details about infectitious arthritis by dr manoj kandoi , leading orthopedic and arthritis expert from Thane district

1. About The Author
Dr Manoj R. kandoi is the founder president of “Institute of Arthritis Care & Prevention”
an NGO involved in the field of patient education regarding arthritis. Besides providing
literature to patient & conducting symposiums, the institute is also engaged in creating
patients “Self Help Group” at every district level. The institute also conducts a certificate
course for healthcare professionals & provide fellowship to experts in the field of
arthritis.
The author has many publications to his credit in various journals. He has also written a
book “ The Basics Of Arthritis” for healthcare professionals.
The author can be contacted at:
Dr manoj R. kandoi
C-202/203 Navare Arcade
Shiv Mandir Road, Opposite Dena Bank
Shiv mandir Road, Opposite Dena bank
Shivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501
State: Maharashtra Ph: (0251)2602404 Country: India
Membership Application forms of the IACR for patients & healthcare professionals
can be obtained from.
Institute of Arthritis Care & Prevention
C/o Ashirwad Hospital
Almas mension, SVP Road, New Colony,
Ambarnath(W) Pin:421501 Dist: Thane
State: Maharashtra Country: India
Ph: (0251) 2681457 Fax: (0251)2680020
Mobile ;9822031683
Email: drkandoi@yahoo.co.in
Preface:
Studies have shown that people who are well informed & participate actively in
their own care experience less pain & make fewer visits to the doctor than do other
people with arthritis. Unfortunately in India & many third world countries we do not
have patient education & arthritis self management programs as well as support groups.
This is an attempt to give a brief account of various arthritis, their prevention & self
management methods which can serve as useful guide to the patients of arthritis.
It would be gratifying if the sufferers of the disease knew most of what is given in the
book.
Acknowledgement
I am thankful to Dr (Mrs) Sangita Kandoi for her immense help in proofreading & for her
invaluable suggestions. The help rendered by Nisha Jaiswal is probably unrivalled.
Thanks also to vidya, praveen, rizwana and parvati for their continous support
throughout the making of the book. The author is grateful to his family for the constant
inspiration they offered. The author alone is responsible for the shortcoming in this piece
of work. He welcomes suggestions for improvement from the readers.

2. Infectious Arthritis:
Septic Arthritis: This is an arthritis caused by pyogenic organisms. It may be acute,
subacute or chronic depending upon duration.
Aetio-Pathogenesis:
Etiological Agents: These include in decreasing order of frequency
 Staphylococcus aureus
 Streptococci
 Staphylococcus epidermidis
 Pheumococci
 Pseudomonos aeruginosa
 Haemophilus influenzae (commonest cause of arthritis in children below 2 years
of age)
 Polymicrobial infection.
Predisposing conditions:
-Underlying chronic joint disease -Malignancy
-Trauma -Immunosuppresive drug therapy
-Joint involvement in RA -Parenteral drug abuse
-Diabetes mellitus -Recent joint infection
-Steroid administration -Injection or Aspiration
-Renal failure -Vascular insufficiency
Commonest joint involved: In decreasing order of frequency these are:
I) Knee II) Hip III) Elbow IV) Shoulder V) Wrist VI) Ankle
Methods of spread: The organisms reach the joint by one of the following routes:
a) Haematogenous: This is the commonest route. There may be a primary focus of
infection such as Septicemia, Skin infection, URTI etc.
b) Secondary to Osteomyelitis: In joints of Hip, Shoulder etc. with intraarticular
metaphysis spread to joints may occur from osteomyelitis.
c) Penetrating wounds : e.g. Superficial joint injuries like knee joint.
d) Latrogenic: This includes
I. Intraarticular steroid injections
II. Femoral artery punctures for blood collection
Pathology
Depending upon the evidence of organisms and individual body resistance, three types of
exudation of fluid in the joint may occur:
The serous type:
Join is distended with clear serous fluid and is associated with mild inflammatory
hyperaemia of vessels of synovial membrane and capsule

