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Concept: Septic arthritis

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BACKGROUND: Despite advances in antimicrobial and surgical therapy, septic arthritis remains a rheumatologic emergency that can lead to rapid joint destruction and irreversible loss of function. In adults, Staphylococcus aureus is the most common microorganism isolated from native joints. Streptococcus gordonii is a prominent member of the viridans group of oral bacteria and is among the bacteria most frequently identified as being primary agent of subacute bacterial endocarditis. To the best of our knowledge, Streptococcus gordonii has not yet been described as agent of septic arthritis.Case PresentationWe describe here two cases of septic arthritis due to Streptococcus gordonii. It gives us an opportunity to review epidemiology, diagnosis criteria and management of septic arthritis. CONCLUSION: Although implication of S. gordonii as aetiologic agent of subacute endocarditis is well known, this organism is a rare cause of septic arthritis. In this case, the exclusion of associated endocarditis is warranted.

Concepts: DNA, Bacteria, Organism, Microbiology, Staphylococcus aureus, Staphylococcus, Microorganism, Septic arthritis

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Septic arthritis is an emergency. In 1999 Kocher et al. identified four clinical criteria to distinguish hip septic arthritis from transient synovitis in children (nonweightbearing, erythrocyte sedimentation rate ≥ 40 mm/L, white blood cell count > 12 × 10(9)/L, temperature > 38.5°C). Subsequent authors evaluating the same criteria produced conflicting results. This calls into question the use of such diagnostic algorithms. The reasons for the differences remain unclear.

Concepts: Red blood cell, Rheumatoid arthritis, Hematology, Blood tests, Erythrocyte sedimentation rate, Septic arthritis, Transient synovitis

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The use of MRI is increasing when evaluating patients with knee pain because it is highly sensitive for detecting intra-articular pathology. However, such changes can be associated with degenerative joint disease, which may be demonstrated with weight-bearing radiographs. The purpose of this study was to determine how often MRI was obtained before orthopaedic referral in patients aged ≥40 years with knee pain, how often weight-bearing radiographs were obtained before MRI, and whether such imaging influenced treatment recommendations.

Concepts: Bone, Rheumatoid arthritis, Osteoarthritis, Knee, Joint, Synovial joint, Ligament, Septic arthritis

14

The aim of this report was to propose a definition for erosive disease in the context of inflammatory arthritis in light of the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) criteria for use in clinical practice and studies. A EULAR task force was formed including 16 rheumatologists and one rheumatology fellow. The process was both evidence based and consensus based, and included, between March 2010 and April 2012, analyses of data from two cohorts, two face-to-face meetings, one online voting and one teleconference. The Leiden Early Arthritis Cohort and the French ESPOIR cohort were used for the evidence-based part. The outcome measures, which were initiation of methotrexate therapy, or any disease-modifying antirheumatic drug therapy within the first year of disease and arthritis persistency over 5 years, were studied with the aim to give the best definition of erosive disease. A decision was made to select a definition with a high specificity and focus on patients who did not otherwise fulfil the 2010 ACR/EULAR RA criteria (<6 points). By a unanimous vote the following definition was selected: erosive disease for use in the 2010 ACR/EULAR RA classification criteria is defined when an erosion (defined as a cortical break) is seen in at least three separate joints at any of the following sites: the proximal interphalangeal, the metacarpophalangeal, the wrist (counted as one joint) and the metatarsophalangeal joints on radiographs of both hands and feet. A highly specific definition for erosive disease has thus been formulated.

