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Thirteen cases (in twelve patients) of septic arthritis complicating rheumatoid arthritis are reported. One ankle, one metacarpophalangeal joint, one shoulder, and ten knees were involved. Staphylococcus aureus was cultured from twelve joints and Escherichia coli , from one. Treatment consisted of repeated needle aspirations in two patients, arthrotomy with Penrose drainage in six, and arthrotomy with through-and-through irrigation in four. Needle aspiration was the least effective therapy. The authors recommend as the treatment of choice: systemic antibiotic therapy and immediate arthrotomy followed by through-and-through irrigation with fluid containing the appropriate antibiotics.

A patient who had systemic lupus erythematosus developed an acute synovitis symptomatically resembling septic arthritis: however, the synovial effusion was chylous, a unique occurrence. Significant differences, quantitatively and qualitatively, between the lipids of the blood and those of the synovial fluid suggested the possibility of synthesis of the lipids in synovial tissues.

A patient with septic arthritis of the knee due to a nonencapsulated strain of Cryptococcus neoformans neoformans is reported. Predisposing factors included repeated trauma and sarcoidosis. Serologic tests and pathologic examination were consistent with the mutant strains recovered from infected tissue. The organism was eradicated by combined synovectomy and chemotherapy with amphotericin B and 5-fluorocytosine. The significance of capsular material is discussed. To our knowledge this is the first reported example of human infection caused by a nonencapsulated C neoformans.

Six hundred patients from a Washington, D.C. population of 20,000 heroin addicts were admitted to D.C. General Hospital between November 1967 and April 1971. Bacterial endocarditis was found in 50 of them (8 per cent). The presenting features were fever (50 patients), pulmonary embolism (32 patients), positive blood cultures (39 patients), subcutaneous abscesses (2 patients), empyema (1 patient), septic arthritis (1 patient) and pericardial effusion (1 patient). The tricuspid valve alone was involved in 36 patients (72 per cent) and with other valves in 6 patients. Staphylococcus aureus was found in 28 patients, Streptococcus viridans in 4 and Streptococcus faecalis in 3. There was an over-all mortality rate of 28 per cent but pure right-sided lesions were found in only 16 per cent (6 of 38 patients). Attention to the auscultatory features of acute tricuspid regurgitation was the predominant factor leading to early diagnosis.

Over a seven-year period, seventy-two patients were diagnosed as suffering from periodic disease; twenty-two of these showed joint involvement. In all patients the disease started in childhood or adolescence. All suffered recurrent attacks of abdominal pain associated with fever. Joint symptoms were caused by a monoarticular arthritis, often with synovial effusion. Recurrent attacks in the same joint were common. Unlike the abdominal attacks, which were of short duration, the joint symptoms were commonly prolonged. Misdiagnoses were common. Seven patients were treated for long periods for atypical rheumatic fever and in two cases the diagnosis was acute septic arthritis. Joint involvement proved transitory and in twenty of the twenty-two cases there was no permanent damage. Biopsy of the synovium showed a non-specific synovitis. It is emphasized that a history of monoarticular arthritis, associated with attacks of fever and abdominal pain, points to the diagnosis. There are no specific laboratory aids and the diagnosis is a clinical one.

1. Septic arthritis of the hip in adults is not common and the diagnosis can be difficult. The value of diagnostic aspiration is emphasised. 2. Predisposing causes in fifty patients are analysed and the possible relationship to pelvic infection is discussed. 3. Loss of joint space is occasionally seen within one week of the onset of the infection. 4. A method of treatment is suggested and the value of decompression by arthrotomy is discussed.

1. Two cases of pseudogout are described with an onset acute enough to be mistaken for septic arthritis. 2. The radiological and laboratory investigations for diagnosis are described.

Fourteen patients with septic arthritis superimposed on a variety of conditions have been reported. Physical examination of joints produces diagnostic suspicion, and joint paracentesis produces dia...

