Letter to the Editor
False Negatives of Synovial Fluid in Septic Arthritis
Falsos negativos del líquido sinovial en la artritis séptica
Joaquín Anino-Fernández
, Marco Aurelio Ramírez-Huaranga, María Dolores Mínguez-Sanchez
Corresponding author
Servicio de Reumatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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array:4 [ "autoresLista" => "Joaquín Anino-Fernández, Marco Aurelio Ramírez-Huaranga, María Dolores Mínguez-Sanchez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Joaquín" "apellidos" => "Anino-Fernández" "email" => array:1 [ 0 => "michaelturra@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Marco Aurelio" "apellidos" => "Ramírez-Huaranga" ] 2 => array:2 [ "nombre" => "María Dolores" "apellidos" => "Mínguez-Sanchez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Reumatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Falsos negativos del líquido sinovial en la artritis séptica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The analysis of the synovial fluid (SF) is a fundamental tool in the study of monoarthritis, as it reflects changes in the synovial membrane and underlying articular cartilage. The findings in the SF are essential in infectious and crystal arthritis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">To date, SF culture continues to be the gold standard for the microbiological diagnosis of septic arthritis.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> The pathogen most frequently isolated in septic joint processes is <span class="elsevierStyleItalic">Staphylococcus aureus</span> (50%–60%), followed by streptococci, found in up to 20% of the cases. Gram-negative bacilli are the cause in only 5%–10% of the cases of septic arthritis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a patient who experienced an episode of septic arthritis in which the SF study showed no evidence of inflammation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 49-year-old man with no toxic habits. He had a history of untreated Rendu–Osler–Weber disease. He presented with monoarthritis in the left knee that had developed several days earlier, without fever or any other accompanying symptoms.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On physical examination, he was afebrile. The only significant finding was joint effusion with functional impairment and inflammation in left knee. He underwent arthrocentesis, which yielded 10<span class="elsevierStyleHsp" style=""></span>mL of SF with inflammatory features: 12,500<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<span class="elsevierStyleSup">3</span>, predominance of polymorphonuclear cells (95%) and glucose level of 82<span class="elsevierStyleHsp" style=""></span>mg/dL. No crystals were observed in a microscopic study. Gram stain was negative. Laboratory tests revealed no evidence of leukocytosis (6100<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>leukocytes, 62% neutrophils and 27% lymphocytes), but showed elevated acute phase reactants (C-reactive protein 1.4<span class="elsevierStyleHsp" style=""></span>mg/dL; fibrinogen: 600<span class="elsevierStyleHsp" style=""></span>mg/dL). The study was completed with radiographies of the knees, which revealed conserved alignment and mineralization, and no periosteal reaction or erosions. While waiting for the results of the microbiological study, we started treatment with nonsteroidal anti-inflammatory drugs (NSAID). Five days after this episode, he presented with more intense pain, without fever or any other symptoms. The physical examination revealed joint effusion and inflammation in left knee, with no other significant changes. Arthrocentesis was repeated, and yielded 38<span class="elsevierStyleHsp" style=""></span>mL of SF with no inflammatory features: 1960<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<span class="elsevierStyleSup">3</span>, 35% polymorphonuclear cells and glucose level of 84<span class="elsevierStyleHsp" style=""></span>mg/dL. However, methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> was identified in 2 separate SF cultures. Urine sediment was normal and blood and urine cultures were negative. The study was completed with bone scintigraphy and labeled white blood cell scan—both of which were positive for septic arthritis—and chest radiography and echocardiography, which ruled out lung and cardiac involvement. Laboratory tests revealed positivity for HLA-B27. Antibiotic therapy was begun with ceftriaxone 2<span class="elsevierStyleHsp" style=""></span>g every 24<span class="elsevierStyleHsp" style=""></span>h and cloxacillin 2<span class="elsevierStyleHsp" style=""></span>g every 6<span class="elsevierStyleHsp" style=""></span>h. Emergency surgical joint lavage with saline solution was carried out. Subsequent cultures were negative. No cancer cells were found in the pathological study. The patient remained in the hospital until he had completed a 15-day intravenous treatment. He experienced clinical improvement, remission of the infectious process and recovery of knee function.