Septic arthritis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

Differential Diagnosis

Differentiating gonococcal arthritis from non-gonococcal arthritis

Characterestic	Gonococcal arthritis	Non gonococcal arthritis
Patient profile	Mostly sexually active young adult Female > male	Patient with history of rheumatoid arthritis or other systemic arthritis Immunocompromised patient Common in extremes of age such as in newborn or elderly
Initial presentation	Migratory polyarthralgia is common Tenosynovitis in majority of patients Dermatitis in majority of patients	Single hot, swollen and painful joint Polyarthralgia is very rare Tenosynovitis and dermatitis are very rare.
Polyarticular involvement	Common (~40–70% of patients) Usually involves 2-3 joints	Rare (~10–20% of patients). Mostly monoarticular involvement (>85%)
Recovery of bacteria	Positive blood culture <10% Positive synovial fluid culture <50%	Positive blood culture 50% Positive synovial fluid culture >90%
Response to antibiotics	Within a few days outcome excellent	Takes weeks Joint drainage must be adequate Outcome often poor

Differential Diagnosis for Bacterial arthritis

Microorganism	Associated risk factors	Key clinical clues	Most definitive tests
Staphylococcus aureus	Rheumatioid arthritis Diabetes mellitus HIV patients	Healthy adult with skin lesions and previously history of damaged joint (e.g, rheumatoid arthritis) or prosthetic joint
Streptococcus pyogenes Streptococcal pneumonia	Autoimmune diseases Chronic skin infections Trauma	Healthy adults with spleenic dysfunction
Groups B Streptococcal infection	Immunocompromised patients Diabetes mellitus Malignancy Severe genitourinary or gastrointestinal infections	Healthy adults with spleenic dysfunction
Neisseria gonorrhoeae	Complement deficiency Systemic lupus erythematosus Male homosexuality low socioeconomic status	Healthy young and sexually active adult with Tenosynovitis Skin lesions such as vesicular pustules Complement deficiency (C5-9 deficiency) Culture negativity on synovial fluid analysis
Gram-negative bacilli Pseudomonas Escherichia coli	History of intravenous drug abuse Extremes of age Immunocompromised patients	Immunocompromised patients Recent history gastrointestinal infections such as infectious diarrhea caused by Shigella, Salmonella, Campylobacter, or Yersinia
Haemophilus influenzae	Unimmunized children
Anaerobes	Diabetes mellitus Patients with prosthetic joints	Immunocompromised hosts Recent history of gastrointestinal infection
Mycobacterium spp.	Recent history of travel to endemic areas	Immunocompromised patients Recent history of travel to endemic areas (e.g. India, South Africa, Mexico etc.) Incidious onset of monoarthritis	Synovial fluid analysis Histology Tissue culture
Fungal infection such as Blastomycosis Cryptococcus Coccidioidomycosis Sporotrichosis	Immunocompromised patients	Immunocompromised patients Incidious onset of monoarthritis
Mycoplasma hominis	Recent history of urinary tract procedure	Immunocompromised patients Recent history of urinary tract procedure
Viral arthritis	Immunocompromised patient	Polyarthritis Fever Rash	Serology
HIV infection	History of multiple sexual partners History of IVDA	Sterile, acute synovitis or reactive arthritis	Serology
Lyme disease	History of recent visit to endemic Lyme area	History of erythema Serology migrans History of recent visit to endemic Lyme area	Serology
Reactive arthritis	Recent gastrointestinal/ genitourinary infection	Recent gastrointestinal/ genitourinary infection Enthesopathy Skin lesions Uveitis Conjunctivitis	Radiological sacroiliitis HLA-B27
Endocarditis	History of endocarditis Damaged heart valves Congenital heart diseases	Fever New onset of heart murmur Septic and sterile synovitis Septic joint more common in IVDA	Blood culture

References

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