Gonoccocal Arthritis

5/07/03

Question: How does synovial fluid analysis compare with blood cultures and other techniques in the diagnosis of gonococcal arthritis?

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Unique Identifier:12006320

Authors: Swan A. Amer H. Dieppe P.

Institution: Division of Medicine, University of Bristol MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, UK. Angela.Swan@bristol.ac.uk

Title: The value of synovial fluid assays in the diagnosis of joint disease: a literature survey. [Review] [60 refs]

Source: Annals of the Rheumatic Diseases. 61(6):493-8, 2002 Jun.

Abstract: OBJECTIVE: To carry out a critical appraisal of the literature in an attempt to assess the current value of synovial fluid (SF) analysis in the diagnosis of joint disease. METHODS: A literature search was undertaken using the Medline, Biomed, Bids, Pubmed, and Embase electronic databases using the keywords: synovial fluid (SF) analysis, SF crystals, joint sepsis, acute arthritis, and SF cell counts, cytology, biomarkers, and microbiology. RESULTS: Publications fell into three main categories. Firstly, reports assessing the value of the three traditional assays (microbiology, white blood cell counts, and microscopy for pathogenic crystals). For these quality control evidence was found to be sparse, and tests for sensitivity, specificity, and reliability showed worrying variations. These poor standards in SF analysis may be due to lack of inclusion of some tests within routine pathology services. Secondly, claims for the usefulness of "new" assays (cytology and biochemical markers). For cytology, the supporting evidence was mainly anecdotal and there were no reports on specificity, sensitivity, and reliability. Interpretation difficulties are a major hindrance to the clinical use of biochemical assays, which remain primarily research tools. Finally, work on the diagnostic value of SF analysis in general. The appraisal confirmed that SF analysis remains of major diagnostic value in acute arthritis, where septic arthritis or crystal arthropathy is suspected, and in intercritical gout. CONCLUSIONS: Given the importance of SF tests, rationalisation of their use, together with improved quality control, should be immediate priorities. Further investigation is recommended into the contribution of SF inspection and white cell counts to diagnosis, as well as of the specificity and sensitivity of SF microbiological assays, crystal identification, and cytology. [References: 60] CAS Registry/EC Number 10086-45-0 (Calcium Pyrophosphate). 69-93-2 (Uric Acid).

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Unique Identifier:11477114

Authors: Johnson JS. Freemont AJ.

Institution: Department of Histopathology, Clinical Sciences Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.

Title: A 10 year retrospective comparison of the diagnostic usefulness of synovial fluid and synovial biopsy examination.

Source: Journal of Clinical Pathology. 54(8):605-7, 2001 Aug.

Abstract: BACKGROUND/AIMS: Synovial fluid examination is thought to be the pathological investigation of choice in most joint disorders, with only a few specific conditions necessitating biopsy, although no evidence based studies are available to support this belief. This study sought to investigate the validity of this assumption. METHODS: One hundred and three cases in which synovial fluid aspiration and synovial biopsy had both been performed at arthroscopy were studied. The amount of diagnostically useful information produced by each investigation was assessed. RESULTS: In most cases, both investigations provided the same amount of information and were generally equally specific or equally non-specific. Overall, the biopsy provided more information than the fluid in 29% of cases and vice versa in 18%. When only those cases in which both tests were adequate were considered, the biopsy provided more specific information than the fluid in a small number (9%) of cases, but these cases could not be predicted. CONCLUSION: The diagnostic usefulness of a biopsy approximates and occasionally exceeds that of a fluid. In the arthroscopic situation, the main advantage of performing both tests is that it provides a "failsafe mechanism" for the rare occasions when one of the samples is inadequate.

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Unique Identifier:9217553

Authors: Barth WF.

Institution: Section of Rheumatology, Washington Hospital Center, Washington, DC 20010, USA.

Title: Office evaluation of the patient with musculoskeletal complaints. [Review] [23 refs]

Source: American Journal of Medicine. 102(1A):3S-10S, 1997 Jan 27.