3. Prognosis
Complete recovery Recovery Seropurulent Purulent
followed by arthritis arthritis
recurrence
Serofibrinous Arthritis:
Here the synovial membrane is hyperaemic and inflamed with serofibrinous exudate
covering the joint aspect. The cavity is filled with cloudy fluid containing a large number
of polymorphs and a few large mononuclear cells. Since there is associated periarticular
inflammation adhesions may occur. In early stages organisms may be demonstrated.
Purulent Arthritis:
The joint cavity is filled with pus containing large numbers of polymorphs, bacteria,
RBCs and fibrin. The capsule and synovial membrane are infilterated with leucocytes and
engorged and there may be small areas of focal necrosis or fatty degeneration.
Pathology Radiographic Corelation
Fibrous or bony ankylosis Bony ankylosis
Pannus with cartilage destruction Joint space loss
Increased blood flow Osteopenia
Arthritic advanced destruction Joint deformity
Pannus with bony destruction Erosions
Fluid accumulation and synovial Periarticular soft tissues
Edema swelling
Clinical Feature:
Symptoms:
1. Continuous severe throbbing pain disturbing sleep
2. Swelling and redness of joint
3. Inability to use the joint
4. Fever is present in 50% of cases
5. Patient may present with pseudoparalysis
6. In subacute form, limp may be the presenting
complaint.
NORMAL FIBROUS BONY
JOINT ANKYLOSIS ANKYLOSIS
Signs:
1. Child is generally severely toxic with a high temperature and tachycardia
2. Joint is swollen and held in the position of ease

4. 3. Palpation: local warmth, effusion and tenderness can be elicited
4. ROM: severely restricted and painful.
Septic arthritis in animal bite:
May occur due to bite by dogs, cats and rodents. Commonest organisms are pasturella
multocida, staphylococcus aureus and streptococcus sp. etc. Treatment of p. multocida
infection should include penicillin G.
Polyarticular septic arthritis:
Uncommon with an incidence of around 10%. Usually seen in immunosuppressed,
immunodeficient, immunocompromised patients, rheumatoid arthritis, multiple
arthroplasties. The mortality rate is
approximately 25%.
Investigations:
A. Radiological examination:
Early stage: Soft tissue shadows of joint swelling can be seen.
Late stage: Joint space is narrowed with irregularity of joint margins.
Ocassionally there may be a subluxation or dislocation of the joint.
B. Haematological investigation:
 Neurophilic leucocytosis and raised ESR can be seen
 HIV if polyarticular or adult patient
 Blood culture may be positive in some cases.
C. Joint aspiration:
Synovial fluid examination
Points Normal Non-Inflammatory Inflammatory Septic
Gross
examination
Volume (Ml) Often < 3.5ml Often> 3.5ml Often> 3.5ml > 3.5ml
Viscosity High High Low Variable
Colour Colourless Straw Yellow Variable
Examination in Lab Yellow
Clarity Transparent Transparent Translucent Opaque
Examination in Lab
WBC count < 200 200-2000 2000- 7500 > 10000
PMN < 25% < 25% >50% > 75%
Leucocytes
Culture - - - +
Mucin clot Firm Firm Friable Friable
Crystal examination may be done in suspected pseudogout.< 25 mg% of
Glucose Equal to Nearly equal > 25 mg%
Level blood glucose to blood glucose blood glucose of blood glucose

5. Role of specialized radiographic studies in septic arthritis:
1. Bone scan:
a. Technetium bone scan: is often positive in 1-2 days but lacks specificity.
b. Gallium scan: It is more specific but lacks sensitivity, gallium scan is more useful
in children with growth plate abnormalities.
c. WBC lebelled indium scan: It is more specific as it relies on migration of WBC to
the site of infection. It is the preferred modality in joint replacement surgeries.
2. CT scan: It may be useful in S1 joint or sternoclavicular joint infection.
3. MRI: It provides early detection of soft tissue changes such as edema and effusion. It
also
demonstrates osteomyelitis.
Acute monoarticular Chronic monoarticular Polyarticular
Differential Diagnosis of Arthritis Syndromes:
Arthritis arthritis arthritis
Staphylococcus Mycobacterium Neisseria meningitis
aureus tuberculosis
Streptococcus Atypical mycobacteria Neisseria gonorrhoea
pneumoniae
 hemolytic Lyme disease Nongonococcal
streptococci bacterial arthritis
Gram-negative Treponema pallidum Bacterial endocarditis
bacillae
Neisserra gonorrhoea Candida species Candida species
Fracture Nocardia species Poncet's disease
Haemarthrosis Brucella species
Osteoarthritis Legg calve perthes Viral lesions
disease
Monoarticular RA Osteoarthritis Reactive arthritis
Crystal induced Serum sickness
arthritis
Ischaemic necrosis Acute rheumatic fever
Inflammatory bowel
disease
SLE
RA/Still's disease
Other vasculitides
sarcoidosis
Organisms commonly found in different age groups of childhood septic arthritis:
Neonates: - Staphylococcus Aureus (Hospital acquired)
- Streptococci
- Gram-negative bacilli
Age < 2 year - Hemophilus influenzae
- Staphylococcus aureus
Age 2-15 years - Staphylocossus aureus
- Streptococcus pyogenes