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although the study of the SF is fundamental and of great help in monoarthritis, in certain specific situations (immunosuppression, previous antibiotic use, and chronic or very acute conditions), the results do not clearly reveal what is taking place at the level of the joints. Thus, the microbiological study continues to be the gold standard for the diagnosis of septic arthritis.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> In these situations, tests like bone scintigraphy or positron emission tomography (PET) lend great support to the diagnosis. Moreover, we found that the Gram stain currently used for SF is of no value in the diagnosis of septic arthritis, as the rate of false negatives ranges from 25% to 50%, according to the literature,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> and was as high as 78% in a retrospective study conducted by the Manchester Royal Infirmary.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> This makes the technique a tool of little use when the clinical picture constitutes an orthopedic emergency with significant morbidity and a mortality of up to 11%.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4,9</span></a> Investigation is underway to find alternative diagnostic techniques, such as the use of lithium heparin containers for SF sample collection to prevent coagulation. These modification are being assessed in order to quantify the extent to which they will reduce false negatives with Gram staining in SF.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7–10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Finally, we can conclude that early diagnosis is essential to limit the morbidity and mortality. A delay in the treatment of septic arthritis can lead to the rapid destruction of the articular cartilage.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–8</span></a> Thus, given the high rate of false negatives with Gram staining, it is necessary either to improve the diagnostic techniques or dissociate SF from the process taking place at the level of the joint.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Anino-Fernández J, Ramírez-Huaranga MA, Mínguez-Sanchez MD. Falsos negativos del líquido sinovial en la artritis séptica. Reumatol Clin. 2016;12:114–115.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aparato locomotor: exploraciones complementarias en Atención Primaria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "SemFYC" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2007" "editorial" => "Sociedad Española de Medicina de Familia y Comunitaria" "editorialLocalizacion" => "Barcelona" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Freire González M. Pruebas de laboratorio en Reumatología. Guía fisterra. Available from: <a id="intr0015" class="elsevierStyleInterRef" href="http://www.fisteraaocom/">http://www.fisteraaocom</a> [accessed 04.05.12]." ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint adults" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "British Society for Rheumatology Standards, Guidelines and Audit Working Group" "etal" => true "autores" => array:6 [ 0 => "G. Coakley" 1 => "C. Mathew" 2 => "M. Field" 3 => "A. Jones" 4 => "G. Kingsley" 5 => "D. Walker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rheumatology (Oxford)" "fecha" => "2006" "volumen" => "45" "paginaInicial" => "1039" "paginaFinal" => "1041" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The outcome of bacterial arthritis a prospective community-based study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.J. Kaandorp" 1 => "P. Krijnen" 2 => "H.J. Moens" 3 => "J.D. Habbema" 4 => "D. van Schaardenburg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/1529-0131(199705)40:5<884::AID-ART15>3.0.CO;2-6" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "1997" "volumen" => "40" "paginaInicial" => "884" "paginaFinal" => "891" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9153550" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidence-based