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Bone and joint infections. I man Abu selmia . S amar Shaheen . Bone infections. I man Abu selmia . overview. Normally, bone and joint are sterile . Infection >>Rare. Significant >> disability ,death . Osteomyelitis. Osteomyelitis is infection in the bone. Infants,children,and adults.

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bone and joint infections
Bone and joint infections

Iman Abu selmia

Samar Shaheen

bone infections

Bone infections

Iman Abu selmia

overview
overview
  • Normally, bone and joint are sterile.
  • Infection >>Rare.
  • Significant >> disability ,death .
osteomyelitis
Osteomyelitis
  • Osteomyelitis is infection in the bone.
  • Infants,children,and adults.
  • In children >>at the ends of the long bones of the arms and legs, affecting the hips, knees, shoulders, and wrists.
  • In adults >>bones of the spine (vertebrae) or in the pelvis.
risk factors
Risk factors
  • Diabetes
  • Hemodialysis
  • Injected drug use
  • Poor blood supply
  • Recent trauma
  • Surgery
  • The elderly
symptoms
Symptoms
  • Bone pain
  • Fever
  • malaise
  • Local swelling, redness, and warmth

Other symptoms may occur :

  • Chills
  • Excessive sweating
  • Low back pain
  • Swelling of the ankles, feet, and legs
classification
Classification
  • Bacterial:
    • Acute osteomyelitis (subacute)
      • hematogenous
      • non- hematogenous
    • Chronic osteomyelitis
      • Nonspecific
      • specific (TB, syphilitic)
slide9
Non- Bacterial
    • Viral osteomyelitis
    • Fungi
    • Radiation osteomyelitis
acute hematogenous osteomyelitis
Acute hematogenous osteomyelitis
  • mostly children
  • history of trauma
  • Long bone >> most common
  • In children >> metaphysis
    • Most vascular part
    • Blood flow slow
    • Most part subject to trauma
  • In adult >> epiphysis
the organisms
The organisms
  • Gram +ve
      • Staphylococus aureus (80-90%)
      • Strep. pyogen
      • Strep. pneumonie
  • Gram -ve
      • Haemophilus influnzae (50% < 4 y)
      • E .coli
      • Pseudomonas auroginosa,
      • Proteus mirabilis
source of infection
Source Of Infection
  • Infected umbilical cord in infants
  • Infection

( respiratory, intestinal, urinary, oral, boils, tonsilitis, skin abrasions)>> bacteramia

  • Traumatic implantation
pathology
Pathology
  • Minor trauma to adjacent joint , suppuration
  • starts at metaphysis
  • Subperiosteal abscess
  • Bone necrosis
  • new bone formation“ ivolucrum”
  • Channels through soft tissue “sinuses”
  • Sinuses appear thick-walled holes “cloacae”
  • Death of bony segment “sequestrum”
complication
Complication
  • Pathological fracture.
  • Direct spread of infection arthritis,myositis
  • Blood spread  septicaemia, pyaemia
  • Chronic suppurrative osteomyelitis .
acute non hematogenous osteomyelitis
Acute non- hematogenous osteomyelitis
  • Causes
    • Infection of fracturedbone
    • Infection of skull bone by direct spread
  • Pathologhy
    • Resemble hematogenous except no Subperiosteal abscess
subacute osteomyelitis
Subacute Osteomyelitis
  • Brodie's abscess, a chronic abscess of bone surrounded by dense fibrous tissue and sclerotic bone.
  • The lesion usually is within the metaphysis, but can occur anywhere.
chronic om
Chronic OM
  • May following acute OM.
  • Sclerosing osteomyelytitis of Garre
    • a chronic form involving the long bones, especially the tibia and femur, marked by a diffuse inflammatory reaction, increased density and spindle-shaped sclerotic thickening of the cortex, and an absence of suppuration.
    • Develop in the jaw and characterized by extensive new bone formation.
complication1
Complication
  • Secondary amyloidosis
  • Squamous cell carcinoma
slide20
According to the pathogenesis
  • Haematogenous osteomyelitis .
  • Contagious spread osteomyelitis.
  • Peripheral vascular disease.
  • Prostheses osteomyelitis .
contagious spread osteomyelitis
Contagious spread osteomyelitis
  • Direct spread of bacteria from infection in adjacent tissues .
    • Long bone (most common)
    • Cranial vault >> head injury.
    • Sacrum >> decubitus ulceration.
    • Sternum >> cardiothoracic surgery.
  • Gram –ve bacilli.
  • Anaerobic bacteria.
peripheral vascular disease
Peripheral vascular disease.
  • Often affects the toes.
  • Streptcocci and anaerobic bacteria.
  • Particularly common in diabetics.
prostheses osteomyelitis
Prostheses osteomyelitis
  • Infections following artificial joint replacement.
  • Caused by
    • Perioperative contamination.
    • Haematogenous spread occurs in the posoperative period.
  • The causal organisms >> bacteria
    • Coagulase-negative staphylcocci
    • Streptococci
    • corynebacteria
major pathogen
Major pathogen
  • Neonates :
    • E. coli or Bacteroides spp.
  • Infants
    • Haemophilus influenzae (< of 4 years )
  • Later
    • S.aureus
    • Streptococcus pyogenes
    • Streptococcus pneumoniae.
special pathogen
Special pathogen
  • Salmonella- immunocomromised,sickle cell disease.
  • Pasteurella multocida
  • M.tuberculosis
  • Fungi- IV drugs abusers or immunosuppression
diagnosis
Diagnosis
  • History and clinical examination
  • Blood cultures
  • Bone biopsy (which is then cultured)
  • Bone scan
  • Bone x-ray
  • MRI of the bone
  • Needle aspiration of the area around affected bones
treatment
Treatment
  • supportive treatment for pain
  • antibiotics
  • surgery
joint infections

