Septic Arthritis and Arthrocentesis

A 33 y/o male comes to the ED for fever, knee swelling and pain.
He has a history of joint surgery because of trauma, and prothesis, dating 4 years before.
He is HIV positive
He presents feverish (38°C), the left knee is swollen and hot.
WBC 34.000/μL, CRP 109 mg/L, PCT 0,05 ng/mL.
As we have seen in previous post, history, clinical examination and serum test are not useful to rule out or in a septic arthritis. It’s time to perform arthrocentesis: sWBC: 60x109, sLactate: 10 mmol/L


Are this findings useful?

Conclusion 

Although arthrocentesis is not a risk-free procedure, synovial fluid analysis is essential for the diagnosis. 

sWBC count has been studied in several trials but a significant heterogeneity was noted so it should not be used in isolation to rule in or rule out the diagnosis of septic arthritis, anyway it should augment the entire clinical evaluation.

Synovial lactate, instead, has consistently demonstrated desirable diagnostic properties to rule in septic arthritis using a threshold of >10 mmol ⁄ L. 

Bibliography 

C. R. Carpenter et al;

Evidence-based Diagnostics: Adult Septic Arthritis

Acad Emerg Med Aug 2011, vol 18 n 8. 

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Ilenia Spallino

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Septic Arthritis

A 33 y/o male comes to the ED for fever, knee swelling and pain.

He has a history of joint surgery because of trauma, and prothesis, dating 4 years before.

He is HIV positive

He presents feverish (38°C), the left knee is swollen and hot.

WBC 34.000/μL CRP 109 mg/L PCT 0,05 ng/mL

Are history, clinical examination, serum test enough to rule out or in a septic arthritis?

Conclusion 

No finding from the history significantly decreases or increase the probability of septic arthritis (SA), included hystory of HIV infection; only recent joint surgery (<3 months ago) or a joint prosthesis with skin infection, significantly increases the risk of septic arthritis, but attention, the absence does not rule out SA!

Data about physical examination and hystory are inconcludent, the presence or absence of classical clinical signs (pain with motion, limited motion, tender swelling, joint effusion, increased heat redness, fever > 37.5°C, axial load pain) is not useful to rule in or rule out septic arthritis.

Serum test like WBC, ESR, CRP are not useful, instead Procalcitonin is generally specific with very poor sensitivity. 

…..So what?

To be continued...

Bibliography 

C. R. Carpenter et al;

Evidence-based Diagnostics: Adult Septic Arthritis

Acad Emerg Med Aug 2011, vol 18 n 8. 

Ilenia Spallino

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Soft tissue abscess: clinical plus ultrasound evaluation

Male 65 y/o, he complains pain and swelling in left groin, he has history of hypertension. He has not fever. Clinical examination shows swelling, skin is hot and  eritematous.






Is it an abscess, a cellulitis or something else? 

Conclusion 

To use ultrasound on eritematous and swelling skin is very helpful 

Abscesses presents as a spherical structure with “pus in movement”.  

Celluliti’s morphology, instead, has a “cooblestoning effect”, with diffuse hyperechogenicity of subcutaneous fat.

Ultrasonography is a useful adjunct to clinical evaluation of soft tissue infection, it increases diagnostic accuracy and guides treatment decision.

Bibliography 

BT Squire, JC Fox, C Anderson

ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections

Acad Emerg Med July 2005, Vol. 12, No. 7 

DW Struk, PL Munk

Imaging of softs tissue infections

Radiol Clin of N Am vol 39 n2 Mar 2001

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Ciro Paolillo

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Soft tissue abscess the clinical evaluation

Male 65 y/o, he complains pain and swelling in left groin, he has history of hypertension. He has not fever. Clinical examination shows swelling, skin is hot and eritematous.








Is it an abscess, a cellulitis or something else?

 

Conclusion 

Differentiating a soft tissue abscess from cellulitis is important because each disorder requires a different treatment.

Clinical examination alone has small role for this scope.

May we need something else?

Bibliography 

BT Squire, JC Fox, C Anderson

ABSCESS: Applied Bedside Sonography for Convenient Evaluation of Superficial Soft Tissue Infections

ACAD EMERG MED July 2005, Vol. 12, No. 7 

To be continued...

Ciro Paolillo

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Acute appendicitis and signs

A 21 y/o man presents to the ED with pain in right low quadrant (RLQ) , anorexia, nausea and vomiting. His abdomen is soft, with a mild tenderness in RLQ, the psoas sign is positive. The pain is aggravate by cough. You perform kindly a rectal examination with pain. 

Are this signs useful for the diagnosis of acute appendicitis?

Conclusion 

No clinical signs alone is able to rule in or out an acute appendicitis. Rectal examination, still diffused, is not of any utility. 

May we need somwthing else?

Bibliography 

Meta-analysis of the clinical and laboratory diagnosis of appendicitis

British Journal of Surgery 2004; 91: 28-37

R.E.B. Anderson

Ciro Paolillo

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Intestinal Ischemia and Lactate

A 84 y/o woman comes accompained by relatives for abdominal pain.

She is oriented and cooperative, she suffers pain (NRS 10/10).
Abdomen is treatable, but very painful in the lower quadrants, you see green watering diarrhea, she has not fever.
Abdominal Radiograph shows air/fluid levels
WBC: 35000/μl PCR: 22 mg/L Lactate: 1,7


Can you rule out intestinal ischemia?

Conclusion 

The performance of lactate and other serological markers is disappointing and not particularly helpful to rule out intestinal ischemia.

Bibliography 

NJ Evennett, MS Petrov, A Mittal, JA Windsor

Systematic Review and Pooled Estimates for the Diagnostic Accuracy of Serological Markers for Intestinal Ischemia

World J Surg (2009) 33:1374–1383 

Ilenia Spallino

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Acute Dyspnoea and Laboratory

It’s a dark night when a red code arrive at the ED by ambulance. 

Paramedics tell you: “called for acute dyspnoea, I think it’s a COPD exacerbation, he is wheezing, I gave him bronchodilators and steroids, but he is worsening”.

He has a history of  COPD and hypertension. 

He presents sweaty, dyspneic, arterial pressure is high (220/110).

Physical examination is normal except for wheezing.

AP Chest x ray shows no signs of congestion. 




What about BNP? 

Conclusion

Natriuretic peptides have a very high negative predictive value that allows us to rule out dyspnoea of cardiogenic origin when values are normal. However, there are several circumstances in which natriuretic peptides may be elevated for other reasons, and data may be confounded. Thus, especially in cases where NT-proBNP levels are only slightly abnormal, the “grey zone”, echographic assessment of pulmonary congestion could help in the management of patients with dyspnoea. 

Moreover, natriuretic peptide analysis is not always available, especially in peripheral emergency departments, as it requires specialised laboratory equipment. If the assay is not available, ULCs may offer a plausible alternative. In patients admitted with acute dyspnoea, pulmonary congestion, sonographically imaged as ULCs, is significantly correlated to NT-proBNP values 

Bibliography 

L. Gargani a, F. Frassi a , G. Soldati b , P. Tesorio c , M. Gheorghiade d , E. Picano a

Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: A comparison with natriuretic peptides

European Journal of Heart Failure 10 (2008) 70–77

Anwaruddin S, Lloyd-Jones DM, Baggish A, et al.

Renal function, con- gestive heart failure, and amino-terminal pro-brain natriuretic peptide measurement: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Study. 

J Am Coll Cardiol 2006;47:91–7.

see also...clinical x ray ultrasound

Ilenia Spallino

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