- Email: [email protected]
Procalcitonin, C-reactive protein, and complement-3a assays in synovial fluid for diagnosing septic arthritis: Preliminary results
Letters to the editor / Joint Bone Spine 75 (2008) 235e241
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[5] Trojan DA, Pouchot J, Pokrupa R, et al. Diagnosis and treatment of ossification of the posterior longitudinal ligament of the spine: report of eight cases and literature review. Am J Med 1992;92:296e306. [6] Isnard J, Candon E, Laporte JP, et al. Te´trapare´sie secondaire a` une ossification du ligament commun verte´bral poste´rieur. Rev Neurol 1993;149: 58e61. [7] Epstein N. Diagnosis and surgical management of cervical ossification of the posterior longitudinal ligament. Spine J 2002;2:436e49. [8] Otake S, Matsuo M, Nishizawa S, et al. Ossification of the posterior longitudinal ligament: MR evaluation. AJNR Am J Neuroradiol 1992; 13:1059e67.
Ajja Assou* Military Hospital, Rabat, Morocco Tel.: þ212 61 33 40 43. E-mail address: [email protected] 24 November 2006 Available online 31 December 2007 1297-319X/$ - see front matter Ó 2007 Published by Elsevier Masson SAS. doi:10.1016/j.jbspin.2007.07.013
Procalcitonin, C-reactive protein, and complement-3a assays in synovial fluid for diagnosing septic arthritis: Preliminary results Keywords: Procalcitonin; Synovial fluid; CRP; Infection
The objective of this study was to evaluate the usefulness of measuring procalcitonin, the C3a complement fraction, and C-reactive protein (CRP) in synovial fluid for diagnosing septic arthritis. 1. Methods We retrospectively studied synovial fluid samples obtained between 2000 and 2005 by aspiration of the knee in patients with rheumatoid arthritis (RA), osteoarthritis, or septic arthritis. The samples were stored in dry tubes at 30 C, without prior centrifugation. We excluded samples with incomplete results or presence of crystals. None of the patients received antibiotic therapy before joint fluid aspiration. Procalcitonin was assayed using a chemiluminescent assay ` LUMItest, Brahms, Berlin, Germany) and C3a (BRAHMSO
and CRP using nephelometry with the Immage system (Beck` ). Cytology was performed as well. man CoulterO The ManneWhitney test was used to compare values for procalcitonin, CRP, and leukocyte counts in the three diagnosis groups. P values smaller than 0.05 were considered statistically significant. 2. Results We examined 38 synovial fluid specimens from 30 patients, including 8 specimens with pyogenic septic arthritis, 18 with RA, and 12 with osteoarthritis. Table 1 reports the main findings. The age and sex distribution showed no significant differences across the three groups of patients. Procalcitonin, C3a, and CRP were detected in all three groups. However, procalcitonin and CRP levels were low, close to the detection threshold, in the patients with osteoarthritis. The procalcitonin level was significantly higher in the group with septic arthritis than in the group with osteoarthritis. Procalcitonin levels were also higher in the septic arthritis group compared to the RA group, but the difference fell short of statistical significance. CRP levels differed significantly across the three groups (Fig. 1). C3a levels, in contrast, were not significantly different across the three groups. 3. Discussion Limitations of this preliminary study include the retrospective design, long specimen storage time of up to 5 years, absence of serum assays for comparison with synovial fluid, and small numbers of patients and samples. Nevertheless, our data establish that procalcitonin is detectable in synovial fluid using a standard assay technique. A multicenter study conducted in France evaluated procalcitonin levels in joint fluid and serum from 11 patients with septic arthritis, 18 with RA, and 13 with crystal-induced arthritis [1]. Serum procalcitonin and CRP levels were significantly elevated in the group with septic arthritis. Procalcitonin levels in synovial fluid were also increased in the septic arthritis group, but the difference was not statistically significant, contrary to our finding. Serum procalcitonin was 55% sensitive and 94% specific for septic arthritis, whereas serum CRP was 100% sensitive and 40% specific [1]. In keeping with earlier studies, we found higher CRP levels in synovial fluid in patients with septic arthritis [2]. Our study seems to be the first in which synovial fluid CRP levels were
Table 1 Results of synovial fluid examination in patients with septic arthritis, rheumatoid arthritis, or osteoarthritis
OA RA SA
N
Sex
Age
Leukocytes (/mm3)
CRP (mg/l)
PCT (ng/ml)
C3a (gll)
12 18 8
7M/5F 7M/11F 4M/4F
58 (44e82) 62 (23e75) 66 (50e84)
130 (80e130) 16,950 (60e44,500) 52,000 (28,000e380,000)
1 (1e4) 12.9 (2e27.4) 50 (2e174)
0.105 (0.1e0.19) 0.14 (0.1e0.71) 0.205 (0.1e1.79)
0.275 (0.21e0.39) 0.245 (0.11e0.84) 0.74 (0e1.12)
The data are medians (range). OA, osteoarthritis; RA, rheumatoid arthritis; SA, septic arthritis; N, number; M, male; F, female; CRP, C-reactive protein; PCT, procalcitonin; C3a, the C3a fraction of complement.
