Infections of muscle, bone and joints.

Y3S2 13/3/2013 Dr. Champa Ratnatunga Department of Microbiology Faculty of Medicine

Objectives
List infections of the musculoskeletal systems. Explain the pathogenesis of osteomyelitis, septic arthritis and infections of muscles. Describe the methods of collection and transport of samples for microbiological diagnosis Outline the principles of treatment and prevention.

Infection of muscle
Bacterial infection
tropical pyo-myositis Staphylococcus aureus Hx- Strenuous activity, muscle trauma, skin infections, infected insect bites, illicit drug injections, connective tissue disorders, diabetes C/F - Fever, malaise, MYALGIA

Psoas abscess - Subtle symptoms fever, flank and hip pain; May manifest as pyrexia of unknown origin.
- cause-

Ix Pus for Gram stain, culture and ABST

FBC, ESR/, .. Rx Drainage of abscess
- IV Antibiotics depending on ABST (empirical treatment depends on history)

Viral infections of muscle

Myocarditis
Coxsackie B virus Coxsackie A, other Enteroviruses, Mumps, Rubella, Influenza, Dengue,( Mycoplasma sp.)

C/F ECG changes, elevated Troponins. Myositis Influenza myositis Childhood form-Fever, malaise, and rhinorrhea followed 1-7 days later by severe pain, Muscle pain worse with movement, especially with walking Symptoms of myositis - Generally last 1-7 days Adult form - Fever, myalgias, generalized weakness

 Acute coxsackievirus myositis Group A virus infection - Myalgias, weakness Group B virus infection - Causes epidemic pleurodynia (Bornholm disease or epidemic myalgia), (considered a form of myositis) acute, febrile disorder with abrupt onset of pain in the abdomen or lower thoracic region. Pain is worse with movement, breathing, or coughing. Virus spread by contact. Usually self limiting. Rx- pain relief.

 Ix viral IgM and IgG levels depending on availability (rising titres required in some infections) Treatment
bed rest, intravenous fluids if required symptomatic management with antipyretics and analgesics.

Other causes
Dengue fever Chikungunya HIV polymyositis Rickettsial infections Parasitic infections
Trypanosimiasis Trichinosis Toxoplasmosis cysticercosis

Necrotizing fasciitis
Life threatening bacterial infection Necrosis of fascia, overlying skin and vasculature Causes group A haemolytic streptococci S aureus, Pseudomonas , E coli, Clostridium spp. monomicrobial or polymicrobial Hx- minor trauma such as contusion, insect bite, frostbite, chronic leg ulcer, or a surgical incision, P/C- severe pain and edema . Cellulitis (skin changes appear late). Quickly spreading erythema, ecchymosis with vesicles enlarging to purple bullae. Necrotizing soft tissue infections -

Mx- early diagnosis, early administration of broad-spectrum antibiotics, and rapid surgical debridement should be performed as soon as NF is identified to arrest the infection process IV Clindamycin with anaerobic and gram negative and positive cover till causative organism is known.

Osteomyelitis
Infection of bone If dead bone present - chronic OM Hx - trauma, surgery, foreign bodies, prosthesis Direct infection / contiguous spread from local site of infection/ trauma Haematogenous spread - Septicaemia Children seeding of long bone metaphysis relatively common Adults vertebral OM

Acute osteomyelitis
Children - S aureus - most common pathogen Adults (vertebral OM) S aureus / E coli Dental extraction associated with Streptococcus viridans infections . Acutely - fever, chills, swelling, and erythema over the affected area. Adults- usually minimal constitutional symptoms and pain.

Chronic OM few symptoms, dull chronic pain, mild swelling, discharging sinuses. -most common form in adults.

..

 Post traumatic osteomyelitis

commonly affects adults and typically occurs in the tibia. local soft-tissue vascularity may be compromised, leading to interference with healing. The most common isolated organism is S aureus. infection begins outside the bony cortex and works its way in toward the medullary canal. Low-grade fever, drainage, and pain may be present. Loss of bone stability, necrosis, and soft tissue damage may lead to a greater risk of recurrence

 Diabetes mellitus
- Vascular compromise. - Predisposed to osteomyelitis because of inadequate local tissue response. - Infection is most often caused by minor trauma to the feet with multiple organisms isolated from bone, including Streptococcus species, Enterococcus species, coagulase-positive and -negative staphylococci, gramnegative bacilli, and anaerobic organisms

Image in a 56-year-old man with diabetes shows chronic osteomyelitis of the calcaneum. Note air in the soft tissues.

Osteomyelitis, chronic. T1- and T2-weighted sagittal MRIs show bone marrow edema in L1 and obliteration of the disk space between L1 and L2 Potts disease -

 Investigations
Blood cultures - positive in only 50% of cases of osteomyelitis. Useful in children Bone biopsy leads to a definitive diagnosis by isolation of pathogens directly from the bone lesion- should be performed through uninfected tissue X-ray Rx antibiotics depend on organism and ABS pattern. Usually require long duration of therapy. Surgical treatment may be required.

Joint infections
Septic arthiritis Reactive arthritis -

Septic arthritis
Normal joints and Prosthetic joints

Normal joints (including joints with other diseases; eg-osteoarthritis) - Staphylococcus aureus infection- cause of majority of cases in adults and in children older than 2 years.
Many other organisms can cause infection. Therefore micrbiological diagnosis is a MUST! Hx - trauma, infection, interventions, immunesupression,

 Ix

Rx

Prosthetic joint infection.

Three major types of prosthetic joint infections exist:
(1) those that occur early, within 3 months of implantation S aureus (2) those that are delayed, within 3-24 months of implantation -coagulase-negative S aureus (CoNS) and gramnegative aerobes (3) those that occur later than 24 months following the implantation. Most cases of early and delayed infections are acquired in the operating room. Late cases of prosthetic joint infection are secondary to heamatogenous spread from various infectious foci

 The biofilm of coagulase-negative S aureus (CoNS) protects the pathogen from the host's defenses, as well as from various antibiotics Overall, the most common organisms of prosthetic joint infections are CoNS and S aureus . Other causes - Enteric gram-negative bacteria, streptococcal spp (GABS),Anaerobes
Prevention ..

Reactive arthritis
Auto-immune disease. Gastrointestinal pathogens associated with reactive arthritis include the following: Salmonella enteritidis Salmonella typhimurium Yersinia enterocolitica Campylobacter jejuni Clostridium difficile Shigella sonnei Entamoeba histolytica Cryptosporidium A reactive/postexposure process may occur months after the gastrointestinal or genitourinary process has resolved.

Post infectious arthritis (Reiters syndrome)

Follows sexually transmitted disease or GI disease Occurs a few weeks (1-5) after the acute infection Most common peripheral inflammatory arthritis in young men in some countries Associated with HLA B27 histocompatibility antigen Arthritis associated with skin and mucosal lesions
Uveitis, bilateral conjunctivitis, keratitis Skin lesions keratoderma blenorrhagia Circinate balanitis Painless erosions on tongue (arthritis, urethritis, conjunctivitis)

Reiters syndrome
A 30 year old man had recurrent attacks of urethritis, arthritis and conjunctivitis. He had a rash on the soles of his feet and lesions on his glans penis.

Urethritis Keratoderma blenorrhagia Circinate balanitis

Summary.
Pyo-myositis . Myocarditis ..... Myositis- .. Acute OM-.. ................................................... DM- Chronic OM- .. Septic arthritis- .. PJI-. Ix

 Emedicine / medscape

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