RHEUMATOLOGY
Managing bone and
joint infections in
rheumatological disease
This review aims to highlight and address the challenges in presentation, investigation and
management of septic arthritis and vertebral osteomyelitis in adults treated with biologic therapies
Georgina Beckley
MBBS MRCP FRCPath
Elizabeth Darley
MBChB MRCP
FRCPath MD
North Bristol NHS Trust,
Bristol, UK
Bone and joint infections are an important cause
of morbidity and mortality worldwide,
particularly in those with inflammatory arthritis.
In the US, the prevalence of septic arthritis is
2–10/100,000 but rises to 30–70/100,000 in
patients with rheumatoid arthritis. Patients with
underlying rheumatological conditions are at an
increased risk of infection due to existing
abnormal joints (in the case of inflammatory
arthritis), as well as immunosuppressive
therapies. The British Biologics Register data
shows that the risk of patients with rheumatoid
arthritis developing septic arthritis doubles in
patients treated with biologic therapy compared
with non-biologic therapy. 1 Overlapping symptoms
A history of pain, swelling and fever as well as
classical symptoms of infection could also be due
to the patient’s underlying inflammatory
arthritis. This can lead to a delay in diagnosis.
Even in patients without underlying
rheumatological disease, the delay in diagnosis
can range from two weeks to nine months. 2
A rheumatological flare may affect several joints;
however, if only a sterile joint is aspirated for
microscopy and culture this could then lead to
a missed infected joint elsewhere.
Clinical manifestations
The classical signs and symptoms of bone and
joint infection are joint pain, fever and swelling.
Presentation of bone and joint infections in
patients with rheumatological conditions can be
variable and more indolent. Correct diagnosis and
management can therefore require a higher index
of suspicion. Immunosuppressed state
The other consideration is that both the use of
immunosuppressive agents and the underlying
inflammatory arthritis can alter the response of
the immune system to infection. This makes
patients more prone to acquiring an infection;
but also once an infection has occurred, can make
the symptoms and signs more insidious.
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HHE 2019 | hospitalhealthcare.com
There are two major challenges: overlapping
symptoms and an immunosuppressed state.