Letters to the editor / Joint Bone Spine 75 (2008) 235e241
239
*Corresponding author. Service de rhumatologie, CHU Jean Minjoz, Universite´ de Franche-Comte´, boulevard Fleming, 25030 Besanc¸on, France. Tel.: þ33 3 81 66 82 41; fax: þ33 3 81 66 86 86. E-mail address: [email protected] (D. Wendling) Available online 7 September 2007 1297-319X/$ - see front matter Ó 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2007.07.012
Sacral stress fracture as a cause of gluteal artery injury: An unusual complication of a common fracture Keywords: Stress fracture; Insufficiency fracture; Sacral fracture
Fig. 1. Distribution of synovial fluid C-reactive protein (CRP) levels.
significantly elevated in patients with septic arthritis compared to those with RA (Fig. 1). Data on C3a levels in joint disease are limited. In one study, synovial fluid C3a levels were not significantly different between 5 patients with osteoarthritis and 12 with RA [3]. In synovial fluid samples, CRP levels seem better than procalcitonin levels for assisting in the diagnosis of septic arthritis. Furthermore, our study seems to supply the first evidence that synovial fluid CRP levels may be significantly higher in septic arthritis than in RA. Available data suggest limited usefulness of C3a. References [1] Martinot M, Sordet C, Soubrier M, et al. Diagnostic value of serum and synovial procalcitonin in acute arthritis: a prospective study of 42 patients. Clin Exp Rheumatol 2005;23:303e10. [2] Castelli GP, Pognani C, Meisner M, et al. Procalcitonin and C-reactive protein during systemic inflammatory response syndrome, sepsis and organ dysfunction. Crit Care 2004;8:R234e42. [3] Neumann E, Barnum SR, Tarner IH, et al. Local production of complement proteins in rheumatoid arthritis synovium. Arthritis Rheum 2002; 46:934e45.
Ge´rald Streit Rheumatology Department, Minjoz Teaching Hospital, Besanc¸on, France Daniel Alber Marie Madeleine Toubin Medical Biochemistry Department, Minjoz Teaching Hospital, Besanc¸on, France Eric Toussirot Daniel Wendling Rheumatology Department, Minjoz Teaching Hospital, Besanc¸on, France
Stress fractures (SF) are common over-use injuries that can reflect a decreased resistance in bone. Several pathological disorders may decrease bone resistance and predispose the development of these fractures. Among them, osteoporosis seems to be the most commonly associated condition. Other processes such as rheumatoid arthritis, Paget’s bone disease, osteomalacia or radiotherapy may also predispose the development of SF [1]. Among these fractures, pelvic fractures are one of the most frequent SF in rheumatological practice and are also fairly common in older patients [1,2]. In general terms, the clinical course of pelvic SF is satisfactory after rest; however, some patients may develop clinical complications. Indeed, recent data indicate that pelvic fractures are associated with an increased morbidity and mortality in the elderly population [3,4]. Other complications such as associated vascular injuries are rare; they have been previously reported only in relation to traumatic pelvic fractures [5,6]. We describe a case of an injury of the superior gluteal artery associated with an initially undetected SF of the sacroiliac joint in an 83-year-old female patient. The patient was admitted to the rheumatology department because of a 2-week history of severe and progressive buttock pain on the right side associated with a marked functional impairment. She also referred to groin pain on left side 6 weeks ago that partially improved with rest and analgesic therapy. She had a previous history of Parkinson’s disease and uterine carcinoma that was treated with hysterectomy and radiotherapy 26 years ago. The clinical examination revealed a palpable and painful mass in the right buttock. She denied any traumatism, fall or previous fractures. Pelvis X-rays showed a displaced right sacro-iliac fracture and left iliac and ischio-pubic ramus fractures (Fig. 1). Routine laboratory tests revealed a microcytic anemia. In proteinogram, renal and liver function test, calcium and phosphate were in normal ranges. Tumoral markers were negative. Pelvic magnetic resonance imaging (MRI) and computer tomography (CT) disclosed a well-defined mass (sized 12 15 cm) over the gluteal muscle next to right sacro-iliac joint associated with a displaced right iliac bone
238
[5] Trojan DA, Pouchot J, Pokrupa R, et al. Diagnosis and treatment of ossification of the posterior longitudinal ligament of the spine: report of eight cases and literature review. Am J Med 1992;92:296e306. [6] Isnard J, Candon E, Laporte JP, et al. Te´trapare´sie secondaire a` une ossification du ligament commun verte´bral poste´rieur. Rev Neurol 1993;149: 58e61. [7] Epstein N. Diagnosis and surgical management of cervical ossification of the posterior longitudinal ligament. Spine J 2002;2:436e49. [8] Otake S, Matsuo M, Nishizawa S, et al. Ossification of the posterior longitudinal ligament: MR evaluation. AJNR Am J Neuroradiol 1992; 13:1059e67.
