osteomyelitis septic arthritisgram negative 2-8% polymicrobial 2-10% fungal/atypical >1%...
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OSTEOMYELITIS
SEPTIC ARTHRITIS
A.C.O.I. BOARD REVIEW 2019 Howard L. Feinberg, D.O., F.A.C.O.I., F.A.C.R.
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OSTEOMYELITIS
Definition: Inflammation
of the bone caused by a
pathogenic organism
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ETIOLOGY
Hematogenous Spread
–Bacteremia of any etiology (ie
pneumonia,abscess, surgery, trauma)
Contiguous Spread
–cutaneous ulcer
–infected joint or joint prosthesis
–abscess
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ORGANISIMSStaph aureus
Coag. Neg. Staph.
Streptococcus
Polymycrobial -especially in diabetic foot
ulscers
Sickle Cell Disease
- 50% salmonella
????
Gram negative
Tuberculosis
HIV– Candida
– Mycobacterium kansasii
– Nocardia asteroides
Cancer
Immunocompromised
host
– histoplasmosis,
– coccidiomycosis,
– blastomycosis
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CLINICAL
MANIFESTATIONS
ACUTE– fever
– point tenderness
– muscle spasm
– vague pain
– CHILDREN -acute onset fever,
chills, lethargy,
irritability
CHRONIC– night sweats
– low grade fever
– weight loss
– draining sinus
– muscle spasm
– point tenderness
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LABORATORY
ACUTE– Elevated ESR
– Increased WBC
– Blood cultures - 50%
are positive
– Bone culture/biopsy
– Other phase
reactants
– Urine cultures
CHRONIC– Elevated ESR
– Normal WBC
– Negative cultures
– Bone culture/biopsy
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RADIOLOGY
Plain X-ray– will not be positive
for at least 10
days
– lytic lesions may
not be present for
6 weeks
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BONE SCAN
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MRI
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SPINAL OSTEOMYELITIS
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TREATMENT
ACUTE -IV antibiotics for
at least 4 - 6
weeks
OVIVA Trial
2017 oral is just
as effective as IV
after
debridement.
CHRONIC
– drainage
– debridement
– vascular
assessment
– remove
prosthesis
– amputation
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TUBERCULOSISWeight bearing
joints are most
commonly affected
Pott’s Disease
– TB of spine
– Destroys disk
– Vertebral collapse
– Spinal cord
compression
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SEPTIC ARTHRITIS
MONOARTICULAR
– Gonococcal 50%
– Non-gonococcal
S. aureus 35%
B-hemolytic strep.
10%
Gram negative 2-8%
polymicrobial 2-10%
Fungal/atypical >1%
POLYARTICULAR
– Gonococcal-variable
– Non-gonococcal
carries a much
worse prognosis
often associated
with other
rheumatic diseases
or immune
suppression
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GONOCOCCAL
ARTHRITISMigratory
polyarthralgias
Tenosynovitis
Bursitis
Arthritis
Fever
Dermatitis
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GONOCOCCAL
ARTHRITISSynovial fluid
cultures usually
negative
Urethral/vaginal
cultures often
positive
PCR (polymerase
chain reaction test
improves accuracy)
Treatment - based
on local sensitivity
– Penicillin
– Penicillinase
resistant penicillin
– ceftriaxone - DOC
Outcome - rapid
response to
treatment 24-48h
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SEPTIC ARTHRITIS
Knee 40-50%
Hip 15 -20%
Shoulder 10%
Wrist 5-8%
Ankle 6-8%
Elbow 3-7%
Hand/Foot 5%
Polyarticular
10-20%
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SEPTIC ARTHRITIS
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SEPTIC ARTHRITIS
Outcome
– 5 - 15% mortality
– 25 - 60% joint
damage
– 22 - 70% full
recovery
Polyarticular
Mortality
– overall 23%
– in RA 56%
Good Prognosis
– Knees 80% - good
outcome
– early treatment -(less than 1 week
duration) - 66%
Poor Prognosis
– delayed treatment
(over 2 weeks) - 22%
– polyarticular
disease
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RHEUMATIC FEVER
Revised Jones Criteria
Evidence of a recent Strep infection (increasing or elevated ASO, Antistreptococcal Antibodies,
Group A Strep on throat culture, Positive rapid group A strep
test)
2 Major or 1 Major and 2 Minor plus
evidence of recent Strep infection
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RHEUMATIC FEVER
Moderate to High Risk
Major: Arthritis,
Carditis,Chorea,
Erythema marginatum,
Nodules
Minor: fever, sed rate
>30, CRP >3.0,
prolonged PR interval
Low Risk
Major: Arthritis,
Carditis,Chorea,
Erythema marginatum,
Nodules
Minor: oligoarthralgia,
fever, sed rate >60, CRP
>3.0, prolonged PR
interval
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RHEUMATIC FEVER
TREATMENTNo carditis – 5 years
Carditis with no residual heart disease– 10
years or age 25
Carditis with residual heart disease – 10
years and cardiac prophylaxis to age 45-
life
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RHEUMATIC FEVER
SURGICAL TREATMENTHeart failure due to valve disease
PAH
Tricuspid regurgitation complicating mitral
valve disease
Progression beyond NYHA Class 2
Progressive LV enlargement > 0.5 cm/year
A fib
Thromboembolisim
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LYME DISEASE
Causative Organism – Borelia Burgdorferi
– Spirochete
95% of U.S. Vector-borne diseases
I scapularis (dammini) – Tick vector
– Nymph – white footed mouse
– Adult - Deer
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LYME DISEASESTAGE I - Early– Erythema Migrans
– Flu-like Syndrome
STAGE II - Early
Disseminated– Erythema migrans
– Borrelia lymphocytoma
– Migratory arthralgia
– peripheral neuropathy
– Carditis (fluctuating A-V
block
STAGE III - Late– Acrodermatitis chronica
atrophicans
– intermittent/chronic
oligoarthritis
– chronic encephalitis
– sensorimotor
neuropathies
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LYME DISEASE
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LYME DISEASEDiagnosis is clinical
Laboratory tests
– Skin culture of Erythema Migrans
– ELISA
– Western blot
– PCR most useful in arthritis
– CNS antibody is confirmatory for CNS disease
– Elevated ESR
– Transient increase in SGOT
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LYME DISEASE
TREATMENTTick bite
– 200mg doxycycline
Early disease
– 21 day oral doxycycline
100mg
– 21 day oral Amoxicillin
500mg tid
– 14 day IV ceftriaxone
Neurologic (28 day)
– Ceftriaxone 2g IV daily
– Cefotaxime 2g IV q8h
Arthritis (30-60 day)
– Doxycycline 100mg bid
– Amoxicillin 500mg tid
– Ceftriaxone 2g IV daily
– Penicillin G 3.5 million units
q4h
Carditis (21 day)
– Ceftriaxone
– Penicillin G
– Amoxicillin
– Doxycycline
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HIVArthralgia
Infectious Arthritis
Reiter’s Syndrome
Psoriatic Arthritis
Sjogren’s Syndrome
Spondyloarthropathy
(undifferentiated)
AIDS associated
arthritis
Avascular necrosis
Myositis
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Contact Information
Howard Feinberg, D.O., F.A.C.O.I., F.A.C.R.
1310 Club Drive
Vallejo, CA 94592