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ANSWERED on Tue 20 Mar 2007 - 1:19 am UTC by nancy

Question: Septic Joints (migrating) in chronic heroin addiction

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Sun 18 Mar 2007 - 10:53 pm UTC

Question

cynthia
Customer

My son is a heroin addict. Last night he was admitted to a hospital with septic joints, and had emergency surgery to remove fluid from his knee. Besides his knee, his feet are extremely swollen, he looks and feels terrible.

How serious is this? Prognosis?
Is there any treatment besides antibiotics?

Links are fine for an answer, I just don't have time to research this myself, I want to go see him, now.

Please, no lectures, I really don't need that right now.

 
 

Sun 18 Mar 2007 - 10:55 pm UTC

Question clarification

cynthia
Customer

I was able to find this:
http://www.fpnotebook.com/RHE39.htm
...but it doesn't really say anything. I'm too upset to search, sorry.

 

Sun 18 Mar 2007 - 11:50 pm UTC

Uclue Researcher Request for clarification

David Sarokin
Researcher

Cynthia,

So sorry to hear about this, and here's hoping for the best.

emedicine.com is one of the first places I turn to for a fast and up-to-date overview on medical topics.

Their article on septic arthritis (same thing as septic joints) is here:


http://www.emedicine.com/orthoped/topic437.htm


but I believe you'll need to register at the site to read it.  An alternative is to view a slightly older archived version of the article here:

http://web.archive.org/web/20060528104913/http://www.emedicine.com/orthoped/topic437.htm


Take a look, and then let us know what more we can do for you.


All the best,

David

 

Mon 19 Mar 2007 - 4:58 am UTC

Uclue Researcher Request for clarification

nancy
Researcher

Hi Cynthia,

It seems your son's doctors are taking the standard steps. Immediate surgery to remove fluid is crucial, as is antibiotic therapy.

Naturally, the prognosis improves depending on how early the problem was caught and treated.

Here's a few additional links. I hope these are of some help.

"Septic Arthritis" from the Mayo Clinic:
http://www.mayoclinic.com/health/bone-and-joint-infections/DS00545

"Septic arthritis is an infection in a joint. Bacteria, or less commonly fungi, can spread from other infected areas in your body to the joint. . . . germs infiltrate the joint and damage it, causing severe pain. Bacteria most commonly target your knee, though other joints can be affected by septic arthritis."

"Treatment":
http://www.mayoclinic.com/health/bone-and-joint-infections/DS00545/DSECTION=8

HealthCares:
http://bone-muscle.health-cares.net/septic-arthritis-treatment.php

"Rest, immobilization, elevation, and warm compresses may be used at the onset of treatment for pain relief measures. Performing exercises for the affected joint aids the recovery process. Septic arthritis often causes intense pain. Patients are given medications to relieve pain, together with hot compresses or ice packs on the affected joint. In some cases the patient's arm or leg is put in a splint to protect the sore joint from accidental movement. Recovery can be speeded up, however, if the patient practices range-of-motion exercises to the extent that the pain allows."

It may take up to 48 hours for your son to feel the effects of antibiotics, and he may need anti-fungal meds. After the immediate crisis has passed, he may also require physical therapy.

See Abstract: "Arthroscopic treatment of septic joints: prognostic factors." By Vispo Seara JL, Barthel T, Schmitz H, Eulert J. at Entrez PubMed:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12029509&dopt=Abstract

"From 1987 to 1993, 88 patients (average age 48 years, range 3 months to 83 years) with septic arthritis were treated at the orthopaedic clinic Konig Ludwig Haus of the University of Wurzburg by arthroscopic means consisting of joint debridement and application of suction drains, combined with appropriate antibiotics and early functional treatment.. . . At the average follow-up evaluation after 2.5 years (range 6 months to 5 years), the functional results were excellent or good in 61% of the patients, satisfactory in 20% and poor in 19% from our series . . . ."

Factors in patient recovery included age (and your son has youth on his side) and quick medical intervention after the onset of infection and symptoms.

