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Value of serum procalcitonin for the diagnosis of bacterial septic arthritis in daily practice in rheumatology

  • Mickaël ChoukEmail author
  • Frank Verhoeven
  • Maxime Sondag
  • Xavier Guillot
  • Clément Prati
  • Daniel Wendling
Original Article
  • 12 Downloads

Abstract

Introduction/objectives

Septic arthritis is a diagnostic and therapeutic emergency because of a high morbidity and mortality. Nevertheless, the etiologic diagnosis is often difficult. The aim of our study was to determine if serum procalcitonin was a discriminatory biomarker in case of arthritis of undetermined etiology.

Method

Patients were separated in five groups: gouty arthritis, calcium pyrophosphate deposition arthritis, osteoarthritis or post-traumatic arthritis (“mechanical” arthritis), chronic inflammatory rheumatic arthritis, and septic arthritis. Levels of serum white blood cells, C-reactive protein and procalcitonin were measured.

Results

Ninety-eight patients were included: 18 in the “gout” group, 26 in the “calcium pyrophosphate deposition arthritis” group, 16 in the mechanical group, 18 in the “chronic inflammatory rheumatic” group, and 20 in the “sepsis” group. The area under the receiver operating characteristic curve of white blood cells, C-reactive protein, and procalcitonin levels to diagnose a septic arthritis were 0.69 (IC95% 0.55–0.83), 0.82 (IC95% 0.73–0.91), and 0.87 (IC95% 0.76–0.98) respectively. For a cutoff of 0.5 ng/ml, procalcitonin sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were 65%, 91%, 65%, 91%, 7.2, and 0.4, respectively. Serum C-reactive protein and procalcitonin levels were correlated, were not different in sepsis or gout groups, and were higher in non-septic arthritis with poly-arthritis than with mono-arthritis (p < 0.05).

Conclusions

Serum procalcitonin is a useful biomarker in arthritis management with diagnosis performances higher than those of other biomarkers (white blood cells, C-reactive protein).

Key Points

• Diagnostic performances of serum procalcitonin level in septic arthritis are higher than those of serum C-reactive protein or white blood cells levels.

• Serum procalcitonin levels are not different in septic arthritis or gouty arthritis.

• Serum procalcitonin levels are higher in non-septic arthritis with poly-arthritis than with mono-arthritis.

Keywords

Arthritis Chronic inflammatory rheumatism Crystal arthropathies Procalcitonin Sepsis 

Notes

Acknowledgments

The authors thank Mr. Marc Puyraveau, statistician, for his help about statistical analyses.

Compliance with ethical standards

Since PCT evaluation is a regular procedure in front of sepsis in emergency room, no specific ethical procedure was required. Nevertheless, informed consent was obtained from each patient.

Disclosures

None.