Abstract: Many musculoskeletal complaints are accompanied by classic signs and symptoms that can be readily diagnosed by the primary care physician. Others are much less obvious and present a diagnostic challenge. In the office evaluation of patients with musculoskeletal complaints, the history is the most informative element. Least helpful are laboratory tests. Although erythrocyte sedimentation rate (ESR), rheumatoid factor, and other widely available tests are sensitive to the presence of rheumatic diseases, they are not specific for any of them. In the initial office evaluation, helpful points of differentiation include the number of joints involved, their location, and, when multiple joints are involved, whether they are symmetric or asymmetric. An acute monarthritis is associated mainly with trauma, infection, or a crystal-induced synovitis such as gout or pseudogout. Patients with polyarthritis may have symptoms that come and go very quickly, sometimes in < 24-36 hours. This migratory pattern characterizes diseases such as gonococcal arthritis, viral disease, and sarcoidosis. "Rheumatoid variants" such as Reiter's syndrome, psoriatic arthritis, and spondylitis may affect no more than a few joints and are accompanied by other signs, such as nail and skin lesions (psoriasis) or urogenital and enteric infections (Reiter's). Like erosive osteoarthritis, the rheumatoid variants may also cause swelling and inflammation of the distal interphalangeal joints. The classic example of symmetric joint disease is rheumatoid arthritis (RA). While RA often occurs in a progressive and additive pattern, its onset may be followed by a remission several months later. Patients who present with the "algias" may have no physical signs but manifest extensive musculoskeletal pain. Fibromyalgia occurs typically in younger women; polymyalgia rheumatica rarely occurs in patients < 50 years of age and is usually accompanied by a strikingly high ESR. Age and gender should be noted in the office evaluation because they can provide clues not only to these "algias," but other rheumatic diseases seen more frequently in one age or gender group than another. [References: 23]

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Unique Identifier:9211079

Authors: Cimmino MA.

Institution: Department of Internal Medicine, University of Genoa, Italy. dimi@unige.it

Title: Recognition and management of bacterial arthritis. [Review] [60 refs]

Source: Drugs. 54(1):50-60, 1997 Jul.

Abstract: Bacterial arthritis is a bacterial infection of the joint. Apart from the classical gonococcal arthritis, nongonococcal arthritides include specific forms such as mycobacterial or Borrelia burgdorferi arthritis. Almost any bacterium can cause arthritis, provided that the route of penetration and the host response are suitable. Weakening of the host's immune competence, pre-existing joint damage and invasive diagnostic or therapeutic procedures are the main risk factors for bacterial arthritis. Gram-positive cocci are the species most frequently involved. The pathogenesis of bacterial damage includes release of toxins, cell production of cytokines and autoimmune reactions to specific antigens. The diagnosis can be suspected clinically put must be confirmed by culture of the synovial fluid, a test which can be complemented by scintigraphy. Amplification of bacterial DNA by polymerase chain reaction is a new procedure that could become an important tool for quick diagnosis. Treatment is based on joint drainage and antibiotics, which should be started as soon as the diagnosis is suspected. Corollary strategies under investigation include corticosteroids to prevent joint damage, monoclonal antibodies to arthritogenic peptides of bacteria or to surface markets of host lymphocytes, and modulators of synovial fluid cytokines. [References: 60] CAS Registry/EC Number 0 (Antibiotics).

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Unique Identifier:2198352

Authors: Shmerling RH. Delbanco TL. Tosteson AN. Trentham DE.

Institution: Department of Medicine, Harvard Medical School, Beth Israel Hospital, Boston, MA.

Title: Synovial fluid tests. What should be ordered?.

Source: JAMA. 264(8):1009-14, 1990 Aug 22-29.

Abstract: To determine which synovial fluid tests are most useful, we prospectively analyzed the synovial fluid test results of 100 consecutive patients undergoing diagnostic arthrocentesis. Each patient's diagnosis was established independently of synovial fluid laboratory test results; in 69 patients a definite inflammatory or noninflammatory categorization could be made. Sensitivity and specificity were estimated for synovial fluid white blood cell count (sensitivity, 0.84; specificity, 0.84), percentage of polymorphonuclear cells (sensitivity, 0.75; specificity, 0.92), glucose (sensitivity, 0.20; specificity, 0.84), protein (sensitivity, 0.52; specificity, 0.56), and lactate dehydrogenase (sensitivity, 0.83; specificity 0.71). Receiver operating characteristic regression analysis indicated that both white blood cell count and percentage of polymorphonuclear cells were found to contribute independent diagnostic information but lactate dehydrogenase did not. In a separate, retrospective analysis of 19 patients with definite septic arthritis, similar results were observed. We conclude that synovial fluid white blood cell count and percentage of polymorphonuclear cells perform well as discriminators between inflammatory and noninflammatory disease. Ordering chemistry studies of synovial fluid should be discouraged because they are likely to provide misleading or redundant information.