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===Plain radiographs of swollen joints===
===Plain radiographs of swollen joints===
*Erosions
*[[Swelling]] of the joint capsule and soft tissue around the joint
* Fat pad displacement
*Joint space widening due to localized [[edema]] and effusion.<ref name="pmid7618566">Jaramillo D, Treves ST, Kasser JR, Harper M, Sundel R, Laor T (1995) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7618566 Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment.] ''AJR Am J Roentgenol'' 165 (2):399-403. [http://dx.doi.org/10.2214/ajr.165.2.7618566 DOI:10.2214/ajr.165.2.7618566] PMID: [https://pubmed.gov/7618566 7618566]</ref><ref name="pmid12364368">Shirtliff ME, Mader JT (2002) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12364368 Acute septic arthritis.] ''Clin Microbiol Rev'' 15 (4):527-44. PMID: [https://pubmed.gov/12364368 12364368]</ref><ref name="pmid21916390">Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML (2011) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21916390 Approach to septic arthritis.] ''Am Fam Physician'' 84 (6):653-60. PMID: [https://pubmed.gov/21916390 21916390]</ref>


===Ultrasonography of painful joints===
===Computed tomography (CT)===
*Detect synovitis and tenosynovitis in the hands and wrists in patients with SLE
*Visualization of joint effusion
* Soft tissue swelling
* Para-articular [[abscesses]]
* Joint space widening due to localized edema, bone erosions, foci of osteitis, and scleroses.<ref name="pmid6725696">Seltzer SE (1984) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6725696 Value of computed tomography in planning medical and surgical treatment of chronic osteomyelitis.] ''J Comput Assist Tomogr'' 8 (3):482-7. PMID: [https://pubmed.gov/6725696 6725696]</ref><ref name="pmid12364368">Shirtliff ME, Mader JT (2002) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12364368 Acute septic arthritis.] ''Clin Microbiol Rev'' 15 (4):527-44. PMID: [https://pubmed.gov/12364368 12364368]</ref>


===Renal ultrasonography===
*To assess kidney size
*To rule out urinary tract obstruction
===Chest radiography===
*For suspected pleural effusion, interstitial lung disease, cardiomegaly
===Echocardiography===
*For suspected pericardial involvement, to assess for a source of emboli, or noninvasive estimation of pulmonary artery pressure; and for evaluation of suspected valvular lesions, such as verrucae
===Computed tomography (CT)===
*For abdominal pain, suspected pancreatitis, interstitial lung disease


===Magnetic resonance imaging (MRI)===
===Magnetic resonance imaging (MRI)===
*For focal neurologic deficits or cognitive dysfunction
*[[Synovial]] enhancement
*Perisynovial [[edema]]
*Joint effusion
*Signal abnormalities in the bone marrow
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==Other Investigation==
==Other Investigation==


===Bronchoscopy===
=== PCR===
Fiberoptic [[bronchoscopy]] with [[Bronchoalveolar lavage|bronchoalveolar lavage (BAL)]] and transbronchial lung biopsies:<ref name="pmid16409858">{{cite journal |vauthors=Shen M, Wang Y, Xu WB, Zeng XJ, Zhang FC |title=[Pleuropulmonary manifestations of systemic lupus erythematosus] |language=Chinese |journal=Zhonghua Yi Xue Za Zhi |volume=85 |issue=48 |pages=3392–5 |year=2005 |pmid=16409858 |doi= |url=}}</ref><ref name="pmid9187214">{{cite journal |vauthors=Susanto I, Peters JI |title=Acute lupus pneumonitis with normal chest radiograph |journal=Chest |volume=111 |issue=6 |pages=1781–3 |year=1997 |pmid=9187214 |doi= |url=}}</ref>
* To substantiate the diagnosis of alveolar [[hemorrhage]]
=== Barium swallow or esophagography ===
*[[Esophageal]] stricture<ref name="pmid12873055">{{cite journal |vauthors=Jiménez-Alonso J, Estev D, Vera C, Sabio JM |title=Dysphagia in patients with systemic lupus erythematosus |journal=Lupus |volume=12 |issue=6 |pages=493 |year=2003 |pmid=12873055 |doi= |url=}}</ref>
**Peptic strictures that appear as smooth, tapered narrowing in the distal [[esophagus]]
*[[Esophageal dilatation]]<ref name="pmid12873055" />
 
