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Septic Bursitis

Septic bursitis is defined as an infection with the accumulation of pus within the sac-like structures which lie between the skin and bone or between the tendons, ligaments, and bone. It may be primary due to direct bacterial inoculation through a cutaneous wound or spread of local cellulitis or secondary to hematogenous spread of infection.


Presentation

Bursae are sac-like structures which either lie superficially between the skin and bone or are located deeply between the tendons, ligaments, and bone. Inflammation of bursae could be septic (with the formation of pus) or non-septic. Septic bursitis (SB) is commonly encountered in the superficial bursae e.g. olecranon and prepatellar bursae. In a majority of the cases, SB follows direct inoculation of traumatic superficial cutaneous wounds or contiguous spread of infection from local cellulitis [1] [2]. Rarely, deep bursae e.g. subacromial and iliopsoas bursae may get infected secondary to hematogenous spread of micro-organisms e.g. in septic arthritis, bacteremia, bacterial endocarditis. Micro-organisms implicated in SB are Staphylococcus aureus in a majority of the cases followed by streptococci, mycobacteria (both tuberculous and nontuberculous strains), fungi (Candida), and algae (Prototheca wickerhamii) [3]. The incidence of SB is reported to be higher in men [4]. Risk factors for SB include loss of skin integrity, impaired response to infection (eg, diabetes mellitus, alcohol abuse), and autoimmune conditions that lead to an increased amount of bursal fluid or tissue (such as rheumatoid arthritis or tophaceous gout) [1] [5] [6].

Clinical presentation may help to differentiate between septic from nonseptic bursitis. SB is almost always associated with symptoms of pain, swelling, and fever [5] while non-septic bursitis is associated with only swelling [6]. Erythema is present in both SB and non-SB [5]. Other symptoms include local tenderness and a history of repeated trauma or movement. Concomitant symptoms of systemic comorbid conditions like syphilis or pulmonary tuberculosis, bacterial endocarditis may also be present.

Fever
  • Fever (body temperature of or 37.8 degrees C) occurred in 20%. Staphylococcus aureus was identified in 88% of culture-proven cases of OBS.[ncbi.nlm.nih.gov]
  • A 48-yearold male fish-merchant with a history of HIV infection with a CD4 cell count of 79 cells/ml presented with pain of the left ankle for 2 weeks and fever for 1 day.[ncbi.nlm.nih.gov]
  • Fever, tenderness, peribursal cellulitis, and skin involvement over the bursa were more common in the septic cases.[ncbi.nlm.nih.gov]
  • SB is almost always associated with symptoms of pain, swelling, and fever while non-septic bursitis is associated with only swelling. Erythema is present in both SB and non-SB.[symptoma.com]
  • Presenting signs included fever with localized swelling, tenderness, and erythema; superficial fluctuance and painless joint motion were helpful diagnostic findings.[ncbi.nlm.nih.gov]
Chills
  • The most common symptoms were pain (87%), redness (77%) and fever or chills (45%). Common signs included erythema (92%), swelling (85%), edema (75%), tenderness (59%), fluctuance (50%), heat (36%) and reduced range of motion (27%).[ncbi.nlm.nih.gov]
  • However, a few symptoms are specific to septic bursitis: Extreme warmth or redness to the area above the joint Extreme tenderness to the area above the joint Fever or chills General feelings of sickness It can be difficult to tell the difference between[arthritis-health.com]
  • Low grade fever and chills may also be present. The prepatellar bursa lies in front of the knee between the patella (kneecap) and the skin.[articlesurfing.com]
  • The main symptoms of an infection include: Extreme warmth and redness of the skin at the joint Acute tenderness of the bursa Fever or chills Joint pain Generally feeling sick Distinguishing between aseptic and septic bursitis can be challenging.[arthritis-health.com]
Fishing
  • A 48-yearold male fish-merchant with a history of HIV infection with a CD4 cell count of 79 cells/ml presented with pain of the left ankle for 2 weeks and fever for 1 day.[ncbi.nlm.nih.gov]
Intravenous Administration
  • The most common antibiotic regimen was sequential intravenous administration of cefazolin (for a median of 4 d) followed by clindamycin orally (for a median of 8 d).[ncbi.nlm.nih.gov]
Gangrene
  • This form is severe and it is necessary to carry out knee bursitis treatment as soon as possible, because it can end up with a formation of gangrene and amputation of your limb.[yourhealthyjoints.com]
Dyspnea
  • At admission she denied any dyspnea, chest pain, rash, dysuria, diarrhea, or intravenous drug abuse.[jrheum.org]
Diarrhea
  • At admission she denied any dyspnea, chest pain, rash, dysuria, diarrhea, or intravenous drug abuse.[jrheum.org]
Chest Pain
  • At admission she denied any dyspnea, chest pain, rash, dysuria, diarrhea, or intravenous drug abuse.[jrheum.org]
Oral Ulcers
  • Six months before, she was diagnosed with systemic lupus erythematosus (SLE) on the basis of nonerosive polyarthritis, painless oral ulcers, positive antinuclear antibody (IFI-Hep2) titer of 1:10,240 with homogeneous pattern, and anti-dsDNA (Farr assay[jrheum.org]
Dysuria
  • At admission she denied any dyspnea, chest pain, rash, dysuria, diarrhea, or intravenous drug abuse.[jrheum.org]
Neglect
  • They are the immunocompromised host, patients with underlying bursal disease and the neglected patient with significant cellulitis. Case reports of these types are presented.[arizona.pure.elsevier.com]

