Effect of flosteron on the content of acute-phase proteins and procalcitonin in infectious arthritis in rats

Infectious arthritis was modeled on white male Wistar rats by injecting a suspension of Staphylococcus aureus microorganisms into the knee joint of animals, and the effects of the synthetic hormone flosteron were also studied. At the same time, the content of acute-phase proteins (ceruloplasmin, haptoglobin, C-reactive protein (CRP)) and procalcitonin (PCT) as markers of the development of the inflammatory process and bacterial infection was studied in the blood serum of rats. Determination of the content of haptoglobin, ceruloplasmin and CRP was carried out on a Cobas 311 biochemical analyzer, the PCT concentration on a Cobas 411 analyzer using Roche Diagnostics test systems. Analysis of the results showed that when flosteron was administered, the concentration of CRP increased by 1.7 times already on the 3rd day, and by more than 4 times on the 14th day. The content of ceruloplasmin and haptoglobin also increased. The PCT concentration was at the level of the control values. Under the conditions of modeling infectious arthritis, changes in the content of acutephase proteins were observed. The greatest deviations from the reference values were found on the 14th day in animals that were injected with the hormone and S. aureus: the concentration of both CRP, the most objective biochemical marker of the inflammatory process, and PCT exceeded the physiological norm 12 times and more than 7 times, respectively. This indicates that the hormonal drug enhances the inflammatory process, which is confirmed by data that reflect changes in the content of acute-phase proteins. It can be assumed that the use of hormonal drugs contributes to the development of postoperative complications.

POS1005 ASSESSMENT OF DAREA AND MODIFIED DAREA IN AN ARGENTINIAN-GUATEMALAN REACTIVE ARTHRITIS COHORT

Background:Reactive Arthritis (ReA) is an inflammatory joint disease and, as in rheumatoid or psoriatic arthritis, composite indices are the most useful tools to measure disease activity. The Disease Activity Index for Reactive Arthritis (DAREA) is the only developed index for ReA, which requires a 66/68 joint count and CRP for its assessment, the latter being difficult to acquire in our setting. Therefore, we developed a simplified index, the modified DAREA (DAREAm), with a lower joint count and ESR for its evaluation.Objectives:1) To evaluate the DAREA and the DAREAm in a cohort of patients with diagnosis of ReA and post-infectious arthritis 2) To assess the correlation of the DAREA and DAREAm with several clinical variables, functional capacity and quality of life in a cohort of patients with ReA.Methods:Patients with diagnosis of ReA (Calin’79) and post-infectious arthritis were included. Demographic data were collected, patient´s pain and global assessment were evaluated through a visual analog scale (VAS) and a 3-point scale (no pain = 0, mild = 1, moderate = 2, severe = 3), physician´s global assessment, morning stiffness (MS) and VAS fatigue. Functional capacity was assessed by HAQ and quality of life according to EuroQol-5 dimensions (EQ-5D), and the activity indices DAS28, DAREA and DAREAm were calculated. Statistical analysis: a descriptive analysis of the variables and correlation between numerical variables with Spearman rank correlation were performed.Results:57 patients were included, 53 with diagnosis of ReA, the majority post urogenital (63%) and gastrointestinal (17%), and 4 with diagnosis of post-infectious arthritis. Fifty six percent were male, mean age: 40 years old (SD ± 14) and median ReA duration: 15 months (IQR 2-45). The number of painful and swollen joints in a 66/68 joint count showed a median of 2 (IQR 0-3) and 1 (IQR 1-2) respectively. Median VAS pain 43 (IQR 15-70), patient´s disease activity 40 (IQR 20-60) and physician´s 40 (IQR 20-60), MS 10 (IQR 0-50) and fatigue 30 (IQR 0-80). Median DAS28 3.6 (IQR 2.3-4.3), DAREA 7.4 (IQR 2.5-10.6), DAREAm 8.6 (IQR 4.6-12.7), HAQ 0.625 (IQR 0.125-1). The dimensions with the greatest compromise in the EQ-5D were pain/discomfort (63%) and anxiety/depression (51%), and the median VAS EQ-5D was 60 (IQR 32-80). DAREA correlated with DAREAm (rs= 0.89; p <0.001), DAS28 (rs= 0.84; p <0.001), medical VAS (rs= 0.60; p <0.001), MS (rs= 0, 50; p <0.001), HAQ (rs= 0.53; p <0.001), VAS fatigue (rs= 0.57; p <0.001) and mobility subscales of the EQ5D (rs= 0.56; p <0.001), pain/discomfort (rs= 0.49; p <0.001) and anxiety/depression (rs= 0.61; p <0.001). The DAREAm correlated with DAS28 (rs= 0.93; p <0.001), physician VAS (rs= 0.58; p <0.001), fatigue VAS (rs= 0.53; p <0.001), HAQ (rs= 0 .51; p <0.001) and the EQ5D subscales: mobility (rs= 0.64; p <0.001), pain/discomfort (rs= 0.56; p <0.001) and anxiety/depression (rs= 0.66; p <0.001)Conclusion:This is the first study that assess activity indices in a cohort of patients with ReA. The DAREAm demonstrated a very good correlation with both DAREA and DAS28. We encourage the use of this simplified index in daily practice to evaluate patients with ReA.Disclosure of Interests:None declared.

