Diagnostic Considerations

Differential Diagnoses

When evaluating a patient with suspected septic arthritis, also consider conditions such as primary rheumatologic disorders (eg, vasculitis, crystalline arthritides), drug-induced arthritis, and reactive arthritis (eg, postinfectious diarrhea syndrome, postmeningococcal and postgonococcal arthritis, arthritis of intrinsic bowel disease).^[2]

In early disseminated gonococcal infection, an early tenosynovitis predominates without actual joint invasion such as occurs in the later variety of disseminated gonococcal infection. A viral infection usually results in a polyarticular arthritis. Pustular lesions are consistent (as is almost any type of skin lesion) with staphylococcal bacteremia. Whenever vesicles are present, one needs to strongly consider staphylococcal infection.

Unlike salmonella osteomyelitis, the frequency of septic arthritis is not greatly increased in patients with sickle cell anemia. However, when septic arthritis does occur, Salmonella is more commonly identified.

Staphylococcus aureus remains the most common infectious agent in people who abuse intravenous drugs. However, a high rate of infections with gram-negative organisms, especially Pseudomonas aeruginosa and Serratia species, occurs in cases of septic arthritis. A higher rate of fungal and anaerobic infections has been documented. Unusual locations, such as the sternoclavicular joint, have more frequently been encountered.

The syndromic approach to the diagnosis of SA

The priority of the clinician is to recognize SA and to initiate appropriate therapy as soon as possible, so as to minimize the morbidity and mortality of the infection. With the proliferation of imaging studies and serologic testing, along with the increase of immunosuppressed patients and IVDA, the practitioner is more and more challenged to avoid basing a diagnosis solely on test result and/or imaging studies. These findings must be validated with a compatible history/symptoms and physical examination. A disease represents a grouping of signs (physical findings, test results, imaging studies) and symptoms that together characterize a particular disease process. Such a diagnostic approach has been termed Syndromic Analysis (Syn Ana).

The following are the 5 steps of Syn Ana^[30]:

1) Identify the primary organ system involved.

2) Determine whether the process is acute, subacute, or chronic in nature.

3) On the basis of history, physical examination, and nonspecific laboratory tests and imaging studies, compile a provisional list of the most likely diagnoses.

4) Factor in any history of relevant diseases and/or medication that would effect the clinical presentation, physical findings, and results of laboratory tests and imaging studies.

5) Arrive at the correct diagnosis and its etiology by utilizing appropriate specific laboratory tests, cultures, imaging studies, and biopsy results to rule out the other preliminary diagnoses.

