Septic arthritis can be defined as the inflammatory joint illness that occurs due to pathologic inoculation of the micro-organism in the joint and joint space. The pathogenesis of this medical condition is multifactorial and directly depends on the interaction amongst the microorganism, host immune response; toxins, immune-avoidance strategies of the pathogen; and adherence factors (Ross, 2017). This presentation will cover the clinical manifestation of “Septic Arthritis”. Further, the pathogenesis causing the clinical manifestations interlinked with the case of Mr D'Souza.
Mr D'Souza is an 83- years-old male patient and presented to the hospital with the chief complaint of pre-syncopal episodes. On examination, he presented with the painful, swollen and malaise knee. Moreover, as per his past medical history, he was suffering from rheumatoid arthritis since he was 18 years old. Further, examination revealed that he had limited right knee movement and had pain score 8/10. His temperature, respiratory rate, blood pressure and heart rate were 38.7 degrees Celsius, 22breath/minute; 90/50mmHg and 120bpm respectively. Additionally, he had deformities of the wrist, metacarpophalangeal and proximal interphalangeal joints. Based on his clinical sign and symptoms, the provisional diagnosis was "septic arthritis of the Right knee”.
Preferably, the diagnosis of the septic arthritis is made based on the bacterial detection in the synovial fluid. Though the clinical sign, symptoms and through history aids in the diagnosis of septic arthritis. In the present case, the diagnosis had been made based on the clinical presentation of the patient. In accord with the literature, person with septic arthritis present with a week history of painful, restricted joint, and redness (Long et al., 2019). Some factors, like, a low virulence factor of causative agents can delay the clinical presentation. In the present case scenario, Mr D'Souza had presented with the painful, swollen and malaise knee. The clinical features of the patients are similar to the discussed clinical manifestation of septic arthritis. Moreover, in approximately 58 per cent of the patient presented with the fever (temperature more than 39 degree Celsius), though the absence of high temperature must not be relied on to eliminate the diagnosis; yet, more than 90 per cent of the people shows mild-low grade fever (body temperature more than 37.5 degree Celsius). In the existing case, the patient had a low-grade fever (Daynes et al., 2016).
A person with septic arthritis has various risk factors. For instance, a patient suffering from rheumatoid arthritis are at high risk of developing septic arthritis because of immunosuppression, poor skin, and joint damage. Rheumatoid arthritis intricate by septic arthritis usually associated with high mortality and morbidity rate. Other hazardous factors are associated with the infection route, including contiguous spread (abscess), direct inoculation (trauma) and hematogenous route (IV drug use). Mr D'Souza had a medical history of rheumatoid arthritis, therefore it can be considered as the risk factor for the development of septic arthritis in the present case (Long et al., 2019).
All bacterial organisms have been reported to associate with septic arthritis. Though, the micro-organism responsible for the cause of septic arthritis depends on the host factor. Staphylococcus aureus is the most common causative organism associated with acute nongonococcal septic arthritis. Another organism can be associated with the septic arthritis are streptococcus, Proteus, E.coli. The bacteria and or any other micro-organism can gain entry inside the joint through haematogenous route, direct inoculation (through aspirational injection surgery and direct trauma) and direct spread from the adjacent focal infection (Infection from the osteomyelitis and inflamed articular surfaces) (Mohammad et al., 2020).