Workup

Although the diagnosis of SB is not based on the clinical presentation, it may be suspected in presence of fever, and bursal inflammation as these symptoms are less severe in non-SB. Also, joint mobility is usually preserved in SB while it is limited in other types of bursitis. A detailed history to exclude trauma, occupation injury, comorbid medical conditions (rheumatoid arthritis, gout, diabetes mellitus, syphilis, HIV) should be obtained. A thorough physical examination needs to be performed to look for signs of inflammation locally as well as to exclude bacteremia. Routine laboratory blood work may reveal leukocytosis, elevated inflammatory markers (erythrocyte sedimentation rate, C-reactive protein) while blood culture is indicated if SB in the deep bursae is suspected. Rheumatoid factor (RF), and anti–citric citrullinated peptide (anti-CCP) tests should also be ordered to exclude autoimmune diseases. Aspiration and analysis of the bursal fluid form the mainstay of diagnosing SB as it is likely to show cell counts exceeding 70,000/µL, with a predominance of polymorphonuclear leukocytes (PMNs). Microbiological analysis of the aspirated fluid demonstrates Staphylococcus aureus and other gram-positive organisms in a majority of the cases [2].

Plain radiography will only reveal joint effusion or soft tissue swelling but does not help to detect SB. Although computed tomography (CT) is not required magnetic resonance imaging (MRI) can help to identify local joint anatomy, soft tissue abscesses as well as the bursal fluid [7]. Ultrasonography is useful when the diagnosis is uncertain and to perform ultrasound guided aspiration of the bursa. Ultrasonography can also differentiate between solid and cystic masses and detect popliteal bursitis in presence of extensive joint deformities [8] [9].

Brucella Abortus
  • Although the most common pathogen is S. aureus, other pathogens such as Brucella abortus play an important role in this infection in our area.[ncbi.nlm.nih.gov]

Treatment

  • In septic bursitis, the effects of delay in treatment are deleterious by prolonging culture-positivity despite adequate antibiotic therapy.[ncbi.nlm.nih.gov]
  • In this article, surgeons from The Philadelphia Hand Center explore the best treatment for septic olecranon bursitis . Since studies of this problem are limited, evidence-based treatment has not been established.[eorthopod.com]
  • Treatment with antimicrobial agents, mostly penicillins, and bursal drainage were successful in 32 cases. Two patients had local spread of the infection and 1 patient chronic bursitis.[ncbi.nlm.nih.gov]
  • He was treated initially with intravenous ceftriaxone 2g once daily for 5 days, followed by oral ciprofloxacin 500mg twice daily for 4 weeks to give a treatment course of 5 weeks.[ncbi.nlm.nih.gov]

Prognosis

  • Keywords : Septic bursitis, Cloxacillin, Rifampicin, Gentamicin, Prognosis[em-consulte.com]
  • Prognosis: Most patients recover completely without sequelae. BIBLIOGRAPHY Ho G, Su EY. Antibiotic therapy of septic bursitis: its implication in the treatment of septic arthritis.[rheumaknowledgy.com]
  • When septic bursitis is diagnosed early and treated accordingly, the prognosis is excellent.[cid.oxfordjournals.org]
  • What Is the Prognosis of Bursitis? The prognosis of bursitis is usually very good. Sometimes adjustment of activities ultimately leads to the best outcome. Infectious bursitis can require surgical resection of the bursa and antibiotics for cure.[emedicinehealth.com]

