Reumatología Clínica (English Edition)

Reumatología Clínica (English Edition)

Volume 15, Issue 6, November–December 2019, Pages e81-e85
Reumatología Clínica (English Edition)

Original Article
Coexistence of septic and crystal-induced arthritis: A diagnostic challenge. A report of 25 casesCoexistencia de artritis séptica y microcristalina: un reto diagnóstico. A propósito de 25 casos

https://doi.org/10.1016/j.reumae.2017.12.004Get rights and content

Abstract

Objective

Septic arthritis is a medical emergency and crystal-induced arthritis is a risk factor for its development. If both occur simultaneously, crystal-induced arthritis may mask the diagnosis of infection and delay antibiotic therapy.

Method

Retrospective analysis of patients with coexistence of septic and crystal-induced arthritis. We included only patients with isolation of crystals in synovial fluid analysis and positive culture of synovial fluid and/or blood culture.

Results

A total of 25 patients (17 men and 8 women) with a mean age of 67 years. The most commonly affected joint was the knee. In synovial fluid cytological studies, the most frequently identified crystals were monosodium urate. Risk factors included diabetes and chronic renal failure. The most frequently isolated germs were methicillin-sensitive Staphylococcus aureus (48%), methicillin-resistant S. aureus (12%) and Mycobacterium tuberculosis (12%). In all, 36% of subjects required surgical drainage (excluding those caused by M. tuberculosis). Clinical outcome was favourable in 56%, although intercurrent complications were usual (40%). Mortality was 8%.

Conclusions

Coexistence of septic and crystal-induced arthritis represents a diagnostic challenge and requires a high index of suspicion. Gout was the most prevalent crystal-induced arthritis. S. aureus was the most commonly causative pathogen, with a high rate of methicillin-resistant S. aureus infection. If treated early, the outcome is usually favourable, making synovial fluid microbiological study imperative.

Resumen

Objetivo

La artritis séptica es una urgencia médica y la artritis microcristalina es un factor de riesgo para su aparición. Si ambas cursan de forma simultánea, la identificación de microcristales puede enmascarar el diagnóstico de la infección y causar un retraso en la instauración del tratamiento antibiótico.

Método

Análisis retrospectivo de pacientes con coexistencia de artritis séptica y microcristalina. Se incluye únicamente a los enfermos con aislamiento del germen en líquido articular y/o hemocultivo e identificación de cristales en el líquido articular.

Resultados

Se identificaron un total de 25 pacientes (17 varones y 8 mujeres) con una media de edad de 67 años. La articulación que se afectó con mayor frecuencia fue la rodilla. Los cristales de urato monosódico fueron los que con mayor frecuencia se identificaron en el estudio citológico del líquido sinovial. Los factores de riesgo más frecuentes fueron la diabetes mellitus y la insuficiencia renal crónica. El germen aislado con mayor frecuencia fue el Staphylococcus aureus sensible a meticilina (48%), seguido del Staphylococcus aureus resistente a meticilina (12%) y Mycobacterium tuberculosis (12%). El 36% de los pacientes precisaron desbridamiento quirúrgico (excluyendo los causados por M. tuberculosis). La evolución fue favorable en el 56% de los pacientes, aunque la presencia de complicaciones intercurrentes fue habitual (40%). La mortalidad fue del 8%.

Conclusiones

La coexistencia de artritis séptica y microcristalina representa un reto diagnóstico y requiere un alto índice de sospecha. La artropatía por cristales de urato monosódico es la más prevalente y S. aureus el germen causal más frecuente, con una tasa elevada de infección por S. aureus resistente a meticilina. Si se instaura de forma precoz el tratamiento adecuado, la evolución suele ser favorable, por lo que el estudio microbiológico del líquido sinovial es imperativo.

Introduction

Septic arthritis is considered a medical emergency due to the rapid anatomical and functional impairment it causes to the affected joint. Arthropathy due to deposition of crystals is a risk factor for its onset. If both occur simultaneously, crystal-induced arthritis can mask a diagnosis of infection, and result in a delay in starting antibiotic treatment. Therefore microbiological study of synovial fluid (Gram staining and cultures) is essential for all episodes of acute arthritis, even if the presence of crystals is detected in the fluid. Although it is not a common situation in clinical practice, the possibility of infection should be considered in all cases of crystal-induced arthritis.

The objective of this paper was to assess the characteristics of patients attended in our hospital with concomitant septic and crystal-induced arthritis. In the Spanish-speaking literature there are 7 case reports,1, 2, 3, 4, 5, 6, 7 but no published series. We only found 2 case series in the English-speaking medical literature,8, 9 which justifies this study.

Section snippets

Patients and method

We performed a retrospective analysis of septic and crystal-induced arthritis cases registered in a rheumatology section, in the setting of a university hospital covering a referral population of around 850,000 inhabitants.

An analysis was made of all the infectious arthritis cases (code IVA of the ACR classification)10 gathered in the service registry from 1985 to 2015 (database with coding of diagnoses). For the purposes of the study we chose the cases with germs in the synovial fluid study

Results

Between 1985 and December 2015, 25 patients with concomitant crystal-induced and septic arthritis were registered in the rheumatology section of the University Hospital Germans Trias i Pujol of Badalona. The distribution by sex was 17 males and 8 females, with a mean ± standard deviation (interval) of age of 67 ± 14 (36–89) years. The mean ± standard deviation (interval) of time between onset of symptoms and diagnosis was 14 ± 13 (1–45) days (data available for 14 patients). The knee was the most

Discussion

Differential diagnosis of septic or crystal-induced arthritis is generally simple; however, it can become complicated when both entities present at the same time, which rarely occurs. Both patients with septic arthritis and those who develop crystal-induced arthritis can manifest fever, pain, rubor and joint swelling, therefore it is essential to perform an arthrocentesis with microbiological study of synovial fluid to establish a precise diagnosis. Regardless of whether or not the leucocyte

Conflict of interests

The authors have no conflict of interest to declare.

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    Please cite this article as: Prior-Español Á, García-Mira Y, Mínguez S, Martínez-Morillo M, Gifre L, Mateo L. Coexistencia de artritis séptica y microcristalina: un reto diagnóstico. A propósito de 25 casos. Reumatol Clin. 2019;15:e81–e85.

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