Workup

Roerdink RL, Huijbregts HJTAM, van Lieshout AWT, Dietvorst M, van der Zwaard BC. The difference between native septic arthritis and prosthetic joint infections: A review of literature. J Orthop Surg (Hong Kong). 2019 May-Aug. 27 (2):2309499019860468. [QxMD MEDLINE Link].
Ross JJ. Septic Arthritis of Native Joints. Infect Dis Clin North Am. 2017 Jun. 31 (2):203-218. [QxMD MEDLINE Link].
Yokoe DS, Avery TR, Platt R, Huang SS. Reporting surgical site infections following total hip and knee arthroplasty: impact of limiting surveillance to the operative hospital. Clin Infect Dis. 2013 Nov. 57(9):1282-8. [QxMD MEDLINE Link].
Eriksson HK, Lazarinis S. Patient-related factors associated with superficial surgical site infection and progression to a periprosthetic joint infection after elective primary total joint arthroplasty: a single-centre, retrospective study in Sweden. BMJ Open. 2022 Sep 19. 12 (9):e060754. [QxMD MEDLINE Link].
Futterman O, Lieber SB, Nasrullah K, Fowler ML, Shmerling RH, Paz Z. Clinical characteristics of patients with polymicrobial septic arthritis. Eur J Clin Microbiol Infect Dis. 2019 Jul. 38 (7):1327-1332. [QxMD MEDLINE Link].
Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009 Aug 20. 361(8):787-94. [QxMD MEDLINE Link]. [Full Text].
Berbari EF, Marculescu C, Sia I, Lahr BD, Hanssen AD, Steckelberg JM, et al. Culture-negative prosthetic joint infection. Clin Infect Dis. 2007 Nov 1. 45(9):1113-9. [QxMD MEDLINE Link].
Cucurull E, Espinoza LR. Gonococcal arthritis. Rheum Dis Clin North Am. 1998 May. 24 (2):305-22. [QxMD MEDLINE Link].
Rice PA. Gonococcal arthritis (disseminated gonococcal infection). Infect Dis Clin North Am. 2005 Dec. 19 (4):853-61. [QxMD MEDLINE Link].
Broy SB, Schmid FR. A comparison of medical drainage (needle aspiration) and surgical drainage (arthrotomy or arthroscopy) in the initial treatment of infected joints. Clin Rheum Dis. 1986 Aug. 12 (2):501-22. [QxMD MEDLINE Link].
McGuire NM, Kauffman CA. Septic arthritis in the elderly. J Am Geriatr Soc. 1985 Mar. 33 (3):170-4. [QxMD MEDLINE Link].
Smith JW, Piercy EA. Infectious arthritis. Clin Infect Dis. 1995 Feb. 20 (2):225-30; quiz 231. [QxMD MEDLINE Link].
Baraboutis I, Skoutelis A. Streptococcus pneumoniae septic arthritis in adults. Clin Microbiol Infect. 2004 Dec. 10(12):1037-9. [QxMD MEDLINE Link].
Raad J, Peacock JE Jr. Septic arthritis in the adult caused by Streptococcus pneumoniae: a report of 4 cases and review of the literature. Semin Arthritis Rheum. 2004 Oct. 34(2):559-69. [QxMD MEDLINE Link].
Corvec S, Illiaquer M, Touchais S, et al. Clinical features of group B Streptococcus prosthetic joint infections and molecular characterization of isolates. J Clin Microbiol. 2011 Jan. 49(1):380-2. [QxMD MEDLINE Link]. [Full Text].
Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis?. JAMA. 2007 Apr 4. 297(13):1478-88. [QxMD MEDLINE Link].
Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore). 2004 May. 83 (3):139-48. [QxMD MEDLINE Link].
Lochhead RB, Strle K, Arvikar SL, Weis JJ, Steere AC. Lyme arthritis: linking infection, inflammation and autoimmunity. Nat Rev Rheumatol. 2021 Aug. 17 (8):449-461. [QxMD MEDLINE Link].
Spinicci M, Corti G. Septic arthritis in the antimicrobial stewardship era. Intern Emerg Med. 2020 Jun. 15 (4):567-569. [QxMD MEDLINE Link].
Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004 Oct 14. 351(16):1645-54. [QxMD MEDLINE Link].
Hsieh PH, Lee MS, Hsu KY, Chang YH, Shih HN, Ueng SW. Gram-negative prosthetic joint infections: risk factors and outcome of treatment. Clin Infect Dis. 2009 Oct 1. 49(7):1036-43. [QxMD MEDLINE Link].