References

  1. 1.
    Sharff KA, Richards EP, Townes JM (2013) Clinical management of septic arthritis. Curr Rheumatol Rep 15:332.  https://doi.org/10.1007/s11926-013-0332-4
  2. 2.
    Ferrand J, El Samad Y, Brunschweiler B et al (2016) Morbimortality in adult patients with septic arthritis: a three-year hospital-based study. BMC Infect Dis 16:239.  https://doi.org/10.1186/s12879-016-1540-0
  3. 3.
    Margaretten ME, Kohlwes J, Moore D, Bent S (2007) Does this adult patient have septic arthritis? JAMA 297:1478–1488.  https://doi.org/10.1001/jama.297.13.1478 CrossRefGoogle Scholar
  4. 4.
    Mathew AJ, Ravindran V (2014) Infections and arthritis. Best Pract Res Clin Rheumatol 28:935–959.  https://doi.org/10.1016/j.berh.2015.04.009
  5. 5.
    Kim H, Kim J, Ihm C (2010) The usefulness of multiplex PCR for the identification of bacteria in joint infection. J Clin Lab Anal 24:175–181.  https://doi.org/10.1002/jcla.20384
  6. 6.
    Whicher J, Bienvenu J, Monneret G (2001) Procalcitonin as an acute phase marker. Ann Clin Biochem 38:483–493.  https://doi.org/10.1177/000456320103800505 CrossRefGoogle Scholar
  7. 7.
    Maruna P, Nedelníková K, Gürlich R (2000) Physiology and genetics of procalcitonin. Physiol Res 49(Suppl 1):S57–S61Google Scholar
  8. 8.
    Shaikh MM, Hermans LE, van Laar JM (2015) Is serum procalcitonin measurement a useful addition to a rheumatologist’s repertoire? A review of its diagnostic role in systemic inflammatory diseases and joint infections. Rheumatol Oxf Engl 54:231–240.  https://doi.org/10.1093/rheumatology/keu416 CrossRefGoogle Scholar
  9. 9.
    Linscheid P, Seboek D, Nylen ES, Langer I, Schlatter M, Becker KL, Keller U, Müller B (2003) In vitro and in vivo calcitonin I gene expression in parenchymal cells: a novel product of human adipose tissue. Endocrinology 144:5578–5584.  https://doi.org/10.1210/en.2003-0854 CrossRefGoogle Scholar
  10. 10.
    Meisner M, Lohs T, Huettemann E, Schmidt J, Hueller M, Reinhart K (2001) The plasma elimination rate and urinary secretion of procalcitonin in patients with normal and impaired renal function. Eur J Anaesthesiol 18:79–87CrossRefGoogle Scholar
  11. 11.
    Zhao J, Zhang S, Zhang L, Dong X, Li J, Wang Y, Yao Y (2017) Serum procalcitonin levels as a diagnostic marker for septic arthritis: a meta-analysis. Am J Emerg Med 35:1166–1171.  https://doi.org/10.1016/j.ajem.2017.06.014 CrossRefGoogle Scholar
  12. 12.
    Wallace SL, Robinson H, Masi AT, Decker JL, Mccarty DJ, Yü T’F (1977) Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 20:895–900CrossRefGoogle Scholar
  13. 13.
    Zhang W, Doherty M, Bardin T, Barskova V, Guerne PA, Jansen TL, Leeb BF, Perez-Ruiz F, Pimentao J, Punzi L, Richette P, Sivera F, Uhlig T, Watt I, Pascual E (2011) European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis. Ann Rheum Dis 70:563–570.  https://doi.org/10.1136/ard.2010.139105 CrossRefGoogle Scholar
  14. 14.
    Rudwaleit M, Landewé R, van der Heijde D et al (2009) The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part I): classification of paper patients by expert opinion including uncertainty appraisal. Ann Rheum Dis 68:770–776.  https://doi.org/10.1136/ard.2009.108217 CrossRefGoogle Scholar
  15. 15.
    Rudwaleit M, van der Heijde D, Landewé R et al (2011) The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 70:25–31.  https://doi.org/10.1136/ard.2010.133645 CrossRefGoogle Scholar
  16. 16.
    Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, Birnbaum NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JM, Hobbs K, Huizinga TW, Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Menard HA, Moreland LW, Naden RL, Pincus T, Smolen JS, Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS, Vencovsky J, Wolfe F, Hawker G (2010) 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 69:1580–1588.  https://doi.org/10.1136/ard.2010.138461 CrossRefGoogle Scholar
  17. 17.
    Newman JH (1976) Review of septic arthritis throughout the antibiotic era. Ann Rheum Dis 35:198–205CrossRefGoogle Scholar
  18. 18.
    Shen C-J, Wu M-S, Lin K-H, Lin WL, Chen HC, Wu JY, Lee MCH, Lee CC (2013) The use of procalcitonin in the diagnosis of bone and joint infection: a systemic review and meta-analysis. Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol 32:807–814.  https://doi.org/10.1007/s10096-012-1812-6 CrossRefGoogle Scholar
  19. 19.
    Paosong S, Narongroeknawin P, Pakchotanon R et al (2015) Serum procalcitonin as a diagnostic aid in patients with acute bacterial septic arthritis. Int J Rheum Dis 18:352–359.  https://doi.org/10.1111/1756-185X.12496
  20. 20.
    Scirè CA, Cavagna L, Perotti C, Bruschi E, Caporali R, Montecucco C (2006) Diagnostic value of procalcitonin measurement in febrile patients with systemic autoimmune diseases. Clin Exp Rheumatol 24:123–128Google Scholar
  21. 21.