6. Differentiating features between gonococcal and nongonococcal septic arthritis:
Gonococcal Nongonococcal
Personality of Young, healthy adults Infants, elderly, immuno-compromised.
Pattern Migratory polyarthlgias/ single joint
arthritis
Tenosynovitis ++ Rare
Skin Lesions ++ Rare
Joint culture Rarely positive +++
Blood culture Rarely positive ++ (40-50%)
Prognosis good in > 95% Poor in half of the patients
Pseudoseptic arthritis:
This term is used when synovial fluid WBC count is more than > 100,000 cells/mm3,
with cultures and staining negative, Commonest type is poorly controlled rheumatoid
arthritis which responds to
increased carticosteroids dosage (not to antibiotics). Other DID include crystal induced
arthrides and seronegative spondyloarthropathies,
Diagnostic clues for septic arthritis coexisting with hemarthrosis:
 Failure of joint to resolve with factor replacement
 Raised WBC count
 HIV infection and other predisposing factors point towards septic arthritis
 Previous joint aspiration, surgery
 Underlying joint damage (chronic arthropathy).
Treatment protocol:
Septic arthritis
Antibiotics based on Aspiration and Supporting therapy
-Age intra articular Immobilization
antibiotics Passive ROM
-Source of (multiple after 48 hours
infection aspirations Active ROM
-Clinical several times exercises once
presentation a day) pain resolves
-Gram Analgesic
staining
-Culture Failure
sensitivity Surgical drainage
(In indicated cases)

7. Absolute indications for drainage in a septic joint:
1. Infected hip joints and probably shoulder joints
2. Prosthetic joints.
3. Inability to remove purulent fluid by needle drainage because fluid is too thick or
laculated.
4. Vertebral osteomyelitis with cord compression.
5. Anatomically difficult to drain joints e.g. sternoclavicular joint.
6. Arthritis associated with foreign body.
7. Delayed onset of therapy (more than 7 days) or failure to respond to therapy.
8. Associated osteomyelitis requiring surgical drainage.
Initial antibiotic therapy based on gram staining report:
Gram stain findings Antibiotic of choice Alternatives
Gram positive cocci Nafcillin Vancomycin
Gram negative cocci Ceftriaxone or cefotaxime Ciprofloxacin
Gram negative bacilli Gentamicin Ceftazidime
Septic picture but Ampicillin plus Vancomycin plus
No organism seen. Gentamicin Ceftizoxime
Antibiotic treatment following culture report:
Organism Antibiotic of choice Alternatives
Staphylococcus aureus Nafcillin Vancomycin
Methicillin resistant vancomycin
S. aureus
Streptococci Penicillin Cefazoline
Vancomycin
Enterococcus Ampicillin plus Vancomycin
Gentamicin Plus aminoglycoside
Enterobacteriaceae Third generation Aminoglycoside
Cephalosporine ciprofloxacine
Haemophilus Ampicillin Third generation
Influenza cephalosporin
Chloramphenicol
Cefuroxime
Pseudomonus Aminoglycoside Ceftazidime
Role of serial joint aspiration in septic arthritis:
Principle:
1. Mechanical debridement by saline lavage
2. To decrease intraarticuJar pressure

