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Septic arthritis and spondylodiscitis, especially in immunocompromised patients, constitute a major differential diagnosis of joint or back pain. This results in the invasion of a joint or spinal disc and its adjacent vertebral body by a pathogen. In most cases this is manifested as unspecific symptoms, such as local joint or back pain, fever and malaise. If this is clinically suspected the bacterial infection of the joint can be confirmed by joint puncture and blood culture. For the diagnosis of spondylodiscitis magnetic resonance imaging should be used for visualization. In addition to adequate pain treatment and empirical antibiotic treatment, an arthroscopic removal of infected intra-articular tissue and debris is imperative. When complications caused by spondylodiscitis arise a surgical removal and stabilization should be performed. The following case report presents the findings of septic polyarthritis and spondylodiscitis in an immunocompromised patient with an HIV infection and provides insights into the occurrence of complications due to the delay of adequate treatment.

Background: The PAPA syndrome, an acronym for pyogenic sterile arthritis, pyoderma gangraenosum and acne, is an autosomal dominant hereditary disease which is caused by a mutation in the PSTPIP1 ("proline-serine-threonine phosphatase interacting protein 1") gene located on chromosome 15 and encodes the proline-serine-threonine phosphatase-interacting protein 1. An association with Crohn's disease (CD), autoimmune diseases of the liver and PAPA syndrome has not yet been reported in the literature., Objective: To thoroughly investigate a family with three affected members (mother and 2 children) with newly diagnosed PAPA syndrome and intestinal and hepatobiliary symptoms., Material and Methods: We performed an in-depth phenotyping, dermatologic, radiologic, rheumatologic, gastroenterologic, histologic and genetic analysis in this family., Results: All three family members could be newly diagnosed as suffering from PAPA syndrome and carried the known disease-causing mutation c.688G > A (p.Ala230Thr) in the PSTPIP1 gene. The younger son suffered from CD in addition to PAPA syndrome. The mother additionally suffered from ulcerative colitis (UC) and an overlap syndrome between autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC). A mutation in in the NOD2 ("nucleotide binding oligomerization domain containing protein 2") gene could not be detected in any of the three persons affected., Conclusion: We extended the symptoms of PAPA syndrome to CD and autoimmune liver disease. These different disease entities might share a similar pathogenetic mechanism or even represent a new syndrome. This can be clarified in the future by screening patients with PAPA syndrome for intestinal and also hepatobiliary diseases.

Objective: Growth disorders (e. g. caused by congenital hip dislocation, Perthes disease or bacterial coxitis) often lead to an infantile deformity of the proximal femur with a shortened femoral neck and displaced grater trochanter. In 1988, Morscher and Buess described a femoral neck lenghtening osteotomy for treatment of adults. For the first time, we show a modification of this osteotomy for children and adolescents with a locking plate system. The aim is to restore the normal anatomy of the femoral neck and biomechanics of the proximal femur., Indications: All symptomatic deformities of the proximal femur with a shortened femoral neck and a proximal displacement of the greater trochanter., Contraindications: Bacterial coxitis within the last two years; elevated infections parameters. Acetabular dysplasia with a lack of femoral head containment., Surgical Technique: Two osteotomies: one at the level of the greater trochanter to transfer it. The second osteotomy at the level of the distal femoral neck. Stabilization with a locking plate system (LCP Pediatric Hip Plate 130°, Synthes, Oberdorf, Switzerland)., Postoperative Management: Full weight bearing to a body weight of 55 kg; partial weight bearing with a body weight >55 kg for 6 weeks., Results: No intraoperative or postoperative complications were observed in 5 female patients (mean age 11.67 years). After a follow-up of 6-12 weeks, none of the patients presented a Trendelenburg's sign. After 3-6 months, full range of motion was possible.

Background: Limb salvage after operations with deep infections of the ankle is often successful using arthrodesis of the hindfoot. The aim of this study was to evaluate the results of arthrodesis using a retrograde intramedullary nail following post-infectious ankle destruction., Patients and Methods: Between 2007 and 2010 a total of 44 patients were treated with tibiotalocalcaneal (TTC) arthrodesis and 14 patients with tibiocalcaneal (TC) arthrodesis using a retrograde hindfoot nail after quieting of infection. Evaluation included the American Orthopaedic Foot and Ankle Society (AOFAS) and the short-form 12-item (SF-12) scores., Results: Of the 58 patients 49 (35 male and 14 female) could be followed-up. The average time of follow-up was 18 months and the mean age was 58 years. In 85.7 % bony union could be achieved and 10.2 % suffered from reinfections. The mean results achieved in the different scores were AOFAS 56 and SF-12 39.1 (physical health summary scale) and 46.1 (mental health summary scale). Statistical analysis showed a significantly higher rate of bony fusion for TTC arthrodesis. Bony non-union showed a significant correlation to patients with reinfection and to diabetic patients., Conclusions: Hindfoot arthrodesis for treatment of septic arthritis after infections is possible by using an intramedullary nail. The results show a high rate of fusion with an acceptable reinfection rate and good patient acceptance.