From "Guideline for the management of the hot swollen joint in adults with a particular focus on septic arthritis," by Vivienne Weston1 and Gerald Coakley, "JAC Advance Access originally published online on July 19, 2006, Journal of Antimicrobial Chemotherapy 2006 58(3):492-493; doi:10.1093/jac/dkl295: 

"The hot swollen joint is a common clinical condition, which has a wide differential diagnosis, the most serious of which that must not be missed being septic arthritis. This has a mortality of up to 11% and results in permanent joint damage in up to a third of patients."

Family Practice Notebook:
http://www.fpnotebook.com/RHE39.htm

"Prognosis
Early joint drainage and antibiotics
Good prognosis

"Delayed management >24 hours
Risk of joint arthrosis, fibrosis and osteonecrosis."

I hope these resources are of some help.

My prayers are with you and your family.

nancy
uclue Researcher

 

Mon 19 Mar 2007 - 5:15 am UTC

Uclue Researcher Request for clarification

byrd
Researcher

Cynthia,

As you probably know, "sepsis" or "septic" means "infection" - usually a bacterial infection. Sepsis of the joints, or "septic arthritis" is a fairly well-known phenomenon among intravenous drug users, heroin users especially. "Arthritis" means inflammation of the joints from any cause. "Osteomyelitis" is an infection of the bone, and is related. The most common infectious agents associated with these conditions appear to be streptococcus, staphylococcus, gonococcus, and pseudomonas, though there are others as well. Treatment is with antibiotics and the prognosis will depend on several factors, including general health and fitness, but can have a favorable outcome.

I may have duplicate some information as others were posting while I was typing, but will just post what I have in hopes it may give you something additional.

I'd recommmend Medscape http://www.medscape.com as a good site in general for some faily comprehensive information on the subject. Google also returns a good list of articles, though many of them are on subscription-only sites and you do have to do a bit of sifting there. You'll probably have to register at Medscape to read the articles, but registration is free and pretty easy.

Here are some links to start:

----------------
SEPTIC ARTHRITIS
----------------
    Septic arthritis:  is a medial emergency.  Bacteria invade a joint, resulting in inflammation of the synovial lining.  If the organisms enter the joint cavity, effusion and pyogenesis follow, with eventual destruction of bone and cartilage....
   
     Causes: In most cases, bacteria spread from a primary site of infection, usually in adjacent bone or soft tissue, through the bloodstream to the joint. Infecting organisms include four strains of gram positive cocci:Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Streptococcus viridans ....

    There are various factors that can predispose a person to septic arthritis... Intravenous drug abuse ( heroin addicts, for example) can also cause septic arthritis ....

    Symptoms: Acute septic arthritis begins abruptly, causing intense pain, inflammation, and swelling of the affected joint, with low grade fever .....

    Treatment: Emergency action is needed.  Seek medical attention promptly. Antibiotic therapy (medication selection requires drug sensitivity studies of the infecting organism)  Bioassays or bactericidal assays of synovial fluid and bioassays of blood may confirm clearing of the infection....

Read more:
http://www.med-help.net/Arthritis.html (scroll down about halfway)
http://www.health-care-tips.org/diseases/saeptic-arthritis.htm

Other links:

MEDSCAPE SEARCH RESULT (17 documents)
http://search.medscape.com/all-search?newSearch=1&queryText=septic+joints+heroin

SERRATIA ARTHRITIS IN HEROIN USERS
http://www.ejbjs.org/cgi/reprint/57/8/1158

COMPARISON OF BONE AND GALLIUM-67 IMAGING IN HEROIN USERS' ARTHRITIS
"Ninecases of primaryseptic arthritis in heroinaddicts are reported...."
http://jnm.snmjournals.org/cgi/reprint/26/12/1377

OSTEOMYELITIS IN DRUG ADDICTS
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1129346

SEPTIC ARTHRITIS AND OSTEOMYELITIS OF THE SYMPHYSIS PUBIS (OSTEITIS PUBIS) FROM INTRAVENOUS DRUG USE
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1306153

MUSCULOSKELETAL INFECTIONS (Google book search result, p. 205)
http://books.google.com/books?id=CS8-ixLF67gC&pg=PA206&lpg=PA206&dq=septic+arthritis+heroin&source=web&ots=G8qpYbg1nU&sig=o3h2HUTTbTVWpMhV9BM-BIIQq7A#PPA205,M1

I hope that's enough to get you going with some basic information. If you do get time to do a little searching, [septic arthritis heroin] will get you better results than [septic joints]. Also try [osteomyelitis heroin].