Joint infections

Samar Shaheen

septic arthritis
Septic arthritis
  • An acute inflammation of a joint caused by infection.
  • Can be:
    • Suppurative
    • Nonsuppurative
    • Monoarticular
    • Polyarticular
  • Commonly involves a single large joint such as the knee or hip.
high risk groups
High risk groups
  • Elderly
  • Diabetes mellitus
  • Rheumatoid arthritis
  • Prosthetic joint
  • Recent joint surgery
  • Skin infection
  • IV drug abusers
route of infection
Route of infection
  • Blood borne infection (the most common route)
  • Direct inoculation
    • entry via penetrating injury
    • entry via iatrogenic means
  • Contiguous spread from osteomyelitis or soft tissue abscess.
    • In adults, the arteriolar anastomosis between the epiphysis and the synovium permits the spread of osteomyelitis into the joint space.
clinical presentation
Clinical presentation
  • fever
  • swelling
  • warmth
  • inability to move the limb with the infected joint
  • severe pain in the affected joint, especially with movement
suppurative septic arthritis
Suppurative septic arthritis
  • Caused by bacteria
  • Virtually every bacterial organism has been reported to causeseptic arthritis.
  • Bacterial species causing septic arthritis vary with the age of the patient.
    • The most common species overall is S. aureus
    • Neisseria gonorrhea is the most common cause in sexually active adults
    • H. infleunzaoccasionally implicated in preschool children.
suppurative septic arthritis1
Suppurative septic arthritis
  • The major consequence of bacterial invasion is damage to articular cartilage.
    • Organism's pathological properties, such as the chondrocyte proteases of S aureus.
    • Host's PMNL response.
      • cytokines and other inflammatory products hydrolysis of essential collagen and proteoglycans.
gram positive
Gram positive

S. aureus

  • The most common cause of septic arthritis:
    • adults
    • children older than 2 years.
    • 80% of infected joints affected by rheumatoid arthritis
    • early prosthetic joint infections (PJI)
    • Polyarticular arthritis
  • Mortality rate approaches 50%.
gram positive1
Gram positive

CNS staphylococci

  • delayed PJI infections

Streptococcal species

  • the second most common cause
    • Streptococcus viridans
    • Streptococcus pneumoniae
    • group B streptococci
gonococcal arthritis
Gonococcal arthritis