Concepts: Rheumatoid arthritis, Rheumatology, Osteoarthritis, Methotrexate, Arthritis, Disease-modifying antirheumatic drug, Septic arthritis, Hydroxychloroquine

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On March 6, 2017, the New Jersey Department of Health (NJDOH) was notified of three cases of septic arthritis in patients who had received intra-articular injections for osteoarthritic knee pain at a private outpatient practice. The practice voluntarily closed the next day. NJDOH, in conjunction with the local health department and the New Jersey Board of Medical Examiners, conducted an investigation and identified 41 cases of septic arthritis associated with intra-articular injections administered during 250 patient visits at the same practice, including 30 (73%) patients who required surgery. Bacterial cultures of synovial fluid or tissue from 15 (37%) patients were positive; all recovered organisms were oral flora. An infection prevention assessment of the practice identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, inappropriate use of pharmacy bulk packaged (PBP) products as multiple-dose containers and handling PBP products outside of required pharmacy conditions, and preparation of syringes up to 4 days in advance of their intended use. No additional septic arthritis cases were identified after infection prevention recommendations were implemented within the practice.

Concepts: Bacteria, Hospital, Osteoarthritis, Joint, Synovial joint, New York City, Septic arthritis, Patrick Dempsey

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Differentiating between septic arthritis and Lyme disease of the knee in endemic areas can be challenging and has major implications for patient management. The purpose of this study was to identify a prediction rule to differentiate septic arthritis from Lyme disease in children presenting with knee pain and effusion.

Concepts: Prediction, Futurology, Rheumatoid arthritis, Lyme disease, Arthritis, Peripheral neuropathy, Septic arthritis, Hydroxychloroquine

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We describe pGALS (paediatric Gait, Arms, Legs and Spine) - a simple quick musculoskeletal assessment to distinguish abnormal from normal joints in children and young people. The use of pGALS is aimed at the non-specialist in paediatric musculoskeletal medicine as a basic clinical skill to be used in conjunction with essential knowledge about red flags, normal development and awareness of patterns of musculoskeletal pathologies. pGALS has been validated in school-aged children and also in the context of acute general paediatrics to detect abnormal joints. We propose that pGALS is an important part of basic clinical skills to be acquired by all doctors who may be involved in the care of children. The learning of pGALS along with basic knowledge is a useful way to increase awareness of joint disease, facilitate early recognition of joint problems and prompt referral to specialist teams to optimise clinical outcomes. We have compiled this article as a resource that can be used by the paediatric rheumatology community to facilitate teaching.

Concepts: Medicine, Physician, Osteoarthritis, Skill, Learning, Medical school, Septic arthritis, Specialty

2

The objective of this ambispective study was to determine outcomes and associated factors for adult patients with confirmed septic arthritis (SA).

Concepts: Arthritis, Septic arthritis

2

Septic arthritis of the sternoclavicular joint is rare. It can be associated with serious complications such as osteomyelitis, chest wall abscess, and mediastinitis. In this report, we describe a case of an otherwise healthy adult with septic arthritis of the sternoclavicular joint with chest wall abscess.

Concepts: Staphylococcus aureus, Joints, Septic arthritis, Sternoclavicular articulation

1

In rheumatoid arthritis (RA), the proliferation of fibroblast-like synoviocytes (FLS) is the cause of chronic inflammation in joints and of joint damage. Delivery of the pro-apoptotic gene PUMA to FLS via human adenovirus type 5 (HAdV5) vectors has been tested as a therapeutic approach, but efficiency is hampered by low transduction, as FLS do not express HAdV5 receptors on the cell surface. Here we show that efficient transduction of PUMA in FLS can be achieved by conjugating HAdV5 to a baculovirus, which binds to the cell surface via the envelope glycoprotein Gp64. Intra-articular injection in an adjuvant-induced rat model of RA induces apoptosis of FLS, leading to significant decrease in joint inflammation, joint damage, and bone loss with improvement in joint function and mobility. Our results demonstrate the therapeutic potential of PUMA gene therapy as a local treatment in various forms of arthritis in which abnormal FLS proliferation is implicated.Proliferation of synoviocytes contributes to joint damage in rheumatoid arthritis. Here the authors show that targeting of these cells by a vector, consisting of a baculovirus conjugated to an adenovirus carrying the pro-apoptotic gene PUMA, has therapeutic efficacy in a rat arthritis model.

Concepts: Bone, Infection, Rheumatoid arthritis, Rheumatology, Osteoarthritis, Joint, Sacroiliac joint, Septic arthritis