A 69-year-old man with liver cirrhosis presented to a surgeon, complaining of pain and swelling involving the right knee joint. A cloudy yellow synovial fluid was aspirated. The examination revealed polymorphonuclear leukocytes and Listeria monocytogenes was grown in the culture. The patient was treated with oral cotrimoxazole. Further follow-up was uneventful. The literature on listerial joint infections is briefly reviewed.

A case of coexistent acute gout and septic olecranon bursitis is presented. Our hypothesis is that asymptomatic monosodium urate crystals, possibly present in the bursa could secondarily been triggered by the infection.

A chronic empyema of the ankle joint often develops after an open fracture or surgery. In the case of the destruction of the joint due to an infection, an arthrodesis should be performed. Normally we use an external fixator with two bone-nails placed into the calcaneus and two into the tibia. The arthrodesis is distracted and Septopal is permanently implemented. At 4-6 weeks after surgery the Septopal is removed, with distraction being reduced and a cancellous bone-graft taken from the dorsal iliac crest is performed to fill the bony defect. After bone healing, the external fixator is removed and the patient mobilized in a brace. Initially, weight-bearing is limited to 10 kg but is increased gradually to full weight. The brace is used for 6-9 months; later the patient is mobilized in orthopaedic shoes. In difficult cases, also in combination with a malposition which has to be corrected or a lengthening of the lower limb, we use the Ilizarov fixator. From 1993 to 2003 we performed arthrodeses of the ankle joint due to infectious destruction in 107 cases. In 82.2%, the empyema was caused by a fracture of the ankle joint and the following treatment. In 58% of the patients, we saw associated diseases such as obesity, alcohol abuse, diabetes and malposition of the foot. In 55% we found Staphylococcus aureus. In 86%, we used the external AO-fixator, in 14% the Ilizarov fixator. The patient retained the fixator for an average of 128 days. In our study, 92.1% of the 101 patients who had completed therapy showed a good stability an average of 4.5 years after the arthrodesis. In 5% we found partial stability, while three patients had to be amputated. In 57 patients (56.4), an arthrosis of the tarsal bones was found, and 38 patients (54.3%) of the 70 patients who at the time of the arthrodesis were still working could return to work.

History and Clinical Findings: A 20-year-old patient was hospitalized with persistent high fever after tonsillitis and swelling of the talocalcanean joint., Investigations: The ECG showed a partial right bundle branch block pattern and pathological T inversions on the left precordial leads. Cardiac Troponin I levels were slightly elevated and echocardiography revealed a dyscinetic area at the right ventricular apex. The anti-streptolysin titer was elevated., Diagnosis: Post-streptococcal rheumatic myocarditis. THERAPY AND FOLLOW-UP: Antibiotic therapy for 2 weeks. The patient showed subjective full recovery after 6 weeks. The anti-streptolysin titer further increases. Nuclear spin tomography of the heart reveal postinflammatory alterations at the apex of the right ventricle., Conclusion: Rheumatoid fever is a rare diagnosis in developed countries. This case, however, illustrates that the true prevalence of rheumatoid carditis might be underestimated in the presence of only minimal heart-and joint-specific symptoms.

Septic arthritis of the hip joint is a condition that can often lead to partial or complete destruction of the hip joint, causing severe functional disability. Reports in the literature indicate that optimal management of these patients is unclear. Our report presents a follow-up of 37 patients (44 hips) who had septic arthritis during infancy or childhood. In general, patients at follow-up had a poor anatomical appearance radiographically, although pain and activity restriction were minimal. Results suggest that surgical efforts should be directed primarily at correcting limb length discrepancy and malalignment of the mechanical axes. In general, patients with a hip deformity of type I-III had a good functional outcome, whereas patients with hip deformity type IV with an instable hip joint had an unsatisfactory outcome. Any indication for hip replacement in these patients should be based not only on radiological findings, but also on the functional situation.

The spectrum of clinical manifestations in HIV infection has expanded considerably over the last few years. Several rheumatological syndromes have been associated with HIV infection such as Reiter's syndrome and other reactive arthritides, undifferentiated spondylarthropathy, but also HLA-B27-negative oligoarthritis, myopathy, Sjögren-like syndrome and vasculitis. Systemic lupus erythematosus and rheumatoid arthritis appear to be modified by the HIV infection. Further insight into interactions between HIV infection and these rheumatological syndromes will enlarge our epidemiological and pathogenetical understanding of the complex mechanisms involved. Awareness of such interactions is critical with respect to factors regarding both prognostic and therapeutic implications in the management of HIV infected patients.

We report the first case in the literature of human infection with Rhodococcus erythropolis in an HIV-positive patient. A 24-year-old bisexual flight attendant had severe HIV-associated immunodeficiency with a CD4 cell count of 0.02 G/l. He complained of multiple subcutaneous nodules at different sites on the extremities. Biopsy of one node at his left knee revealed granulomatous inflammation filled with acid-fast rods. These bacteria were identified as Rhodococcus erythropolis. The disseminated infection was restricted to the skin and showed a slow response to long-term therapy with amoxicillin/clavulanic acid. No relapse has been observed more than 6 months after discontinuation of antibiotic therapy. The etiology of a concomitant polyarthritis remains unknown; a relationship with the rhodococcus infection is possible as the arthritis responded well to the antibiotic therapy and did not reactivate after discontinuation of antibiotics. Due to the difficult isolation technic, this pathogen may be overlooked in routine diagnostic procedures. The implications in clinical practice are discussed.