The synovial membrane does not have any restrictive basement plate under the synovium; therefore hematogenous entry of the micro-organism is easy. Bacteria can gain entry inside the joint through direct inoculation and/ or from the infectious site. After gaining the entry inside the joint, the bacteria are seeded. Further, the bacteria get to adhere to the joint surface as there is little fluid sheer. Colonization is also aided in the condition where the joint has a recent injury incident due to production of fibronectin (aids in the bacterial attachment). Subsequently colonization, the bacteria proliferate rapidly and active the host’s acute inflammatory reaction, for instance, secretion cytokines, including interleukin 6 and 1-β by the synovial cells in the synovial fluid. Further, interleukin activates the production of C-reactive protein that binds to the pathogen cells and promotes complement system activation and opsonisation. Moreover, humoral and T-cell mediated immune responses aids in clearing pathogens. Cytokines lead to dilatation of the blood vessels at the injection site to allow adequate blood flow with the mediators to the infection site. With the systematic response, the blood vessels dilate and lead to hypotension therefore, in the present case; Mr D'Souza had blood pressure 90/50 mmHg that indicates hypotension (Pathan & Inman, 2019).
The acute inflammatory reaction is characterised by five cardinal signs: redness, pain, swelling, functional loss and increased heat. Therefore, in the present case, the patient had presented with the painful, swollen and malaise knee. Redness and swelling are because of the amplified blood flow and accumulation of the fluid in the inflamed area. Further, the body tries to kill the pathogen by raising the body temperature; therefore the patient develops a fever in septic arthritis. Further, tachycardia and tachypnea are a common response of the host towards the infection. Inflammatory mediators released in response to the pathogens leads to stimulation of the ventilatory centre and causes a high respiratory rate (more 20 bpm) to compensate the metabolic acidosis. In the present case, the patient had developed a high heart rate and respiratory rate (due to the release of inflammatory mediators in response to pathogens (Hotchkiss et al., 2016).
When the infection not cleared by the host then stimulation of the immune system leads to the production of the reactive oxygen species and cytokines, which causes joint destruction. Further, the joint is damaged due to bacterial toxins and lysosomal enzymes. If septic arthritis left untreated then the infection can spread to the underlying tissue and bone and leads to the formation of sinus and abscess. Moreover, the healing can occur with complete resolution, joint fibrosis, partial loss of the articular cartilage and bony destruction. Therefore, patients with septic arthritis develop the restricted movement of the infected joint. Mr D’Souza had limited right knee movement and deformities of the wrist, metacarpophalangeal and proximal interphalangeal joints (Nair et al., 2017).
It can be concluded that the patient's sign and symptoms were indicative of septic arthritis. The patient was presented with a typical sign of septic arthritis. The sign and symptoms are directly linked with the pathophysiology of the disease. Redness, pain and warmth felling is due to the entry of the bacteria inside the joint space and activation of the immune system of the host. Swelling occurs in the joint area due to pus formation and accumulation. Restricted movement is due to joint fibrosis and ankylosis during the healing stage.
Daynes, J., Roth, M. F., Zekaj, M., Hudson, I., Pearson, C., & Vaidya, R. (2016). Adult native septic arthritis in an inner city hospital: effects on length of stay. Orthopedics, 39(4), e674-e679.
Hotchkiss, R. S., Moldawer, L. L., Opal, S. M., Reinhart, K., Turnbull, I. R., & Vincent, J. L. (2016). Sepsis and septic shock. Nature reviews Disease primers, 2(1), 1-21.
Long, B., Koyfman, A., & Gottlieb, M. (2019). Evaluation and management of septic arthritis and its mimics in the emergency department. Western Journal of Emergency Medicine, 20(2), 331.
Mohammad, M., Hu, Z., Ali, A., Kopparapu, P. K., Na, M., Jarneborn, A., ... & Pullerits, R. (2020). the role of Staphylococcus aureus lipoproteins in hematogenous septic arthritis. Scientific reports, 10(1), 1-11.
Nair, R., Schweizer, M. L., & Singh, N. (2017). Septic arthritis and prosthetic joint infections in older adults. Infectious Disease Clinics, 31(4), 715-729.
Pathan, E., & Inman, R. D. (2019). Pathophysiology of Reactive Arthritis. In Infections and the Rheumatic Diseases (pp. 345-353). Springer, Cham.
Ross, J. J. (2017). Septic arthritis of native joints. Infectious Disease Clinics, 31(2), 203-218.
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