My thoughts and prayers are with you and your son in hoping for a good outcome to this crisis.

All my best, 
 
Byrd
uclue Researcher

 

Mon 19 Mar 2007 - 8:05 pm UTC

Question clarification

cynthia
Customer

Today the Doctors are worried that the infection may have spread to his heart. First up is an ultrasound, if that is negative they take a more aggressive look with a microscope down the throat.

They may also have to tap his feet which are not improving yet.

This is a nightmare.

 

Tue 20 Mar 2007 - 1:19 am UTC

Uclue Researcher Answer

nancy
Researcher

Hello again, Cyn.

Usually, it's a pleasure to assist a fellow researcher, but not in a case like this.

David and Byrd have provided you with some helpful resources. In addition to the information I found for you previously, I have researched the newest development in your son's case.

My previous information:

It seems your son's doctors are taking the standard steps. Immediate
surgery to remove fluid is crucial, as is antibiotic therapy.

Naturally, the prognosis improves depending on how early the problem was caught and treated.

Here's a few additional links. I hope these are of some help.

"Septic Arthritis" from the Mayo Clinic:
http://www.mayoclinic.com/health/bone-and-joint-infections/DS00545

"Septic arthritis is an infection in a joint. Bacteria, or less commonly fungi, can spread from other infected areas in your body to the joint. . . germs infiltrate the joint and damage it, causing severe pain. Bacteria most commonly target your knee, though other joints can be affected by septic arthritis."

"Treatment":
http://www.mayoclinic.com/health/bone-and-joint-infections/DS00545/DSECTION=8

HealthCares:
http://bone-muscle.health-cares.net/septic-arthritis-treatment.php

"Rest, immobilization, elevation, and warm compresses may be used at the onset of treatment for pain relief measures. Performing exercises for the affected joint aids the recovery process. Septic arthritis often causes intense pain. Patients are given medications to relieve pain, together with hot compresses or ice packs on the affected joint. In some cases the patient's arm or leg is put in a splint to protect the sore joint from accidental movement. Recovery can be speeded up, however, if the patient practices range-of-motion exercises to the extent that the pain allows."

It may take up to 48 hours for your son to feel the effects of
antibiotics, and he may need anti-fungal meds. After the immediate crisis has passed, he may also require physical therapy.

See Abstract: "Arthroscopic treatment of septic joints: prognostic
factors." By Vispo Seara JL, Barthel T, Schmitz H, Eulert J. at Entrez
PubMed:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12029509&dopt=Abstract

"From 1987 to 1993, 88 patients (average age 48 years, range 3 months to 83 years) with septic arthritis were treated at the orthopaedic clinic Konig Ludwig Haus of the University of Wurzburg by arthroscopic means consisting of joint debridement and application of suction drains, combined with appropriate antibiotics and early functional treatment.. . . At the average follow-up evaluation after 2.5 years (range 6 months to 5 years), the functional results were excellent or good in 61% of the patients,satisfactory in 20% and poor in 19% from our series . . . ."

Factors in patient recovery included age (and your son has youth on his side) and quick medical intervention after the onset of infection and symptoms.

From "Guideline for the management of the hot swollen joint in adults with a particular focus on septic arthritis," by Vivienne Weston and Gerald Coakley, "JAC Advance Access originally published online on July 19, 2006, Journal of Antimicrobial Chemotherapy 2006 58(3):492-493;doi:10.1093/jac/dkl295": 

"The hot swollen joint is a common clinical condition, which has a wide differential diagnosis, the most serious of which that must not be missed being septic arthritis. This has a mortality of up to 11% and results in permanent joint damage in up to a third of patients."