=== Biopsy ===
* [[Renal]] biopsies:<ref name="pmid22977215">{{cite journal |vauthors=Giannico G, Fogo AB |title=Lupus nephritis: is the kidney biopsy currently necessary in the management of lupus nephritis? |journal=Clin J Am Soc Nephrol |volume=8 |issue=1 |pages=138–45 |year=2013 |pmid=22977215 |doi=10.2215/CJN.03400412 |url=}}</ref><ref name="pmid24969191">{{cite journal |vauthors=Singh A, Ghosh R, Kaur P, Golay V, Pandey R, Roychowdhury A |title=Protocol renal biopsy in patients with lupus nephritis: a single center experience |journal=Saudi J Kidney Dis Transpl |volume=25 |issue=4 |pages=801–7 |year=2014 |pmid=24969191 |doi= |url=}}</ref>
** Determining the degree of renal involvement
** Delineating treatment decisions and prognosis in certain clinical scenarios
** Assess activity and damage (i.e., chronicity)
** Helping with classification
 
* [[Endomyocardial]] biopsy:<ref name="pmid2684953">{{cite journal |vauthors=Salomone E, Tamburino C, Bruno G, Di Paola R, Silvestri F |title=The role of endomyocardial biopsy in the diagnosis of cardiac involvement in systemic lupus erythematosus |journal=Heart Vessels |volume=5 a|issue=1 |pages=52–3 |year=1989 |pmid=2684953 |doi= |url=}}</ref>
** May be helpful in guiding treatment towards the use of [[corticosteroids]]
 
=== Paracentesis ===
* [[Paracentesis]] in the presence of the following conditions either for symptomatic relief (therapeutic) or fluid evaluation (diagnostic):
** [[Ascites]]<ref name="pmid22324961">{{cite journal |vauthors=Prasad S, Abujam B, Lawrence A, Aggarwal A |title=Massive ascites as a presenting feature of lupus |journal=Int J Rheum Dis |volume=15 |issue=1 |pages=e15–6 |year=2012 |pmid=22324961 |doi=10.1111/j.1756-185X.2011.01659.x |url=}}</ref>
** Massive [[pleural effusion]]<ref name="pmid25417677">{{cite journal |vauthors=Palavutitotai N, Buppajarntham T, Katchamart W |title=Etiologies and outcomes of pleural effusions in patients with systemic lupus erythematosus |journal=J Clin Rheumatol |volume=20 |issue=8 |pages=418–21 |year=2014 |pmid=25417677 |doi=10.1097/RHU.0000000000000179 |url=}}</ref>
** Massive [[pericardial effusion]] and [[tamponade]]<ref name="pmid24579442">{{cite journal |vauthors=Kruzliak P, Novak M, Piler P, Kovacova G |title=Pericardial involvement in systemic lupus erythematosus: current diagnosis and therapy |journal=Acta Cardiol |volume=68 |issue=6 |pages=629–33 |year=2013 |pmid=24579442 |doi=10.2143/AC.68.6.8000011 |url=}}</ref>
 
=== Arthrocentesis ===
=== Arthrocentesis ===
* In the presence of joint effusion to differentiate between different causes of [[arthritis]]<ref name="pmid642792">{{cite journal |vauthors=Goldenberg DL, Cohen AS |title=Synovial membrane histopathology in the differential diagnosis of rheumatoid arthritis, gout, pseudogout, systemic lupus erythematosus, infectious arthritis and degenerative joint disease |journal=Medicine (Baltimore) |volume=57 |issue=3 |pages=239–52 |year=1978 |pmid=642792 |doi= |url=}}</ref>
* In the presence of joint effusion to differentiate between different causes of [[arthritis]]<ref name="pmid642792">{{cite journal |vauthors=Goldenberg DL, Cohen AS |title=Synovial membrane histopathology in the differential diagnosis of rheumatoid arthritis, gout, pseudogout, systemic lupus erythematosus, infectious arthritis and degenerative joint disease |journal=Medicine (Baltimore) |volume=57 |issue=3 |pages=239–52 |year=1978 |pmid=642792 |doi= |url=}}</ref>