diagnosis: adult septic arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.R. Carpenter" 1 => "I.D. Schuur" 2 => "W.W. Everett" 3 => "J.M. Pìnes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1553-2712.2011.01121.x" "Revista" => array:6 [ "tituloSerie" => "Acad Emerg Med" "fecha" => "2011" "volumen" => "18" "paginaInicial" => "781" "paginaFinal" => "796" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21843213" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Synovial fluid analysis. A critical reappraisal" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.H. Shemerling" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rheum Dis Clin North Am" "fecha" => "1994" "volumen" => "20" "paginaInicial" => "503" "paginaFinal" => "512" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8016423" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Septic arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.L. Goldenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(97)09522-6" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "1998" "volumen" => "351" "paginaInicial" => "197" "paginaFinal" => "202" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9449882" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "False negative rate of Gram-stain microscopy for diagnosis of septic arthritic: Suggestions for improvement" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Stirding" 1 => "R. Faroung" 2 => "S. Amanat" 3 => "A. Ahmed" 4 => "M. Armstrong" 5 => "P. Sharma" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Int J Microbiol" "fecha" => "2014" "volumen" => "2014" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Septhic arthritis (non-gonococcal) of the adult: practical aspects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Vostrel" 1 => "L. Legout" 2 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 51 | 16 | 67 |
| 2024 September | 76 | 19 | 95 |
| 2024 August | 87 | 39 | 126 |
| 2024 July | 73 | 28 | 101 |
| 2024 June | 58 | 37 | 95 |
| 2024 May | 75 | 25 | 100 |
| 2024 April | 73 | 18 | 91 |
| 2024 March | 80 | 40 | 120 |
| 2024 February | 64 | 29 | 93 |
| 2024 January | 51 | 28 | 79 |
| 2023 December | 46 | 30 | 76 |
| 2023 November | 75 | 26 | 101 |
| 2023 October | 78 | 40 | 118 |
| 2023 September | 77 | 48 | 125 |
| 2023 August | 74 | 15 | 89 |
| 2023 July | 73 | 29 | 102 |
| 2023 June | 65 | 25 | 90 |
| 2023 May | 67 | 31 | 98 |
| 2023 April | 44 | 14 | 58 |
| 2023 March | 58 | 27 | 85 |
| 2023 February | 49 | 33 | 82 |
| 2023 January | 39 | 15 | 54 |
| 2022 December | 63 | 42 | 105 |
| 2022 November | 47 | 34 | 81 |
| 2022 October | 51 | 43 | 94 |
| 2022 September | 58 | 34 | 92 |
| 2022 August | 51 | 48 | 99 |
| 2022 July | 28 | 40 | 68 |
| 2022 June | 46 | 53 | 99 |
| 2022 May | 62 | 35 | 97 |
| 2022 April | 91 | 41 | 132 |
| 2022 March | 76 | 66 | 142 |
| 2022 February | 62 | 32 | 94 |
| 2022 January | 65 | 58 | 123 |
| 2021 December | 48 | 48 | 96 |
| 2021 November | 47 | 45 | 92 |
| 2021 October | 181 | 60 | 241 |
| 2021 September | 54 | 41 | 95 |
| 2021 August | 70 | 30 | 100 |
| 2021 July | 33 | 48 | 81 |
| 2021 June | 53 | 32 | 85 |
| 2021 May | 58 | 42 | 100 |
| 2021 April | 147 | 82 | 229 |
| 2021 March | 63 | 28 | 91 |
| 2021 February | 42 | 23 | 65 |
| 2021 January | 44 | 17 | 61 |
| 2020 December | 58 | 19 | 77 |
| 2020 November | 56 | 22 | 78 |
| 2020 October | 30 | 10 | 40 |
| 2020 September | 53 | 21 | 74 |
| 2020 August | 27 | 14 | 41 |
| 2020 July | 21 | 18 | 39 |
| 2020 June | 37 | 15 | 52 |
| 2020 May | 66 | 12 | 78 |
| 2020 April | 45 | 15 | 60 |
| 2020 March | 11 | 7 | 18 |
| 2020 February | 1 | 0 | 1 |
| 2018 May | 2 | 0 | 2 |
| 2018 April | 57 | 6 | 63 |
| 2018 March | 44 | 8 | 52 |
| 2018 February | 37 | 3 | 40 |
| 2018 January | 27 | 6 | 33 |
| 2017 December | 30 | 7 | 37 |
| 2017 November | 39 | 7 | 46 |
| 2017 October | 15 | 6 | 21 |
| 2017 September | 18 | 4 | 22 |
| 2017 August | 16 | 10 | 26 |
| 2017 July | 20 | 11 | 31 |
| 2017 June | 31 | 21 | 52 |
| 2017 May | 33 | 14 | 47 |
| 2017 April | 26 | 5 | 31 |
| 2017 March | 8 | 8 | 16 |
| 2017 February | 13 | 13 | 26 |
| 2017 January | 15 | 7 | 22 |
| 2016 December | 46 | 15 | 61 |
| 2016 November | 34 | 15 | 49 |
| 2016 October | 49 | 13 | 62 |
| 2016 September | 46 | 9 | 55 |
| 2016 August | 31 | 10 | 41 |
| 2016 July | 28 | 9 | 37 |
| 2016 May | 1 | 0 | 1 |
| 2016 April | 2 | 22 | 24 |
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