A 12-year-old boy with severe hemophilia A fell ill with high fever and painful swelling of joints. There was a delay of four days in the diagnosis of septic arthritis. The course of the disease shows some important distinguishing criteria, speaking in favour of septic arthritis: 1. longlasting temperature above 39 degree C; 2. an elevated peripheral leukocyte count; 3. increasing complaints despite normalisation of the coagulation defect.

It is reported about the results after operative mobilization of knee joint in 19 patients with contractures of extension muscles of knee joints. After operative arthrolysis and/or Payr-Plasty the range of motion has increased on average from 23 degrees to 92 degrees (a relative gain of 52%). Patients with traumatic knee contracture of extension muscle achieved an improvement in the range of movement on average by 76 degrees, whereas those with contracture due to infection improved on average by only 43 degrees. The etiology, the duration, and the preoperative loss of movement are important for success of treatment.

Among 2369 children who had been admitted and treated in the Rheumatic Children's Hospital Garmisch-Partenkirchen between 1952 and 1979 under the diagnosis "juvenile chronic arthritis (JCA)" or, "collagenosis", there were 244 patients (= 10.3%) for whom in the end a different diagnosis was set. The major part of these children suffered from arthritides where there was proof of a direct or an indirect connection with bacterial infections or where there existed a corresponding suspected diagnosis (altogether 162 out of these 244 children, = 66.4%). The remaining 82 cases differentiated into 26 further diagnoses with various frequencies. Our examinations show that six criteria are found relatively frequently in arthropathies not caused by juvenile chronic arthritis. These require special consideration in the differential diagnosis: oligoarthritic onset of the disease, high fever - especially septic intermittent fever, erythema nodosum, endomyocarditis, no (or only very slight) functional resp. morphological changes of the joints.

Between 1971 and 1976 clinical and chemical examinations of 165 joint fluids in 149 patients were made. The comparison of clinical findings and results of laboratory tests lead us to distinguish between inflammatory and non-inflammatory joint fluids. The reported tests are simple and results can be given quickly. We do not know of any literature on the incidence of CHE in joint fluids. It seems to be of considerable importance that there is a correlation between the degree of CHE-activity and the degree of cartilagenous lesions. As far as we know no comparative tests on Caeruloplasmin in the serum and in the synovial fluid have been made. The quantitative measurement of uric acid in the synovial fluid is more efficient than other methods. The reported methods simplify the differential diagnosis of synovial fluid effusions.

Medical complications of heroin overdose and the diseases of addicts play an increasingly important role in the daily routine of hospital medical departments. The percentage of drug-related admissions to the Medical Clinic of the University Hospital, Zürich, increased from 0.18% to 4.45% between 1972 and 1983. During this 12-year period, 492 patients were admitted 569 times because of heroin overdose or intoxications combined with other drugs, and 191 drug addicts were hospitalized 226 times for a variety of medical problems. Certain complications, such as heroin pulmonary edema and talc granulomas of the lung, occur only in parenteral drug addiction. Other diseases such as right heart endocarditis, Candida-endophthalmitis, septic arthritis and osteomyelitis are almost exclusively observed in intravenous drug abusers. Sexually transmitted infections and hepatitis B are frequently diagnosed in addicts.

Yersinia arthritis is an acute oligo- or, more rarely, polyarthritis. It occurs after pyrexic diarrhoea of several days, often associated with right-sided lower abdominal pain. The disease is caused by Yersinia enterocolitica and four such cases, confirmed serologically in three, are described. In one case fluid from the knee-joint was antibody-positive. It was not possible to culture the causative organism, probably because all patients had previously been treated with an antibiotic. Rheumatic fever and Reiter's disease must be considered in the differential diagnosis. Because pharyngitis, transitory ECG changes and conjunctivitis may occur in the early stages of Yersinia arthritis, the diagnosis may be missed. Prognosis of Yersinia arthritis is good, with complete cure within weeks or months. Demonstration of HLA-B 27 in all four cases points to a genetic disposition.

One hundred and twenty one Baker cysts demonstrated by arthrography have been analysed. Morphologically one must distinguish between distension cysts and dissection cysts. Distension cysts are more common with various diseases of the knee joint (68% of all cysts). Dissection cysts (32%) are found particularly with inflammatory-rheumatic diseases and are rarely of degenerative or post-traumatic origin. Acute rupture of the cyst was observed on ten occasions. Repeated rupture, which had only been suspected previously, was demonstrated by arthrography in four patients. It is pointed out that Baker cysts may imitate the features of acute thrombophlebitis.

Two cases are reported of toxic shock syndrome in patients with pyogenic arthritis due to Staph. aureus with proven production of enterotoxin F and pyogenic exotoxin C. An ischemic complication of both lower extremities in one of the patients may be related to the use of a heparin-dihydroergotamine combination for postoperative prophylaxis of deep vein thrombosis.