8. 3. To reduce leukocyte enzyme activity
4. To instill antibiotics in the joint if required
5. To monitor response to medication
Method:
Preferable once daily as reaccumulation of fluid is very prompt
Progression of disease and response to therapy can be monitored by serial synovial fluid
WBC count which should reduce by atleast 50% by one wk. of therapy.
Arthritis of tuberculosis:
Tuberculous arthritis accounts for about 1 % of all cases of tuberculosis and for 10% of
extrapulmonary cases.
Types:
2 major groups
Monoarticular tuberculous arthritis Atypical group
Poncet's disease Polyarthalgias of Atypical mycobacterial
Akt drugs arthritis
Unusual forms of arthritis in tuberculosis:
Poncets disease: It is a reactive symmetrical form of polyarthritis that affects persons
with visceral or disseminated tuberculosis. No organisms can be seen in the joints and
symptoms tend to resolve with AKT drugs.
Polyarthralgias of AKT therapy: Polyarthlgias are known to occur with pyrazinamide
therapy and tend to regress with the withdrawal of drug.
These are less common with other AKT drugs.
Atypical mycobacterial arthritis: Atypical mycobacteria found in water and soil may
cause arthritis of digits, wrists and knees by direct inoculation during farming, gardening
etc. Commonest etiological agents include
M. marinum, M. avium intracellular, M. terrae etc. Haematogenous spread may occur in
imunocompromised patients leading to involvement of joints by organisms such as
M.kansasii, M. haemophilum etc. Diagnosis
should be confirmed by biopsy and culture and treatment is based on sensitivity patterns.
SYPHILIS OF JOINT:
Types of syphilitic of joints:
A) Joint lesions in congental syphilis:
1. Parots syphilic osteochondritis
2. Clutton's joint: symmetrical hydrarthrosis
B) Joint lesions in acquired (early) syphillis:
1. Arthralgia
2. Hydrarthrosis SYPHILITIC OSTEOPERIOSTITIS

9. 3. Plastic arthritis (very uncommon)
C) Joint lesions in acquired (late) syphilis:
Gummatous arthritis:
1. The synovial form.
2. The oseous form
3. Charcot's anthropathy.
A. Joint lesions in congenital syphilis:
Parots syphilitic osteochondritis: It is a juxtaepiphyseal inflammation involving growing
ends of bone of more commonly upper limb. Occuring during the first few months of life
the child presents with large and tender epiphyses and sometimes pseudoparalysis.
Features similar to scuvry may be seen including seperation of epiphysis. Diagnosis is by
strongly positive treponema immobilization reaction. Early and prompt treatment with
antisyphilic therapy may produce complete resolution unless damage to growth cartilage
has occured.
Cluttons joint: Symmetrical hydrarthrosis: Children (between 8 to 16 years of age) may
present with painless symmetrical hydrarthrosis of knee with ability to walk unaffected.
Associated features such as eye changes & other stigmata congenital syphilis are present.
It is a gradually progressive disease (with spontaneous recovery in few cases) responding
slowly to treatment.
B. Joint lesion in early acquired syphilis
Arthralgia: Mild nocturnal arthlgia may occur in secondary stage before or after
appearance of early rashes. Usually affecting one or more of larger joints there is good
prognosis with respect of joint deformity or motion.
Hydrarthrosis: Changes similar to clutton joint may be seen in later stages of secondary
syphilis with abundant fluid & synovial membrane edema. Pain is moderate & gentle
passive movements are painless.
C. Joint lesions in acquired (late) syphilis (Tertiary syphililic arthritis):
The gummatous arthritis occurs usually in insidous (rarely acute) form consisting of
following variants:
1. Synovial form: The outer layer of capsule of joint becomes thickened with
perivascular infiltration with abundant synovial effusion. Pain may or may not be
present.
Joints involved: Knee, ankle, elbow, shoulder & rarely IP joints.
2. Osseous form: Only knee joint in involved with feature of osteoarthritis & chronic
synovitis present. Spine sometimes if affected resembles that of tuberculous spine.
Diagnosis is by serological tests & should be preferably done in all cases of OA
knee not responding to routine medication. .
3. Charcots joints: It usually occurs in acquired syphilis but may sometimes be seen
in congenital syphilis. The features are similar to charcot's joint, diagnosis is
mainly base on presence of locomotor ataxia (tabes dorsalis), associated
neurotrophic features such as perferating ulcers may be seen.

