joint involvement
Nongonococcal bacterial/suppurative arthritis
The pattern of joint involvement is an extremely important diagnostic feature. Of cases of nongonococcal suppurative arthritis, 85-90% are monoarticular. If the disease affects more than one joint, S aureus is most commonly implicated. Polyarticular arthritis usually is observed in gonococcal disease, various viral infections, Lyme disease, reactive arthritis, and various noninfectious processes.
Group B streptococci most commonly infect the sacroiliac and sternoclavicular joints.
Gonococcal bacterial/suppurative arthritis
Gonococcal musculoskeletal involvement may present in one of two ways, as described below. [2, 8, 9, 27]
Fever, arthralgias of multiple joints, and multiple skin lesions (dermatitis-arthritis syndrome) characterize disease that develops soon after the gonococcus disseminates from the cervix, urethra, or pharynx. Usually, this disease exhibits no clinical direct joint findings, but the process is one of tenosynovitis of asymmetric distribution. Typically, hand joints most often are involved, as well as those of the knee, wrist, ankle, and elbow. Skin lesions are multiple, but seldom number more than 12, whereas lesions associated with meningococcemia may number more than 100. The lesions evolve over a few days from papular to pustular or vesicular to necrotic. This course may recur for several months. Findings on cultures of blood and mucosal surfaces often are positive; findings on cultures of joint fluid usually are negative. Sixty percent of disseminated gonococcal infections are of this type.
Monoarticular arthritis without associated systemic symptoms, tenosynovitis, or skin lesions characterizes gonococcal disease that begins later after gonococcal dissemination than does dermatitis arthritis syndrome. [26] Dermatitis-arthritis syndrome may or may not precede this phase. In a joint infected by the Lyme organism, swelling may be disproportionate to the level of pain. Baker cysts are a frequent feature of this type of infectious arthritis. Because the pain of an infected hip joint may not be localized directly and swelling of the joint is inconspicuous, perform specific maneuvers, such as the Fabere maneuver. Infection of the sacroiliac joint often presents as buttock, hip, or anterior thigh pain. Direct pressure usually elicits tenderness in the joint. Alternatively, hyperextension of the hip and leg while the patient is lying down (ie, Gaenslen maneuver) elicits pain in a suppurative sacroiliac joint.
Septic bursitis most commonly involves the olecranon and prepatellar bursae. Swelling and pain are present. However, an infected bursa does not limit the range of motion of the underlying joint the way an actual joint infection does. [28]
Prosthetic joint infections
Physical findings of PJI, such as swelling, usually are minimal. The most distinctive is a draining sinus presumed to originate in the underlying infected prosthetic joint.
Reactive, viral, and tuberculous arthritides
Most cases of reactive arthritis involve a few large joints in an asymmetric fashion, whereas viral arthritis usually exhibits symmetric involvement of the smaller joints, especially the hands, with a concurrent rash. The joints of tuberculous arthritis can appear to be boggy on palpation. [29]
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A 30-year-old man who was taking steroids presented with a joint effusion and knee pain. Anteroposterior view of the knee demonstrates patchy demineralization of the tibia and femur and joint-space narrowing. This was caused by tuberculoid infection of the joint.
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Septic arthritis. Anteroposterior view of the shoulder demonstrates subchondral erosions and sclerosis in the humeral head. These are relatively late findings of septic arthritis. Periosteal reaction due to coincident osteomyelitis is present adjacent to the surgical neck of the humerus.
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During the progression of infectious arthritis of the hip, this image was obtained early in the disease and shows only concentric joint-space loss.
Tables
Virus |
Clinical Features of Viral Disease–Associated Arthritis |
Parvovirus B19 |
Occurs in adult women with erythema infectiosum; often an itchy rash |
Hepatitis A |
Muscle aches and rash in 10% of cases |
Hepatitis B |
Onset in the preicteric phase; usually resolves as jaundice develops; chronic arthritis possible in patients with chronic hepatitis B infection |
Hepatitis C |
History similar to hepatitis B joint infection; usually associated with cryoglobulinemia |
Rubella (natural infection and vaccine related) |
Onset is possible before, during, or after the appearance of the rash; usually resolves in a few weeks; may recur and, more commonly, may persist |
Human immunodeficiency virus [HIV] (2 types occur, both with noninflammatory, sterile joint fluid) |
Develops over several days, and severe knee or ankle pain is characteristic; excellent response to nonsteroidal anti-inflammatory agents (NSAIDS) |
Sudden onset of severe pain in the shoulders and elbows, closely resembling an acute gouty attack; opiates often necessary to control pain |
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Mumps |
Occurs in adult men 2 weeks after the presentation of parotitis |
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