In 1966 we published our experience with 117 cases of septic arthritis seen on the pediatric services of Parkland Memorial Hospital and Children's Medical Center in Dallas. That review brought to attention the hitherto unrecognized frequency of Hemophilus influenzae in this disease and, by emphasizing the wide variety of bacteria involved, tried to make the point that precise bacteriological diagnosis was essential to optimal therapy. This follow-up report of 221 patients adds the 104 patients treated from 1966 through 1970 to the previous series. The tabular material is arranged in the same manner as in the report covering the years 1955 through 1965 for easy comparison. (Tables I to IV) This analysis excludes patients with joint involvement secondary to osteomyelitis except for the unique situation of septic hip in which it is difficult to determine whether joint infection or bone infection is the primary event. The average number of cases per year has steadily risen but this appears to reflect mainly the even-enlarging medical population served rather than a real increase in frequency of septic arthritis. For example, total pediatric admissions rose by 32% from 1960 to 1970 while septic arthritis cases increased 46%. 1955-59: 6.4 cases per year 1960-65: 14.2 cases per year 1966-70: 20.8 cases per year A bacteriological diagnosis was established in 66.5% of cases overall (Table I) but the figure is higher during the past decade when the quality of diagnostic bacteriology was improved. 1955-59: 34% 1960-65: 71% 1966-77: 73% Part of the improved percentage of bacteriological diagnosis stems from better use of blood cultures.

Fifty-two cases of nontuberculous purulent arthritis seen at the Tobey Hospital during a 16 year period following the introduction of antibiotic therapy were reviewed. The clinical picture was found to be a consistent one with only one or two joints involved. There was usually high fever, leukocytosis, and severe pain, tenderness, and swelling of the involved joints. Early arthrocentesis with attempts to isolate the causative organism is important. Although antibiotic therapy has virtually eliminated the mortality from septic arthritis, significant residual disability occurs, especially when the hip is involved. Methods to facilitate early diagnosis and treatment are discussed.

One year after renal homotransplantation, a patient developed gingival ulcers infected with Serratia marcescens. Serratia bacteremia followed and insidious septic arthritis of four large joints then required surgical drainage and systemic gentamicin to eradicate the infection. Vigorous surgical and antibiotic therapy is recommended in this condition. The apparent association of avascular necrosis and infection is once more noted.

Therapeutic concentrations of antimicrobial agents in infected joints during systemic therapy were demonstrated in 29 patients by measuring synovial fluid antibacterial activity. Antimicrobial agents used were penicillin G, phenoxymethyl penicillin, nafcillin, cephaloridine, tetracycline, erythromycin and lincomycin. Passage of antibiotic into synovial fluid was evaluated in simultaneously collected serum and synovial fluid specimens by two methods: a) a tube-dilution procedure for antibacterial liter of the two fluids against the microorganism recovered from the joint or a suitable laboratory species and b) a bioassay test of antibiotic concentration. In general, the bioassay results closely supported the information obtained by tube-dilution antibacterial activity determination. Demonstration that effective concentrations of an antibiotic are present in an infected joint during systemic therapy obviates the need for local instillation of drug into the synovial space. Since passage of antimicrobial agents into synovial fluid during systemic therapy can be reliably established by the more simple tube-dilution method, every patient with septic arthritis should be monitored by such determinations during the course of therapy.

1. A review of the literature has revealed that only two cases of an acute septic arthritis caused by Clostridium welchii have been reported. Both of these infections involved the knee. 2. Two new cases of an acute septic arthritis of the knee due to Clostridium welchii are discussed. 3. The varied clinical manifestations of Clostridium welchii as reported in the literature are briefly discussed. 4. It was observed that, in an acute septic arthritis due to Clostridium welchii , the local and systemic findings were of the nature and magnitude expected with any pyarthrosis due to more common organisms. Also, there was apparently little or no cartilage destruction with subsequent excellent functional recovery. 5. The primary purpose of this paper has been to establish Clostridium welchii as a possible cause of an acute septic arthritis.