Ajja Assou* Military Hospital, Rabat, Morocco Tel.: þ212 61 33 40 43. E-mail address: [email protected] 24 November 2006 Available online 31 December 2007 1297-319X/$ - see front matter Ó 2007 Published by Elsevier Masson SAS. doi:10.1016/j.jbspin.2007.07.013
Procalcitonin, C-reactive protein, and complement-3a assays in synovial fluid for diagnosing septic arthritis: Preliminary results Keywords: Procalcitonin; Synovial fluid; CRP; Infection
The objective of this study was to evaluate the usefulness of measuring procalcitonin, the C3a complement fraction, and C-reactive protein (CRP) in synovial fluid for diagnosing septic arthritis. 1. Methods We retrospectively studied synovial fluid samples obtained between 2000 and 2005 by aspiration of the knee in patients with rheumatoid arthritis (RA), osteoarthritis, or septic arthritis. The samples were stored in dry tubes at 30 C, without prior centrifugation. We excluded samples with incomplete results or presence of crystals. None of the patients received antibiotic therapy before joint fluid aspiration. Procalcitonin was assayed using a chemiluminescent assay ` LUMItest, Brahms, Berlin, Germany) and C3a (BRAHMSO
and CRP using nephelometry with the Immage system (Beck` ). Cytology was performed as well. man CoulterO The ManneWhitney test was used to compare values for procalcitonin, CRP, and leukocyte counts in the three diagnosis groups. P values smaller than 0.05 were considered statistically significant. 2. Results We examined 38 synovial fluid specimens from 30 patients, including 8 specimens with pyogenic septic arthritis, 18 with RA, and 12 with osteoarthritis. Table 1 reports the main findings. The age and sex distribution showed no significant differences across the three groups of patients. Procalcitonin, C3a, and CRP were detected in all three groups. However, procalcitonin and CRP levels were low, close to the detection threshold, in the patients with osteoarthritis. The procalcitonin level was significantly higher in the group with septic arthritis than in the group with osteoarthritis. Procalcitonin levels were also higher in the septic arthritis group compared to the RA group, but the difference fell short of statistical significance. CRP levels differed significantly across the three groups (Fig. 1). C3a levels, in contrast, were not significantly different across the three groups. 3. Discussion Limitations of this preliminary study include the retrospective design, long specimen storage time of up to 5 years, absence of serum assays for comparison with synovial fluid, and small numbers of patients and samples. Nevertheless, our data establish that procalcitonin is detectable in synovial fluid using a standard assay technique. A multicenter study conducted in France evaluated procalcitonin levels in joint fluid and serum from 11 patients with septic arthritis, 18 with RA, and 13 with crystal-induced arthritis [1]. Serum procalcitonin and CRP levels were significantly elevated in the group with septic arthritis. Procalcitonin levels in synovial fluid were also increased in the septic arthritis group, but the difference was not statistically significant, contrary to our finding. Serum procalcitonin was 55% sensitive and 94% specific for septic arthritis, whereas serum CRP was 100% sensitive and 40% specific [1]. In keeping with earlier studies, we found higher CRP levels in synovial fluid in patients with septic arthritis [2]. Our study seems to be the first in which synovial fluid CRP levels were
Table 1 Results of synovial fluid examination in patients with septic arthritis, rheumatoid arthritis, or osteoarthritis
OA RA SA
N
Sex
Age
Leukocytes (/mm3)
CRP (mg/l)
PCT (ng/ml)
C3a (gll)
12 18 8
7M/5F 7M/11F 4M/4F
58 (44e82) 62 (23e75) 66 (50e84)
130 (80e130) 16,950 (60e44,500) 52,000 (28,000e380,000)
1 (1e4) 12.9 (2e27.4) 50 (2e174)
0.105 (0.1e0.19) 0.14 (0.1e0.71) 0.205 (0.1e1.79)
0.275 (0.21e0.39) 0.245 (0.11e0.84) 0.74 (0e1.12)
The data are medians (range). OA, osteoarthritis; RA, rheumatoid arthritis; SA, septic arthritis; N, number; M, male; F, female; CRP, C-reactive protein; PCT, procalcitonin; C3a, the C3a fraction of complement.