Hannu T. Reactive arthritis. Best Pract Res Clin Rheumatol. 2011 Jun. 25 (3):347-57. [QxMD MEDLINE Link].
Malek Mahdavi A, Varshochi M, Hajialilo M, Dastgiri S, Khabbazi R, Khabbazi A. Factors associated with COVID-19 and its outcome in patients with rheumatoid arthritis. Clin Rheumatol. 2021 Jun 29. 40(5):884-92. [QxMD MEDLINE Link].
Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013 Jan. 56 (1):1-10. [QxMD MEDLINE Link].
Kaandorp CJ, Dinant HJ, van de Laar MA, et al. Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis. 1997 Aug. 56(8):470-5. [QxMD MEDLINE Link].
Nair R, Schweizer ML, Singh N. Septic Arthritis and Prosthetic Joint Infections in Older Adults. Infect Dis Clin North Am. 2017 Dec. 31 (4):715-729. [QxMD MEDLINE Link].
Colston J, Atkins B. Bone and joint infection. Clin Med (Lond). 2018 Mar. 18 (2):150-154. [QxMD MEDLINE Link].
Zimmermann B 3rd, Mikolich DJ, Ho G Jr. Septic bursitis. Semin Arthritis Rheum. 1995 Jun. 24(6):391-410. [QxMD MEDLINE Link].
Goldenberg DL. Septic arthritis and other infections of rheumatological significance. Rheum Clin NA. 1991. 17:149. [QxMD MEDLINE Link].
Cunha CB, Cunha BA. Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine. 4th. Boca Raton, FL: CRC Press; June 13, 2022.
Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. J Arthroplasty. 2018 May. 33 (5):1309-1314.e2. [QxMD MEDLINE Link].
Chouk M, Verhoeven F, Sondag M, Guillot X, Prati C, Wendling D. Value of serum procalcitonin for the diagnosis of bacterial septic arthritis in daily practice in rheumatology. Clin Rheumatol. 2019 Aug. 38 (8):2265-2273. [QxMD MEDLINE Link].
Garcia-De La Torre I. Advances in the management of septic arthritis. Rheum Dis Clin North Am. 2003 Feb. 29(1):61-75. [QxMD MEDLINE Link].
Wilson ML, Winn W. Laboratory diagnosis of bone, joint, soft-tissue, and skin infections. Clin Infect Dis. 2008 Feb 1. 46(3):453-7. [QxMD MEDLINE Link].
Sebastian S, Malhotra R, Sreenivas V, Kapil A, Chaudhry R, Dhawan B. Sonication of orthopaedic implants: A valuable technique for diagnosis of prosthetic joint infections. J Microbiol Methods. 2018 Mar. 146:51-54. [QxMD MEDLINE Link].
Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol. 2008 Jul. 20 (4):457-62. [QxMD MEDLINE Link].
Wise CM, Morris CR, Wasilauskas BL, et al. Gonococcal arthritis in an era of increasing penicillin resistance. Presentations and outcomes in 41 recent cases (1985-1991). Arch Intern Med. 1994 Dec 12-26. 154(23):2690-5. [QxMD MEDLINE Link].
Berlina AN, Zherdev AV, Dzantiev BB. Monitoring Antibiotics and Inflammatory Markers in Human Blood: Impact in Choice of Antibiotic Therapy and used Methods. Biomedical and Pharmacology Journal. 2020. 13(3):
Lim W, Barras CD, Zadow S. Radiologic Mimics of Osteomyelitis and Septic Arthritis: A Pictorial Essay. Radiol Res Pract. 2021. 2021:9912257. [QxMD MEDLINE Link].
Palestro CJ. FDG-PET in musculoskeletal infections. Semin Nucl Med. 2013 Sep. 43(5):367-76. [QxMD MEDLINE Link].
Li HK, Rombach I, Zambellas R, Walker AS, et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. N Engl J Med. 2019 Jan 31. 380 (5):425-436. [QxMD MEDLINE Link].
Gundavda MK, Katariya A, Reddy R, Agarwal MG. Fighting Megaprosthetic Infections: What are the Chances of Winning?. Indian J Orthop. 2020 Jul. 54 (4):469-476. [QxMD MEDLINE Link].
Walter N, Rupp M, Baertl S, Alt V. The role of multidisciplinary teams in musculoskeletal infection. Bone Joint Res. 2022 Jan. 11 (1):6-7. [QxMD MEDLINE Link].
Gjika E, Beaulieu JY, Vakalopoulos K, Gauthier M, Bouvet C, Gonzalez A, et al. Two weeks versus four weeks of antibiotic therapy after surgical drainage for native joint bacterial arthritis: a prospective, randomised, non-inferiority trial. Ann Rheum Dis. 2019 Aug. 78 (8):1114-1121. [QxMD MEDLINE Link].