Flock-level risk factors for outbreaks of infectious arthritis in lambs, Norway 2018

Background Outbreaks of infectious arthritis in young lambs associated with Streptococcus dysgalactiae subspecies dysgalactiae (SDSD) lead to reduced animal welfare, increased use of antibiotics and economic losses for sheep farmers. Understanding risk factors is essential when developing strategies to prevent such outbreaks. This questionnaire-based cross-sectional study classified sheep flocks of respondents as cases or controls. Flock-level risk factors for outbreaks of infectious arthritis were assessed using a multivariable logistic regression model. Results Eighty-four of 1498 respondents (5.6%) experienced an outbreak of infectious arthritis in their flock in 2018, the year of study. Factors associated with a higher risk of outbreak were larger flock size (OR 1.3, 95% CI 1.1–1.4, per 100 lambs), plastic mesh flooring in the lambing pen (OR 3.0, 95% CI 1.7–5.3) and a lambing percentage greater than 200 (OR 2.0, 95% CI 1.1–3.5). Flocks where farmers observed infections around the ear tags of lambs also had an increased risk of outbreak (OR 2.6, 95% CI 1.6–4.3). Conclusions The risk factors identified in this study are characteristic of modern and intensively managed sheep farms in Norway. A distinguishing feature of Norwegian sheep farming is winter housing and indoor lambing. One might expect that this in itself is a risk factor because of high stocking densities during lambing. However, outbreaks of infectious arthritis in young lambs are reported by the industry to be a more recent phenomenon. The current study indicates that intensification of indoor management systems with larger flocks and higher production per ewe may predispose to outbreaks. The results provide a basis for further studies on transmission dynamics of SDSD in sheep flocks with indoor lambing.

Differential Diagnosis of Reactive and Infectious Arthritis after Anterior Cruciate Ligament Reconstruction

Summary. Relevance. Negative results of the anterior cruciate ligament (ACL) reconstruction occur in 10-20% of cases. The incidence of infectious arthritis can reach up to 1.7% and even up to 7.1%, according to the literature. However, ACL reconstruction can be complicated not only by infectious but also by reactive arthritis. Differential diagnosis between infectious and reactive arthritis is often hard to be done, but it is necessary for effective treatment. Objective: to determine the possible causes of the development of reactive and infectious arthritis after ACL reconstruction, peculiarities of their diagnostics and differential diagnostics. Materials and Methods. The literature data regarding the frequency of reactive and infectious arthritis after various methods of surgical treatment of ACL injury and the use of different types of implants, as well as laboratory indicators of the activity of the inflammatory process in the postoperative period and such indicators in reactive and infectious arthritis, were analyzed. We also analyzed literature data on the sensitivity and specificity of various methods of microbiological studies in patients with infectious synovitis or arthritis. Results. Numerous probable causes of a higher incidence of infectious arthritis in ACL reconstruction are suspected. Synthetic implants may be the cause of the development of reactive arthritis, according to a number of studies. Our experience in using different biodegradable fixators from various manufacturers suggest that the percentage of complications depends not only on the fact of the biodegradability of the implant, but on its composition, and even on the percentage of tricalcium phosphate or the manufacturer. Therefore, it is impossible to unambiguously state that biodegradable fixators are worse or better then metallic or non-biodegradable polymeric ones. However, on average, if we consider all existing fixators from various manufacturers, the number of complications when using biodegradable implants is higher. Diagnosis of reactive arthritis is often based on negative bacteriological findings. Given the not always high sensitivity of bacteriological inoculation of synovial fluid and the duration of the investigation, we cannot rely only on its results. Conclusions. The most difficult for differential diagnosis between infectious and reactive arthritis (synovitis) is acute synovitis after ACL reconstruction with normal results of bacteriological studies, but high biochemical parameters of inflammation. We suggest to suspect infectious arthritis after ACL reconstruction in the following hemogram values: 1) CRP >40-50 mg/l, 2) ESR >30-50 mm/h, 3) fibrinogen >800 mg/ml, 4) procalcitonin in blood plasma >0.5 ng/ml, 5) leukocytosis and left shift of the leukocyte formula, with the following synovial fluid test parameters: a) CRP >40-50 mg/l, b) leukocytosis with an increase in the percentage of polymorphonuclear leukocytes >75%.