Letters to the editor / Joint Bone Spine 75 (2008) 235e241
239
*Corresponding author. Service de rhumatologie, CHU Jean Minjoz, Universite´ de Franche-Comte´, boulevard Fleming, 25030 Besanc¸on, France. Tel.: þ33 3 81 66 82 41; fax: þ33 3 81 66 86 86. E-mail address: [email protected] (D. Wendling) Available online 7 September 2007 1297-319X/$ - see front matter Ó 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2007.07.012
Sacral stress fracture as a cause of gluteal artery injury: An unusual complication of a common fracture Keywords: Stress fracture; Insufficiency fracture; Sacral fracture
Fig. 1. Distribution of synovial fluid C-reactive protein (CRP) levels.
significantly elevated in patients with septic arthritis compared to those with RA (Fig. 1). Data on C3a levels in joint disease are limited. In one study, synovial fluid C3a levels were not significantly different between 5 patients with osteoarthritis and 12 with RA [3]. In synovial fluid samples, CRP levels seem better than procalcitonin levels for assisting in the diagnosis of septic arthritis. Furthermore, our study seems to supply the first evidence that synovial fluid CRP levels may be significantly higher in septic arthritis than in RA. Available data suggest limited usefulness of C3a. References [1] Martinot M, Sordet C, Soubrier M, et al. Diagnostic value of serum and synovial procalcitonin in acute arthritis: a prospective study of 42 patients. Clin Exp Rheumatol 2005;23:303e10. [2] Castelli GP, Pognani C, Meisner M, et al. Procalcitonin and C-reactive protein during systemic inflammatory response syndrome, sepsis and organ dysfunction. Crit Care 2004;8:R234e42. [3] Neumann E, Barnum SR, Tarner IH, et al. Local production of complement proteins in rheumatoid arthritis synovium. Arthritis Rheum 2002; 46:934e45.
Ge´rald Streit Rheumatology Department, Minjoz Teaching Hospital, Besanc¸on, France Daniel Alber Marie Madeleine Toubin Medical Biochemistry Department, Minjoz Teaching Hospital, Besanc¸on, France Eric Toussirot Daniel Wendling Rheumatology Department, Minjoz Teaching Hospital, Besanc¸on, France
Stress fractures (SF) are common over-use injuries that can reflect a decreased resistance in bone. Several pathological disorders may decrease bone resistance and predispose the development of these fractures. Among them, osteoporosis seems to be the most commonly associated condition. Other processes such as rheumatoid arthritis, Paget’s bone disease, osteomalacia or radiotherapy may also predispose the development of SF [1]. Among these fractures, pelvic fractures are one of the most frequent SF in rheumatological practice and are also fairly common in older patients [1,2]. In general terms, the clinical course of pelvic SF is satisfactory after rest; however, some patients may develop clinical complications. Indeed, recent data indicate that pelvic fractures are associated with an increased morbidity and mortality in the elderly population [3,4]. Other complications such as associated vascular injuries are rare; they have been previously reported only in relation to traumatic pelvic fractures [5,6]. We describe a case of an injury of the superior gluteal artery associated with an initially undetected SF of the sacroiliac joint in an 83-year-old female patient. The patient was admitted to the rheumatology department because of a 2-week history of severe and progressive buttock pain on the right side associated with a marked functional impairment. She also referred to groin pain on left side 6 weeks ago that partially improved with rest and analgesic therapy. She had a previous history of Parkinson’s disease and uterine carcinoma that was treated with hysterectomy and radiotherapy 26 years ago. The clinical examination revealed a palpable and painful mass in the right buttock. She denied any traumatism, fall or previous fractures. Pelvis X-rays showed a displaced right sacro-iliac fracture and left iliac and ischio-pubic ramus fractures (Fig. 1). Routine laboratory tests revealed a microcytic anemia. In proteinogram, renal and liver function test, calcium and phosphate were in normal ranges. Tumoral markers were negative. Pelvic magnetic resonance imaging (MRI) and computer tomography (CT) disclosed a well-defined mass (sized 12 15 cm) over the gluteal muscle next to right sacro-iliac joint associated with a displaced right iliac bone