Family Practice Notebook:
http://www.fpnotebook.com/RHE39.htm

"Prognosis
Early joint drainage and antibiotics
Good prognosis

"Delayed management >24 hours
Risk of joint arthrosis, fibrosis and osteonecrosis."

*******************************************************************

As to the new development, the possible spread of the infection to the heart:

From UpToDate Patient,"Patient information: Joint infection," by Don L Goldenberg, MD:
http://patients.uptodate.com/topic.asp?title=heart&file=bone_joi%2F9211&mark=1&submit=find

"BACTERIAL (NONGONOCOCCAL) ARTHRITIS . . .Nongonococcal bacterial arthritis is a potentially destructive form of acute arthritis. Prompt diagnosis and treatment is critical to minimize joint damage. Several factors increase the risk of developing this type of septic arthritis."

" . . .Intravenous drug use: A large number of bacteria can enter the bloodstream when street drugs (eg, heroin) are injected. Endocarditis, an infection within the heart, can occur in this setting, and is often associated with septic arthritis."

For an overview of Endocarditis, see U.S. News & World Report, "Endocarditis," August 31, 2006. This article concerns congenital Endocarditis, but some information here is still relevant to your son's case:

http://www.usnews.com/usnews/health/heart/congenital/congenital.manage.endocarditis.htm

"Endocarditis is a dangerous infection of the endocardium, the lining of the inside of the heart's four chambers. Certain bacteria and other microorganisms that occasionally circulate in the blood may settle and multiply on the heart valves . . . ."

"Treatment of endocarditis may require four to six weeks or more of intravenous antibiotics and may include surgery. Penicillin (amoxicillin/ampicillin) and gentamicin are the most commonly used antibiotics. Other antibiotics can be used as well: vancomycin, cephalosporin, clindamycin, or azithromycin. Although powerful antibiotics are available, treatment can be difficult and complications of endocarditis may occur."

Your son should discuss the antibiotics with his doctors. I do know vancomycin can cause kidney problems in some patients, and sepsis can also cause kidney problems. You may want to ask your son if he has discussed the benefits and possible risks of his specific meds with his doctors.

Tests

According to the paper David referenced, "Septic Arthritis," by Gabriel Munoz, MD and Edmund W Raycraft, MD:
http://www.emedicine.com/orthoped/topic437.htm

"Ultrasound can be used to define the extent of septic arthritis and help guide treatment.

Ultrasound helps to differentiate septic arthritis from other conditions (eg, soft tissue abscesses, tenosynovitis) in which treatment may differ."

Microscope down the Throat

Microorganisms associated with Endocarditis often colonize in the throat. This test is a further attempt to assess any damage to the heart valves and to get a closer look at the infection.

From the CardiologyChannel:
http://www.cardiologychannel.com/endocarditis/diagnosis.shtml

"In some cases of suspected endocarditis, a special type of echocardiogram called a transesophageal echo (TEE) may be performed. A transesophageal echo uses a long tube with a special microphone-like device mounted on one end. The tube is passed through the mouth and throat and then down the esophagus (organ that connects the throat to the stomach, located directly behind the heart). This allows the imaging part of the transesophageal echo to be placed in close proximity to the heart and enables the doctor to obtain high-quality images of the heart and the heart valves.

"This procedure is able to detect more than 90% of heart valve infections . . . ."

You will also see other commonly performed tests for Endocarditis at that page.

Treatment:

From the Mayo Clinic:
http://www.mayoclinic.com/health/endocarditis/DS00409/DSECTION=8

"You may need to take antibiotics for up to six weeks to clear up the infection. Once your fever and the worst of your signs and symptoms have passed, you may be able to leave the hospital and continue antibiotic therapy in an outpatient setting."