AB1322-HPR NON-INFECTIOUS ACUTE INFLAMMATORY ARTHRITIS IN JOINT ARTHROPLASTY

Background:Acute inflammatory arthritis (AIA) in a native knee joint is a common pathology with a well-defined differential diagnosis which includes crystal-induced arthritis. Presenting symptoms in a knee joint arthroplasty (KJA) can mimic a periprosthetic hematogenous infection (PHI). There are few studies in current literature that describe possible causes of non-infectious arthritis in KJA. PHI requires, in most cases, an urgent combined surgical and antibiotic (AB) treatment. Describing and studying other possible diagnoses that may resemble PHI in a KJA is mandatory in order to minimize diagnostic errors and avoid unnecessary treatments.Objectives:To analyze the characteristics of AIA in KJA with negative cultures in patients with an initial diagnosis suspicion of PHI.Methods:A retrospective case series was conducted at a tertiary-level hospital including all patients diagnosed with an AIA in KJA with negative cultures from January 2012 to December 2019. Demographic data, clinical presentation, management and outcomes were recorded and analyzed.Results:A total of 11 cases in 9 patients were included (6 females and 3 males) with a median age of 69 years at the time of diagnosis. All patients had risk factors for AIA (6 had chondrocalcinosis (CC), 2 hyperuricemia and 1 psoriasis). However, crystal deposits in synovial fluid (SF) for none of the patients had been previously found.The median time from the index surgery to clinical presentation was 6 months, and from initial clinical presentation signs to referral was 24 hours. All cases presented with pain and swelling and 5 presented with erythema. Median body temperature on admission was 37.2°C. All patients presented with no acute distress.Initial blood tests showed a median white blood cell count and CRP of 11.160/mm3 and 90mg/L, respectively. Blood and SF cultures were taken for all cases. The median white blood cell count in SF was 75.883/mm3.Three cases had received AB treatment during a median of 6 days prior to microbiological sampling. After initial sampling, 6 cases received AB prior to surgery, 1 received AB after surgery, 1 received only AB and 3 were treated only with NSAIDs. In all cases, surgical treatment consisted in radical surgical debridement and polyethylene insert exchange.Further blood and SF tests were performed 4 days after admission. The mean decrease for systemic white blood cell count, CRP and synovial leukocyte count was 46%, 58% and 56%, respectively. All cultures were negative and crystal deposits were not identified for any of the samples.The median duration of symptoms was 127 days with a good outcome. 6 patients received AB for a median of 69 days.Conclusion:Non-infectious AIA in KJA is a rare entity that should be accounted for the differential diagnosis of periprosthetic joint infection. The initial diagnosis of infection could not be confirmed, although three patients had taken AB before sampling. It is important for physicians to have a suspicion for non-infectious arthritis, especially in patients with clinical and blood test result dissociation, radiological CC, medical history of hyperuricemia or psoriasis, in order to avoid unnecessary AB and surgical treatment.References:[1]Merit P. George, Floranne C. Ernste, Aaron Tande, Douglas Osmon, Tad Mabry, Elie F. Berbari. Clinical Presentation, Management, and Prognosis of Pseudogout in Joint Arthroplasty: A Retrospective Cohort Study. J. Bone Joint Infect. 2019, Vol. 4 (1): 20-26.Disclosure of Interests:None declared

Alternative Treatment for Infectious Arthritis in a Complicated Diabetes Mellitus Patient with Ankle Joint Instability

Treatment of diabetic foot infections requires attention to both local and systemic issues, as diabetes mellitus is accompanied by a high incidence of complications that delay wound healing and restrict treatment options. We present a patient with diabetes who had infectious arthritis of the ankle joint with a soft tissue defect involving the joint capsule. The comorbidities of the patient limited the options for treatment in reconstruction of the ankle joint defect. Therefore, nonabsorbable sutures bridging the periosteum of the fibula and calcaneus bones were applied to mimic the calcaneofibular ligament and secure the joint capsule. In addition, negative pressure wound therapy (NPWT) was administered to protect the joint space, absorb extra fluid, and promote wound healing. Acellular dermal matrix was used in combination with NPWT to enhance wound healing and tissue regeneration. Although methicillin-resistant Staphylococcus aureus was cultured from the wound several times, there were no signs that this treatment aggravated the infection. After 7 months of inpatient treatment, stable soft tissue coverage and ankle joint stabilization were achieved, allowing fair standing balance, gait and plantar flexion.