N .gonorrhoeae

  • Gonococcal arthritis
  • the most common pathogen (75% of cases) among younger sexually active individuals
  • Pathogenesis is ultimately a consequence of disseminated gonococcal infection (DGI).
gonococcal arthritis1
Gonococcal arthritis
  • Arthritis-dermatitis syndrome includes the classic triad of
    • dermatitis
    • tenosynovitis
    • migratory polyarthritis.
  • Unlike in S. aureusseptic arthritis, joint destruction is rare low mortality rate.
gram negative
Gram negative
    • H .infleunzaoccasionally implicated in preschool children.
  • Escherichia coli in the elderly, IV drug users and the seriously ill
  • Salmonella spp.
  • Pseudomonas aeruginosa or Serratiaspecies cause infection of the sternoclavicular and sacroiliac joints almost exclusively in persons who abuse intravenous drugs.
gram negative1
Gram negative
  • Aeromonas  Persons with leukemia are predisposed .
  • Pasteurella multocida, Capnocytophaga species (dog and cat bites)
  • Brucella spp. lumbosacral spine involvement.
other
Other

Acid fast

  • Mycobacteria are a rare cause of septic arthritis.

Anaerobes

  • usually a consequence of trauma or abdominal infection.
  • 5% of cases
  • Fusobacteriumnucleatum
  • Eikenellacorrodens
  • Streptococcal species (human bites)
other1
Other

Polymicrobial joint infections

  • 5-10% of cases
nonsuppurative septic arthritis
Nonsuppurative septic arthritis
  • Viruses
  • Fungi
  • Borrelia burgdorferi
viruses
Viruses
  • Viral infections may cause:
    • direct invasion  rubella virus
    • production of antigen/antibody complexes.
      • hepatitis B,
      • parvovirus B19
      • lymphocytic choriomeningitis viruses
viruses1
Viruses

Hepatitis viruses

  • Hepatitis A
  • Hepatitis B
    • Onset in the prodromic stage.
    • Usually resolves as jaundice develops
    • Chronic arthritis possible in patients with chronic hepatitis B infection
  • Hepatitis C
viruses2
Viruses

Parvovirus B19

  • Occurs in adults esp. women
  • Mainly involves the small joints of the hands and feet bilaterally.

Rubella (natural infection and vaccine related)

    • Onset possible before, during, or after the appearance of the rash
    • Mild, short lived and without major impairment of joint function.
viruses3
Viruses

HIV

  • 2 types occur, both with noninflammatory sterile joint fluid

Mumps

  • Occurs in adult men 2 weeks after the presentation of parotitis
  • Mild, short lived and without impairment of joint function.
fungi
Fungi
  • Candida albicans
  • Sporothrix schenckii
  • Coccidioides immitis, Histoplasma species, and Blastomyces species
borrelia burgdorferi
Borreliaburgdorferi

Spirochete

  • Borreliaburgdorferi.
    • Lyme arthritis
    • Develops in 60%-80% of untreated patients.
    • The dominant feature of late disease (stage 3)
    • may produce nonsuppurative joint infection
    • Borreliaantigens cross react with proteins in the joints
reactive arhtritis
Reactive arhtritis
  • Acute inflammation of the joints that follows infection with various bacteria, but the joints are sterile.
  • i.e. inflammation is a “reaction” to the presence of bacterial antigen elsewhere in the body.
  • Usually oligoarticular and asymmetric.
  • Bacterial infection precedes the arthritis by a few weeks.
reactive arhtritis1
Reactive arhtritis
  • Antibiotics have no effect
  • Anti-inflammatory agents are typically used.
  • Increased risk in persons with HLA-B27 locus
  • Thought to be immunologically mediated.
  • Reiter’s syndrome icludes reactive arthritis, but affects multiple organs.
reactive arhtritis2
Reactive arhtritis
  • Reactive arthritis is associated with:
    • Enteric infections
      • Salmonella spp.
      • Shigella spp.
      • Campylobacter spp.
      • Yersinia spp
    • urethritis
      • Chlamydia trachomatis
reiter s syndrome
Reiter’s syndrome
  • The syndrome is characterized by the triad of:
    • Arthritis
    • Conjunctivitis
    • Urethritis
  • Infection by one of the following predisposes to the disease:
    • Salmonella spp.
    • Shigella spp.
    • Campylobacter spp.
    • Yersiniaspp
    • Chlamydia trachomatis
diagnosis1
Diagnosis

Septic arthritis

  • Joint fluid aspiration
    • Microscopy
      • Absence of crystals to rule out gout & pseudogout
    • Culture
diagnosis2
Diagnosis

Reactive arthritis

  • Clinically: a history of previous infection in the intestinal or genitourinaty tract.
  • RF is usually negative.
  • The HLA-B27 gene marker blood test can be helpful.