The case reports of five patients with sepsis, localizing in the hip joint, are presented. The age of onset was before 30 days of age. The weights at birth were in the premature range in three, normal in two; the first clinical sign was swelling of the region of the hip and thigh. The organisms were coagulase positive staphylococci in three cases, unknown in two cases. The differential diagnosis included cellulitis, trauma to the hip, and septic arthritis with abscess formation. Poliomyelitis, cancer, toxic synovitis and osteomyelitis of the femur were considered. Roentgenograms have been selected to show the slightness of the changes at onset, and the changes at 1, 5, and 12 years of age. Treatment should include general supportive measures, including administration of blood and nutritive elements, antibiotics and early drainage of the joint to prevent permanent damage of the head of the femur. This condition must be suspected in every instance of regional swelling of the hip in the newborn infant. Such swelling is an urgent indication for diagnostic aspiration of the joint.

Sixteen cases of suppurative arthritis of the hip in fifteen infants who had had femoral venipunctures are reported. Twelve of the fifteen infants had neonatal jaundice. Although bacteriological evidence to prove the causal relationship between the venipuncture and hip-joint sepsis was not available, the circumstantial evidence was strongly suggestive. The findings in this study emphasized that the diagnosis of acute septic arthritis in the acutely ill infant is still frequently missed and that failure to make a prompt diagnosis results in irreparable damage to the hip. It was concluded that femoral venipuncture should be avoided so far as possible and that any infant who has had femoral venipuncture should be closely observed for evidence of septic arthritis of the hip and septicemia.

INFECTIONS due to Hemophilus influenzae type B occur frequently in children. Infection in adults is uncommon and usually associated with lowered resistance as in agammaglobulinemia, diabetes mellitus, alcoholism, nephrotic syndrome, and trauma. 1 The low incidence to infection in the neonate is due to passive transfer of antibody, 2 in the adult previous contact gives rise to specific antibody. The H influenzae type B causes meningitis, 3 pneumonia, 4,5 endocarditis, 6-8 pericarditis, 9 laryngitis, 10 or septic arthritis. There are six previous reports of septic arthritis (Table 1). The present study reports two additional cases, one associated with hypercalcemia. Report of Cases Case 1. —First Admission. —A 37-year-old single, Negro trashman was admitted to Strong Memorial Hospital on Oct 13, 1964, because of pain in the right hip. Thirty days before while the patient was at work his right ilium was struck anteriorly by a garbage can as he negotiated a narrow passageway. He had immediate pain

A case of vibriosis in man is reported from the State of Missouri, where Vibrio fetus infection in cattle is widespread. Case summaries of twenty-nine additional reports apppearing in the world literature are presented. The bacteriologic and serologic characteristics of Vibrio fetus are discussed. Since the morphologic characteristics can only suggest a spirillum or vibrio organism, serologic and biochemical identification of the organism is needed before a definitive diagnosis can be established. The epidemiology and incidence of Vibrio fetus infection in man is unknown but is believed to be more prevalent than is reported in the medical literature.

A technique for arthrodesis of the knee, using two eight-inch stainlesssteel plates applied to the anterior and medial aspects of the femur and tibia at 90 degrees to each other, is presented. The procedure has been used successfully on four knees with neurogenic arthropathy secondary to tabes dorsalis, three knees with old septic arthritis, two knees with tuberculous arthritis, three knees with post-traumatic arthritis, as well as four knees with rheumatoid arthritis, one knee with a segmental resection of the proximal end of the tibia for giant-cell tumor, and one knee with degenerative arthritis. There was only one failure, and this knee went on to solid fusion after a second plating procedure. External support was seldom required, and walking with crutches shortly after operation was possible in most instances, with partial weight-bearing usually permitted by three months and full weight-bearing after six months. The method described makes it possible to preserve maximum length and even to bridge defects; it assures arthrodesis in the optimum position with minimum hospitalization. Of the eighteen cases reported, removal of the plates was subsequently performed in five instances.