Etiology

  • Although skin necrosis is frequently cited as a complication of open bursectomy, there is limited information in the medical literature on the etiology and management of this rare but serious complication.[ncbi.nlm.nih.gov]
  • Staphylococcus aureus was isolated from 70% of bursal fluid aspirations; other etiologic organisms included gram negative bacteria and Mycobacterium marinum. The majority of patients were able to be treated as outpatients with oral antibiotics.[ncbi.nlm.nih.gov]
  • Abstract In a retrospective study the etiology was verified in 35/52 patients with suspected septic prepatellar or olecranon bursitis. Staphylococcus aureus was the most common pathogen and 86% of them were penicillinase-producing.[ncbi.nlm.nih.gov]
  • Salmonella should be considered in the differential of the etiology of immunosuppressed patient with septic bursitis.[ncbi.nlm.nih.gov]
  • Etiology and Pathogenesis 150 bursae in the human body Bacterial inoculation, spread from soft tissue, or hematogenous Superficial bursae – direct inoculation or contiguous spread Separate skin from deeper tissues Prepatellar or infrapatellar – athletes[slideshare.net]

Epidemiology

  • Patient characteristics and epidemiologic exposures may provide clues to unusual causative organisms that are occasionally encountered, such as Neisseria gonorrhoeae, Pasteurella multocida, atypical mycobacteria, fungi, and protothecosis.[ncbi.nlm.nih.gov]
  • BACKGROUND: The epidemiology, outcome and management of olecranon septic bursitis (OSB) have not been described in a large cohort of ambulatory patients.[ncbi.nlm.nih.gov]
  • Introduction Swelling and inflammation of the anterior knee Epidemiology incidence most common bursitis of the knee location bursa anterior to patella risk factors excessive kneeling common in wrestlers concern for septic bursitis in wrestlers Pathophysiology[orthobullets.com]
  • […] synonyms: coal miner's elbow, student's elbow Olecranon Bursitis ICD-10 Olecranon Bursitis ICD-9 726.33 (olecranon bursitis) Olecranon Bursitis Etiology / Epidemiology / Natural History Definition: inflammation of the olecranon bursa Associated with football[eorif.com]
Sex distribution
Age distribution

Pathophysiology

  • Introduction Swelling and inflammation of the anterior knee Epidemiology incidence most common bursitis of the knee location bursa anterior to patella risk factors excessive kneeling common in wrestlers concern for septic bursitis in wrestlers Pathophysiology[orthobullets.com]
  • Pathophysiologically, the exudation of synovia![healio.com]

Prevention

  • Aggressive surgical management is particularly important in tenosynovitis to prevent tendon necrosis. Empiric antibiotic coverage should be directed toward staphylococci and streptococci.[ncbi.nlm.nih.gov]
  • Early recognition, prompt therapy, and preventive measures are necessary to reduce the morbidity of septic bursitis.[ncbi.nlm.nih.gov]
  • Early recognition, prompt therapy, and preventive measures are necessary to reduce the morbidity of septic bursitis. FULL TEXT[annals.org]
  • Elbow (Olecranon) Bursitis Hip (Trochanteric) Bursitis Septic Bursitis Treatment Septic bursitis requires medical attention and antibiotic treatment to prevent the infection from spreading to other parts of the body or into the bloodstream.[arthritis-health.com]

References

Article

  1. Valeriano-Marcet J, Carter JD, Vasey FB. Soft tissue disease. Rheum Dis Clin North Am. 2003;29(1):77.
  2. Zimmermann B 3rd, Mikolich DJ, Ho G Jr. Septic bursitis.Semin Arthritis Rheum. 1995;24(6):391.
  3. Torralba KD, Quismorio FP Jr. Soft tissue infections. Rheum Dis Clin North Am. 2009 Feb; 35(1):45-62.
  4. Laupland KB, Davies HD, Calgary Home Parenteral Therapy Program Study Group. Olecranon septic bursitis managed in an ambulatory setting. The Calgary Home Parenteral Therapy Program Study Group. Clin Invest Med. 2001;24(4):171.
  5. Ho G Jr, Tice AD, Kaplan SR. Septic bursitis in the prepatellar and olecranon bursae: an analysis of 25 cases. Ann Intern Med. 1978;89(1):21.
  6. Canoso JJ, Yood RA. Reaction of superficial bursae in response to specific disease stimuli. Arthritis Rheum. 1979;22(12):1361.
  7. Guanche CA. Clinical update: MR imaging of the hip. Sports Med Arthrosc. 2009 Mar; 17(1):49-55.
  8. Blankstein A, Ganel A, Givon U, Mirovski Y, Chechick A. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. 2006 Dec; 27(6):568-71.
  9. Tsai YH, Huang TJ, Hsu WH, et al. Detection of subacromial bursa thickening by sonography in shoulder impingement syndrome. Chang Gung Med J. 2007 Mar-Apr; 30(2):135-41.

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Last updated: 2018-06-22 09:16