Revision as of 20:05, 9 April 2018

Septic arthritis resident survival guide:

Complete diagnostic approach:

Common Presentation

Symptoms in newborns or infants:

  • Cries when infected joint is moved (e.g. diaper change causes crying if hip joint is infected)
  • Fever
  • Inability to move the limb with the infected joint (pseudoparalysis)
  • Irritability

Symptoms in children and adults:

Less common Presentation

 
 
 
 
 
 
 
 

Focused History

  • Intravenous drug use
  • Sexual activity
  • Terminal complement deficiency
  • Dog or cat bite
  • Ingestion of unpasteurized dairy products
  • Nail through shoe
  • Soil exposure/gardening
  • Soil or dust exposure containing decomposed wood

(north-central and southern United States)

  • Southwestern United States, Central and South America

(primary respiratory illness)

  • Cleaning fish tank
 
 
 
 
 
 
 
 

Physical Examination

Appearance of the Patient

Vital Signs

Skin

  • Warmth over the joint

Extremities

Most commonly involves knee > hip > shoulder > ankle.[2] Other joints such as sacroiliac joint (~10%), sternoclavicular or costoclavicular joints may be involved in patient with history of intravenous drug abuse (IVDA), penetrating trauma, animal or human bites and local steroid injections.

  • Swelling of the joint that involved
  • Decreased range of motion such as pseudo paralysis
  • Patient hold the hip in flexed and externally rotated position if SA involving hip.
  • If child, unwillingness to bear weight on the affected joint (antalgic gait)
 
 
 
 
 
 
 
 

Laboratory Workup

 
 
 
 
 
 
 
 

Imaging Study

Plain radiographs of swollen joints

  • Swelling of the joint capsule and soft tissue around the joint
  • Fat pad displacement
  • Joint space widening due to localized edema and effusion.[3][4][5]

Computed tomography (CT)

  • Visualization of joint effusion
  • Soft tissue swelling
  • Para-articular abscesses
  • Joint space widening due to localized edema, bone erosions, foci of osteitis, and scleroses.[6][4]


Magnetic resonance imaging (MRI)

  • Synovial enhancement
  • Perisynovial edema
  • Joint effusion
  • Signal abnormalities in the bone marrow
 
 
 
 
 
 
 
 

Other Investigation

PCR

Arthrocentesis

  • In the presence of joint effusion to differentiate between different causes of arthritis[7]
 
 
  1. ↑ Goldenberg DL (1998) Septic arthritis. Lancet 351 (9097):197-202. DOI:10.1016/S0140-6736(97)09522-6 PMID: 9449882
  2. ↑ Barton LL, Dunkle LM, Habib FH (1987) Septic arthritis in childhood. A 13-year review. Am J Dis Child 141 (8):898-900. PMID: 3498362
  3. ↑ Jaramillo D, Treves ST, Kasser JR, Harper M, Sundel R, Laor T (1995) Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol 165 (2):399-403. DOI:10.2214/ajr.165.2.7618566 PMID: 7618566
  4. ↑ 4.0 4.1 Shirtliff ME, Mader JT (2002) Acute septic arthritis. Clin Microbiol Rev 15 (4):527-44. PMID: 12364368
  5. ↑ Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML (2011) Approach to septic arthritis. Am Fam Physician 84 (6):653-60. PMID: 21916390
  6. ↑ Seltzer SE (1984) Value of computed tomography in planning medical and surgical treatment of chronic osteomyelitis. J Comput Assist Tomogr 8 (3):482-7. PMID: 6725696
  7. ↑ Goldenberg DL, Cohen AS (1978). "Synovial membrane histopathology in the differential diagnosis of rheumatoid arthritis, gout, pseudogout, systemic lupus erythematosus, infectious arthritis and degenerative joint disease". Medicine (Baltimore). 57 (3): 239–52. PMID 642792.
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