Summary Six cases of septic osteomyelitisand arthritis in infancy are reported. Four of these occurred in the neonatal period, and the other two were under 8 months of age. Four males and two females were affected. In four of this series, the patients were followed up for three years, and these showed excellent functional recovery. All these patients were submitted to intensive penicillin therapy as soon as possible.

The authors believe that the radical excision of diseased bone and of the ischaemic and fibrosed soft tissue, the immediate covering of the defect created with a split-thickness skin graft, and, when necessary, the subsequent filling of the defect with bone covered with a pedicle skin graft constitute the best treatment for chronic infection of bone. While these procedures obviously are not advocated as a routine treatment for joint tuberculosis or septic arthritis, it is believed that their usefulness in certain of these cases has been demonstrated.

A case of septic arthritis due to Vibrio fetus is presented. This rare human infection occurred in a knee joint with a background of old and recent trauma. Treatment by repeated joint aspirations plus administration of parenteral penicillin and streptomycin had little effect on control of the infection until ampicillin was added to the regimen. After surgical removal of an old corroded screw and washer, recovery was uneventful and return of function was complete.

1. 1. Two strikingly similar cases of mycotic aneurysm of the abdominal aorta, with rupture, are reported. The primary focus in both was septic arthritis caused by the Str. hemolyticus . The diagnosis was made ante mortem in one of the cases. 2. 2. Two rare cases of saccular aneurysms of the abdominal aorta, due to atheromatous degeneration in association with tuberculous cold abscesses, are presented. 3. 3. Three cases of malignant tumor of contiguous structures affecting the aorta are described. In two similar cases, the process was an epidermoid carcinoma of the esophagus; in the third, it was a reticulum-cell sarcoma. Secondary infection occurred in both cases and was the immediate cause of death in the third case.

Three cases of children with retroperitoneal abscess which appeared to be septic arthritis of the hip have been presented. The clinical characteristics of fourteen cases of retroperitoneal abscess have been compared with those of twenty cases of septic arthritis of the hip. Also, the usefulness of testing hip motion, aspirating the hip joint, examining the rectum, and viewing abdominal roentgenograms has been described.

A review of 117 cases of septic arthritis in infants and children revealed that the concept of staphylococci and streptococci as the major etiologic organisms should be modified to stress the frequency of Hemophilus influenzae in the 6-month to 2-year age bracket and to emphasize the variety of bacteria that must be anticipated in individual cases. Suggestions are made for increasing the frequency of bacteriologic diagnoses and for initiating the antibiotic therapy of patients with septic arthritis based upon age groups and observations of bacterial stains of joint fluid.

Seven bacterial species causing septic arthritis and infection of prosthetic joints (Staphylococcus aureus, coagulase-positive; Staphylococcus albus, co-agulase-negative; Streptococcus pyogenes, group A; Pseudomonas aeruginosa; Diplococcus pneumoniae; Neisseria gonorrhoeae; and Hemophilus influenzae, type b) were exposed in vitro to three common arthrographic contrast materials for 30 minutes. Quantitative cultures showed no significant inhibition of bacterial growth, compared to controls. All strains except D. pneumoniae and N. gonorrhoeae grew after contact with contrast media for up to 72 hours. Thus, arthrography with the tested contrast agents is not expected to interfere with the culturing of bacteria from subsequently aspirated specimens.

The disease in question is known by a number of names, such as "joint evil," "joint ill," "rheumatism," "pyosepticemia of sucklings," "pasteurellosis neonatorum," "....navel ill," "omphalophlebitis septica," "pyemic and septic joint disease of sucklings" and "septic arthritis." Septic arthritis is an infectious disease of new-born animals, found most commonly in young colts. The disease is quite common in this and foreign countries and spreads rapidly in large stables, abounding in soiled bedding and where aseptic precautions are unheeded. In this territory, infectious arthritis is often found associated with colts that come alive in a stud of mares afflicted with infectious abortion.