From the CardiologyChannel:
http://www.cardiologychannel.com/endocarditis/diagnosis.shtml

"Treatment

Primary treatment for endocarditis involves an intensive course of antibiotics . . . . usually for at least 4 to 6 weeks. For much, if not all of this time, the antibiotics are administered intravenously (i.e., through a vein). To increase the chances of successfully treating the infection, a combination of antibiotics is often used. . .

"Sometimes, the infection is not controlled with antibiotics, and the bacteria continue to grow on the infected heart valve, and possibly in the blood. If this occurs, open heart surgery may be necessary to remove and replace the infected heart valve."

Also see

"Neurological Complications of Endocarditis in Persons Taking Drugs Intravenously,"by Harry Openshaw, MD.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1130040

From the Abstract:

"The clinical and neuropathological features encountered are compared with those reported in persons with endocarditis who were not addicts. The review indicates that neurological complications in nonaddicts and in addicts are similar in type but are more common and severe in addicts."

Read the full paper by following the links under "Full Text."

By "tapping" his foot, I assume you mean they're going to drain the foot to relieve the swelling (and to test the fluid)?

I'm afraid sepsis and Endocarditis require a long recovery period, but it sounds like your son's doctors are being very thorough in their treatment, and in trying to determine just what they're dealing with and the extent of the infection.

The key thing is your son got to a hospital and got help. I'm not sure how quickly he got there following the onset of his symptoms, but he appears to be receiving excellent care, and he certainly is getting loving support from his family.

I hope my Answer is of help, and that your son's condition improves very soon.

Take care,
nancy
uclue Researcher

 
 

Tue 20 Mar 2007 - 2:46 am UTC

Accepted and rated

cynthia
Customer

Thanks Nancy, your answer is just what I needed. As an update, I spoke with his primary Doctor and Cardiologist today. Travis presented in the ER with an astounding array of problems. I also learned from the cardiologist that septic joints are usually a result of a primary infection in the heart (endocarditis) that migrates to other parts of the body, not the other way around. Travis had a preliminary ultrasound today that showed no heart infection, but ultrasound misses half of all endocarditis infections so they are going to do the microscope test (down his throat) Tuesday at 1pm.

Here's his diagnosis, and the results are still trickling in:

Bacterium - (blood infection) is STREP
Septic Arthritis (infected joints) is STAPH - Knee and Ankle
Urinary Tract Infection
Pneumonia
Anemia
Hep C antibodies (inconclusive, he MAY develop full blown Hep C, maybe not)
Dangerously low potassium
Low iron
Malnutrition (even though food was always available!)

And of course the worst one:

(possible) Endocarditis

Except for having what he and I thought was a flu bug, he did not appear this sick until the last 24 hours when the problems grew exponentially. He woke me up at 4am asking to go to the ER. One look at him then and I flew out of bed.

Thanks again Nancy, I'll post back the results of the test tomorrow. If it's positive, he has already been told it is more likely that not, he will remain in the hospital for 4-6 more weeks.

 

Tue 20 Mar 2007 - 4:21 am UTC

Uclue Researcher Comment

nancy
Researcher

The number of problems they've identified so far are certainly astonishing. That's so overwhelming.

It sounds like you got him to the hosptial right after the sepsis symptoms materialized, and prompt medical attention is crucial.

I'm glad to know they're doing the TEE test, as it does sound like endocarditis.

Glad I was able to help you, Cynthia, and thank you for the tip.

Please do update me. In the meantime, I'll be keeping you in my thoughts.

Best,
nancy

 

Tue 27 Mar 2007 - 2:07 pm UTC

Comment

markvmd
User

Cyn, it's been a week; everyone is hopeful for positive news. While you must be terribly busy (and not too likely to see this note), when you get a chance would you provide an update?

 

Fri 30 Mar 2007 - 4:02 pm UTC

Uclue Researcher Comment

nancy
Researcher

Mark, Cynthia is planning to post an update (understandably, she's quite busy) and is grateful for your concern.

I can tell you her son is doing better. I'll leave it to Cynthia to provide any additional information.

Thank you very much for caring enough to ask.

Nancy

 

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