Dubost J J, Fis I, Denis P, Lopitaux R, Soubrier M, Ristori J M, Bussiere J L, Sirot J, Sauvezie B
Department of Rheumatology, Hôpital Gabriel-Montpied, Clermont-Ferrand, France.
Medicine (Baltimore). 1993 Sep;72(5):296-310. doi: 10.1097/00005792-199309000-00002.
Twenty-five cases of polyarticular septic arthritis (PASA) were observed in our department over a 13-year period. They accounted for 16.6% of all septic arthritis (15% on average in the literature). A male predominance was noted in our patients, as well as in the literature. The knee was the most frequent location followed by the elbow, shoulder, and hip, in varying order depending on the series. An average of 4 joints was involved. The causative microorganism was Staphylococcus aureus in 20/25 of our patients and in about 50% of published cases. Other frequently causative organisms were streptococci and gram-negative bacteria. Blood cultures and joint aspirations were positive in 19/22 and 23/25 of our cases, respectively. Other septic lesions were noted in 10/25 of our cases. Fever and severe leukocytosis were absent at admission in 5/25 (literature, 37%) and 10/25 of our 25 patients, respectively. The underlying disease was rheumatoid arthritis in 13/25, while 9 of the other patients had immunodepression caused by drugs or by concurrent illness. Typically, rheumatoid arthritis was long-standing and erosive, patients having ulcerated calluses on the feet. This skin source was also noted in 23/36 published cases of PASA in rheumatoid arthritis. Systemic lupus erythematosus was an uncommon disease in PASA, but its presence promoted gram-negative infection. Despite effective therapy with 2 antibiotics, 8/25 patients died, a prognosis that is equally severe in cases reported in the literature (30%) and one that has remained surprisingly stable over the last 40 years. For comparison, the death rate was only 4% in our patients with MASA. Factors contributing to a poor prognosis were age greater than 50 years, rheumatoid arthritis as an underlying disease, and disease of staphylococcal origin. Septic polyarthritis should be considered even when the clinical picture is not florid--when patients have low fever and normal white blood cell counts. Nor should the simultaneous involvement of distant joints rule out infection. Indeed, the frequency of underlying rheumatic disease and its treatment may further confuse the clinical presentation. Joints suspected of harboring infection should be aspirated, including those previously affected by the concurrent rheumatism.
在13年期间，我们科室共观察到25例多关节化脓性关节炎（PASA）。它们占所有化脓性关节炎的16.6%（文献报道平均为15%）。我们的患者以及文献报道中均显示男性居多。膝关节是最常受累的部位，其次是肘关节、肩关节和髋关节，受累顺序因系列研究而异。平均累及4个关节。20/25的患者致病微生物为金黄色葡萄球菌，在已发表病例中约占50%。其他常见的致病微生物为链球菌和革兰氏阴性菌。我们的病例中，血培养和关节穿刺培养分别有19/22和23/25呈阳性。25例中有10例还存在其他化脓性病变。25例患者中分别有5例（文献报道为37%）和10例入院时无发热及严重白细胞增多。25例患者中13例的基础疾病为类风湿关节炎，另外9例患者因药物或并发疾病导致免疫抑制。典型的类风湿关节炎病程长且有侵蚀性，患者足部有溃疡胼胝。在已发表的36例类风湿关节炎相关PASA病例中，23例也有这种皮肤来源。系统性红斑狼疮在PASA中是一种罕见疾病，但其存在会增加革兰氏阴性菌感染的风险。尽管使用了两种抗生素进行有效治疗，25例患者中有8例死亡，这一预后与文献报道的病例同样严重（30%），并且在过去40年中一直惊人地稳定。相比之下，我们的单关节化脓性关节炎（MASA）患者死亡率仅为4%。导致预后不良的因素包括年龄大于50岁、基础疾病为类风湿关节炎以及葡萄球菌源性疾病。即使临床表现不典型，如患者低热且白细胞计数正常时，也应考虑化脓性多关节炎。远处关节同时受累也不能排除感染。事实上，基础风湿性疾病的发生率及其治疗可能会使临床表现更加复杂。对于怀疑有感染的关节应进行穿刺，包括那些先前受并发风湿病影响的关节。