10. Signs suggestive of syphilis are:
1. Joint disease without heat, pain or tenderness
2. Bilateral painless hydrops of knees
3. Pupillary changes or absent knee jerks
4. Rheumatic fever type picture not responding to salicylates
5. Positive VDRL test of Blood
Diagnostic tests for syphilis:
A. Nonspecific tests: Venereal Diseases Research laboratory (VDRL) test is widely used
flocculation test as it is easy to perform False positive: Viral pneumonia, malaria,
leptospirosis & following inoculation, certain chronic disorders such as Tuberculosis,
collagen, vascular disorder.
B. Specific tests: a) Fluorescent Treponemal Antibody (FTA) test
b) Treponemal Hemagglutination test (TPHA)
c) Treponemal immobilization test (TPI)
Treatment:
a. Benzathin penicillin > 6-9 mega units in divided doses
b. P.A.M: 2-4 mega units stat then every 3rd day for 6-10 injections
c. Erythromycin 500 mg qds for one month
d. Tetracyclin 3 to 4 gm over 10-15 days.
GONOCOCCAL ARTHRITIS
It is an uncommon sequalae of gonorrhoea occurying in less than 1% of case. Usually it
develops during the third week of infection but may also occur some months after the
infection.
Pathology:
 It is more common in young adult males.
 Mono articular involvement of large joints occur in 40% of cases, including knee,
ankle, shoulder, wrist etc.
 Small joints of hands & feet may also be involved in polyarticular case.
Clinical Types:
Acute cases: there are 4 types of presentation:
1. Arthralgia: One or more joints are painful with no detectable physical signs.
2. An acute infection with effusion in one or more of the larger joint.
3. Acute infection with effusion & erosion of cartilage.
4. Acute infection with purulent exudate with severe unceration & erosion of all
cartilaginous surfaces.
Subacute & chronic case: 2 types:
1. Synovial type: Features suggestive of chronic synovitis mainly involving knee
joint

11. 2. Mixed type: Polyarticular involving smaller joints, associated with fibroblastic &
serofibrinous exudate. Proliferative fibroblastic changes in the periarticular region
is noticeable.
Patterns of arthritis with gonorrhea
Migratory polyarthralgia 70%
Tenosynovitis 67%
Purulent arthritis 42%
Monoarthritis 32%
Polyarthritis 10% .
Clinical Picture:
Acute cases have presentation similar to acute pyogenic arthritis with associated pyrexia
& chills or rigors.
Chronic cases resemble that of chronic synovitis with associated inflammatory changes in
tendons, tendonsheaths, bursae & the periosteum.
More commonly tendons of wrist & ankle & retrocalcaneal bursae are involved. Most
important diagnostic due for Gonorrhoea is tenosynovitis.
Laboratory diagnosis:
1. Examination of urethral Dischange:
a. Gram staining
b. Cultural tests
c. Sugar formentation
d. Oxidase reaction
Differential diagnosis:
I. Acute Rheumatism
II. Arthritis following pneumonia, dysentary, cerebrospinal infection, typhoid or
scarlet fevers, acute
tonsillitis & tuberculosis
III. Reiter's Syndrome
Differentiating features between Reiter's syndrome & gonococcal arthritis
Features Reiters Gonococcal
Migratory polyarthlgia - +
Enthesitis + -
Spondylitis + -
Differential diagnosis between acute rheumatism and gonococcal arthritis: -
Uveitis +
Oral ulcers + -
Skin lesions Keratoderma, balanitis Pustules
Culture Negative May be positive
HLA B27 positive > 80% < 10%
Arthritis Lower limbs Knees, Upper limb
Response to penicillin - +

12. Acute Rheumatism Gonococcal Arthritis
- No evidence of genitourinary -Mild to moderate signs and
disease symptoms may be present
- Marked pyrexia & constitutional -Except in purulent case, very
symptoms moderate pyrexia and
constitutional symptoms
- Pain intense & increased by the -Pain less intense
slightest touch
- Sweating very profuse with -Very little sweating except in
acid odour purulent cases
- Fleeting joint pain +ve -Absent
- Tendon sheaths & periarticular -Very frequent
tissues rarely involved
IMP-TIPS:
- Cardiac involvement with an -Very rare
Gonorrhoea must always be excluded if there is an acute, subacute or chronic affection of
active focus of tonsilitis
- Responds well painful, persistent & associated periarticular changes.
a joint which is to salicylates -Little effect on pain & swelling
Prognosis:
Prognosis
Acute Subacute or chronic
Arthraligia Exudation Exudation Severe erosion Recurrences Complete
With mild with suppuration
recovery
erosion
Adequate treatment
Fibrous ankylosis
Good prognosis
Treatment:
a. Rest
b. Physiotherapy
c. Penicillin compounds
d. Aspiration and injection of antibiotics in purulent type
e. Rarely surgical debridement
f. Patient should also be tested for syphilis and HIV
Antimicrobial therapy:

13. 1. Cefriaxone 1-2 gm im or IV per day till symptoms resolve followed by outpatient
therapy for 7 days with cefuroxime (500 mg 1-1) or amoxicillin calvulanate (500
mg 1-1-1)
2. Alternatively ciprofloxacin or norfloxacin may be used
3. Doxycyclin (100 mg 1-1 x (7) days) must also be given for coexistent chlamydial
infection.
Parasitic arthritis:
Guinea warm (Dracunculus medinesis): May sometimes cause destructive lesions in the
lower extremities as migrating gravid female worms invade joint or may cause ulcer in
the surrounding soft tissue which may become secondarily infected.
Hydatid cyst (1 to 2% bone involvement caused by E granulosus): May sometime burst
into joint from neighbouring bone involvement eg. Hip joint.
Lymphatic filariasis: It may be associated with monoarticular arthritis in children and
responds well to diethylcarbamizine treatment.
Reactive arthritis: It may occur due to
 Hookwarm
 Strongyloides
 Cryptosporidium
 Giardia infestations
Fungal arthritis
Etiological agents:
 Candida species
 Aspergillus species
 Cryptococcus neoformans
 Blastomyces dermatitidis etc
Methods of spread:
 Direct inoculation
 Disseminated hematogenous infection in immunocompromised patient.
Differentiating Features:
The synovial fluid usually contains 10,000 to 40,000 cells with about 70% neutrophilis.
Stained specimen and cultures of synovial tissue should be done in cases of disseminated
fungal infections to confirm diagnosis.
Treatment:
 Drainage and lavage of joint
 Intra-articular installation of amphotericin - B
 Systemic therapy with antifungals (including amphotericin -B, flucanazole or
itracanozole etc).
Spirochaetal arthritis (Lyme disease):
The disease caused by borrelia burgderferi may lead to arthritis in 70% of cases if left
untreated.

14. Clinical presentation:
1. Monoarthritis or oligoarthritis : Commonest, involving knee and/or other large
joints. The symptoms may wax or wane over period of months or years and
spontaneous remission may also occur without treatment.
2. Waxing and waning arthralgias
3. Chronic inflammatory synovitis with erosion or destruction of the joint
Treatment:
 Oral doxycyclin
 Oral amoxycillin plus probenecid, over a period of 3 to 4 weeks
 Parenteral cefriaxone
Viral arthritis:
Common viral disorder that may be accompanied by arthritis
Hepatitis B Mumps
Parvovirus B19 (fifth disease) Chickenpox
Rubella Human
immunodificiency
virus (HIV)
Arthritis of brucellosis:
Clinical types include:
1. Arthralgias and ostealgias
2. Fibrositis
3. Hydrarthrosis
4. Acute arthritis
5. Chronic arthritis
6. Osteitis, osteomyelitis and osteoperiostitis
Commonest presentation:
Spondylitis resembling pott's spine is one of the commonest presentation and brucellosis
should be kept in mind in those cases of pott's spine not responding to AKT.
Etiopathogenesis:
Arthritis of brucellosis
Acute type Chronic type
Invasion by microbes Usually due to an allergic
inside the joint inflammatory response of
mesenchymal tissue
Inflammatory arthritis
Associated conditions:
 Psychic asthenia

15.  Autonomous nervous system disturbances
 Fever (mayor may not be present)
 Changes of the eight cranial nerve
Laboratory findings:
Salient features are:
1. Positive intradermal reaction of bund
2. Anaemia with anisocytosis, leucopenia with neutropenia and lymphocytosis
3. Normal ESR
4. Positive agglutination titre to brucella of (SAT) > 80
5. Estimation of serum anti-brucella immunoglobulin (lgA, IgG, IgM) by
radioimmunoessay or ELISA
Treatment:
 Streptomycin 19m intramuscular daily
and Chlortetracyclin 2gm daily x 3 wks.
 Steroids may be used to reduce inflammation
 Some authors reserve use of streptomycin (1 gm/day 1M) or gentamicin (6
mg/day IV /1M) for first 3 weeks of a 6 week course of chlortetracyclin in case of
failure of response or relapse.
Lymphogranuloma venereum
 Chronic process with acute flare-up & a tendency to relapse
 Usually polyarticular involvement including knees, ankles & wrists
 Swelling usually confined to periarticular tissues
Associated conditions:
a. Inguinal bubo
b. Multiple discharging sinus in the inguinal region
c. Rectal strictures in females
d. Elephentiasis of genitalia
Diagnosis:
1. Smear to identify HP inclusion bodies
2. PREI intradermal test
Treatment:
1. Sulfonamides 1 gm qds for 7-14 days
2. Tetracyclin 250-500 mg 4 times daily for 15 days