In a 63-year-old Negro male, septic arthritis developed in the right knee (already the site of advanced degenerative changes) after an upper respiratory infection. The causative organism was identified as Hemophilus influenzae only after the fluid aspirated from the knee was inoculated into chocolate-agar under CO2, four days after admission to the hospital. Re-accumulated fluid was aspirated repeatedly from the joint. Antibiotics were administered intra-articularly, intravenously and later orally. The patient also was treated symptomatically and with physiotherapy. He recovered satisfactorily to the point of being able to walk with crutches, and left the hospital eight weeks after admission.

In a patient with an exacerbation of systemic lupus erythematosus with neurological involvement, Serratia species septicemia developed. This responded to appropriate treatment. However, septic arthritis of the left hip with the same organism subsequently developed and required surgical debridement and removal of the left femoral head. The rarity of arthritis due to Serratia species is noted and the possible role of multiple femoral artery punctures contributing to the pathogenesis of this unusual complication of septicemia is discussed.

When one joint is affected, trauma or septic arthritis may be incorrectly identified; in polyarticular disease, the principal confusion is with acute rheumatic fever. Dr. Fink outlines a variety of techniques available to assist in the differentiation of rheumatoid from other arthritides in children and calls for a team approach to the variety of long-term problems involved in managing these cases.

A five-year review of group B β-hemolytic streptococcal infections of infancy was made to determine the spectrum and incidence of disease caused by this organism. Seventy-one infants with streptococcal disease were seen from 1969 through 1973. The incidence of streptococcal disease increased significantly in 1973, while the rate of Escherichia coli disease was unchanged during the five-year period. Twelve (17%) of the 71 infants showed unusual or previously unrecognized forms of group B streptococcal disease: asymptomatic bacteremia in four infants, septic arthritis in three infants, and osteomyelitis, ethmoiditis with orbital cellulitis, pneumonia with empyema, facial cellulitis, and conjunctivitis in one infant each.

During 12 selected years between 1935 and 1972, Haemophilus influenzae was grown from cerebrospinal fluid of 79 patients with meningitis and from blood of 72 others without meningitis. The vast majority of strains identified serologically were type b. Haemophilus parainfluenzae was identified in one additional case in each category. Most (85%) of the patients with meningitis were less than three years old; four were adults. Mortality associated with influenzal meningitis declined to a very low rate after the introduction of broad-spectrum antibiotics. Cases of bacteremia due to H. influenzae without meningitis increased after 1957. In infants and children, such cases were associated most frequently with pneumonia or tracheobronchitis and cellulitis, and also with otitis, epiglottitis, and septic arthritis; the rate of mortality was low, except in patients in the first six months of life. In adults, the focus of bacteremia due to H. influenzae was either the respiratory tract or not determined, and mortality was > 50%.

The rare occurrence of septic arthritis due to Hemophilus influenzae in an adult with systemic lupus erythematosus is reported. The clinical presentation mimicked disseminated gonococcemia with associated gonococcal arthritis. The features of this case as well as other bacterial infections known to cause confusion with gonococcal arthritis are reviewed, and the clinical and laboratory characteristics of septic arthritis caused by H influenzae are described.

Fifty-four postirradiation arthropathies were found among 536 patients with radiation-induced osteodysplasias. There were three main types of joint changes: degenerative arthrosis, inflammatory arthritis, and ankylosis. Degenerative arthropathy was the most common. Degenerative and necrotic changes occurred in the cartilage, joint capsule, and bones in the vicinity of the joint. A slowly progressive septic arthritis occurred in some patients, due to infection by bacteria of low virulence. This arthritis led ultimately to ankylosis or amputations. Like bones, joints must be considered to be radiosensitive and their resistance to various insults, especially bacterial infection, is lessened after radiation damage.

Two cases of infective arthritis of the right hip due to Crohn's fistulas are presented. These cases may present to the orthopaedic surgeon and require fairly radical surgical treatment.