Bernard L, Arvieux C, Brunschweiler B, et al. Antibiotic Therapy for 6 or 12 Weeks for Prosthetic Joint Infection. N Engl J Med. 2021 May 27. 384 (21):1991-2001. [QxMD MEDLINE Link].
Manning L, Metcalf S, Clark B, et all. Clinical Characteristics, Etiology, and Initial Management Strategy of Newly Diagnosed Periprosthetic Joint Infection: A Multicenter, Prospective Observational Cohort Study of 783 Patients. Open Forum Infect Dis. 2020 May. 7 (5):ofaa068. [QxMD MEDLINE Link].
Watkins RR, Gowen R, Lionakis MS, Ghannoum M. Update on the Pathogenesis, Virulence, and Treatment of Candida auris. Pathog Immun. 2022. 7 (2):46-65. [QxMD MEDLINE Link].
Koeppe J, Johnson S, Morroni J, Siracusa-Rick C, Armon C. Suppressive antibiotic therapy for retained infected prosthetic joints: case series and review of the literature. Infect Dis Clin Pract. 2008. 16(4):224-9. [Full Text].
Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5. 64 (RR-03):1-137. [QxMD MEDLINE Link].
Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis. 2010 Jan 1. 50(1):8-16. [QxMD MEDLINE Link].
Abram SGF, Alvand A, Judge A, Beard DJ, Price AJ. Mortality and adverse joint outcomes following septic arthritis of the native knee: a longitudinal cohort study of patients receiving arthroscopic washout. Lancet Infect Dis. 2020 Mar. 20 (3):341-349. [QxMD MEDLINE Link].
Pouderoux C, Becker A, Goutelle S, Lustig S, Triffault-Fillit C, Daoud F, et al. Subcutaneous suppressive antibiotic therapy for bone and joint infections: safety and outcome in a cohort of 10 patients. J Antimicrob Chemother. 2019 Jul 1. 74 (7):2060-2064. [QxMD MEDLINE Link].
Cunha BA, Hage JE, Cunha CB, et al. Empiric therapy based on clinical syndrome. Cunha CB, Cunha BA. Antibiotic Essentials. 17. New Deli London: Jaycee Brothers Medical publishers; 2020. 17: 134-139.
Renz N, Trampuz A, Zimmerli W. Controversy about the Role of Rifampin in Biofilm Infections: Is It Justified?. Antibiotics (Basel). 2021 Feb 5. 10 (2):[QxMD MEDLINE Link].
Tonnelier M, Bouras A, Joseph C, Samad YE, Brunschweiler B, Schmit JL, et al. Impact of rifampicin dose in bone and joint prosthetic device infections due to Staphylococcus spp: a retrospective single-center study in France. BMC Infect Dis. 2021 Feb 12. 21 (1):174. [QxMD MEDLINE Link].
Cunha CB, Cunha BA. Antibiotic pearls and pitfalls. Cunha CB, Hage JE, Cunha BA. Antibiotic Essentials. 17. New Delhi, London: JayPee Medical Publishers; 2020. 17: 525-538.
Ribeiro TC, Honda EK, Daniachi D, Cury RPL, da Silva CB, Klautau GB, et al. The impact of sonication cultures when the diagnosis of prosthetic joint infection is inconclusive. PLoS One. 2021. 16 (7):e0252322. [QxMD MEDLINE Link].
Yakkanti RR, Vanden Berge D, Summers SH, Mansour KL, Lavin AC, Hernandez VH. Extended Postoperative Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Systematic Review. J Am Acad Orthop Surg. 2022 Jun 1. 30 (11):e822-e832. [QxMD MEDLINE Link].

Media Gallery

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.
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.
During the progression of infectious arthritis of the hip, this image was obtained early in the disease and shows only concentric joint-space loss.

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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
Mumps	Occurs in adult men 2 weeks after the presentation of parotitis

Septic Arthritis Differential Diagnoses

Diagnostic Considerations

References

Tables

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