    Chen D-Y, Chen Y-M, Ho W-L, Chen HH, Shen GH, Lan JL (2009) Diagnostic value of procalcitonin for differentiation between bacterial infection and non-infectious inflammation in febrile patients with active adult-onset Still’s disease. Ann Rheum Dis 68:1074–1075.  https://doi.org/10.1136/ard.2008.098335 CrossRefGoogle Scholar
  22. 22.
    Schwenger V, Sis J, Breitbart A, Andrassy K (1998) CRP levels in autoimmune disease can be specified by measurement of procalcitonin. Infection 26:274–276CrossRefGoogle Scholar
  23. 23.
    Moosig F, Csernok E, Reinhold-Keller E, Schmitt W, Gross WL (1998) Elevated procalcitonin levels in active Wegener’s granulomatosis. J Rheumatol 25:1531–1533Google Scholar
  24. 24.
    Zycinska K, Wardyn KA, Zielonka TM et al (2008) Procalcitonin as an indicator of systemic response to infection in active pulmonary Wegener’s granulomacytosis. J Physiol Pharmacol Off J Pol Physiol Soc 59(Suppl 6):839–844Google Scholar
  25. 25.
    Okada Y, Minakami H, Tomomasa T et al (2004) Serum procalcitonin concentration in patients with Kawasaki disease. J Infect 48:199–205Google Scholar
  26. 26.
    Herrmann K, Schinke S, Csernok E, Moosig F, Holle JU (2015) Diagnostic value of procalcitonin in ANCA-associated vasculitis (AAV) to differentiate between disease activity, infection and drug hypersensitivity. Open Rheumatol J 9:71–76.  https://doi.org/10.2174/1874312901409010071 CrossRefGoogle Scholar
  27. 27.
    Liu W, Sigdel KR, Wang Y, Su Q, Huang Y, Zhang YL, Chen J, Duan L, Shi G (2015) High level serum procalcitonin associated gouty arthritis susceptibility: from a southern Chinese Han population. PLoS One 10:e0132855.  https://doi.org/10.1371/journal.pone.0132855 CrossRefGoogle Scholar
  28. 28.
    Steichen O, Bouvard E, Grateau G, Bailleul S, Capeau J, Lefèvre G (2009) Diagnostic value of procalcitonin in acutely hospitalized elderly patients. Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol 28:1471–1476.  https://doi.org/10.1007/s10096-009-0807-4 CrossRefGoogle Scholar
  29. 29.
    Caterino JM, Scheatzle MD, Forbes ML, D’Antonio JA (2004) Bacteremic elder emergency department patients: procalcitonin and white count. Acad Emerg Med Off J Soc Acad Emerg Med 11:393–396CrossRefGoogle Scholar
  30. 30.
    Zhang H, Wang X, Zhang Q, Xia Y, Liu D (2017) Comparison of procalcitonin and high-sensitivity C-reactive protein for the diagnosis of sepsis and septic shock in the oldest old patients. BMC Geriatr 17:173.  https://doi.org/10.1186/s12877-017-0566-5
  31. 31.
    Zhang J, Liu J, Long L, Zhou Q, Cheng J, Zhou B (2015) Value of procalcitonin measurement in the diagnosis of bacterial infections in patients with fever and flare of chronic gouty arthritis. Zhonghua Yi Xue Za Zhi 95:2556–2559Google Scholar
  32. 32.
    Choi ST, Song JS (2016) Serum procalcitonin as a useful serologic marker for differential diagnosis between acute gouty attack and bacterial infection. Yonsei Med J 57:1139–1144.  https://doi.org/10.3349/ymj.2016.57.5.1139 CrossRefGoogle Scholar
  33. 33.
    Martinon F (2010) Mechanisms of uric acid crystal-mediated autoinflammation. Immunol Rev 233:218–232.  https://doi.org/10.1111/j.0105-2896.2009.00860.x CrossRefGoogle Scholar
  34. 34.
    Dalbeth N, Haskard DO (2005) Mechanisms of inflammation in gout. Rheumatol Oxf Engl 44:1090–1096.  https://doi.org/10.1093/rheumatology/keh640 CrossRefGoogle Scholar
  35. 35.
    Becker KL, Nylén ES, White JC, Müller B, Snider RH Jr (2004) Clinical review 167: procalcitonin and the calcitonin gene family of peptides in inflammation, infection, and sepsis: a journey from calcitonin back to its precursors. J Clin Endocrinol Metab 89:1512–1525.  https://doi.org/10.1210/jc.2002-021444 CrossRefGoogle Scholar
  36. 36.
    Kettelhack C, Hohenberger P, Schulze G, Kilpert B, Schlag PM (2000) Induction of systemic serum procalcitonin and cardiocirculatory reactions after isolated limb perfusion with recombinant human tumor necrosis factor-alpha and melphalan. Crit Care Med 28:1040–1046CrossRefGoogle Scholar
  37. 37.
    Talebi-Taher M, Shirani F, Nikanjam N, Shekarabi M (2013) Septic versus inflammatory arthritis: discriminating the ability of serum inflammatory markers. Rheumatol Int 33:319–324.  https://doi.org/10.1007/s00296-012-2363-y CrossRefGoogle Scholar
  38. 38.
    Streit G, Alber D, Toubin MM, Toussirot E, Wendling D (2008) Procalcitonin, C-reactive protein, and complement-3a assays in synovial fluid for diagnosing septic arthritis: preliminary results. Jt Bone Spine Rev Rhum 75:238–239.  https://doi.org/10.1016/j.jbspin.2007.07.012 CrossRefGoogle Scholar
  39. 39.
    Saeed K, Dryden M, Sitjar A, White G (2013) Measuring synovial fluid procalcitonin levels in distinguishing cases of septic arthritis, including prosthetic joints, from other causes of arthritis and aseptic loosening. Infection 41:845–849.  https://doi.org/10.1007/s15010-013-0467-2 CrossRefGoogle Scholar
  40. 40.
    Wang C, Zhong DA, Liao Q et al (2014) Procalcitonin levels in fresh serum and fresh synovial fluid for the differential diagnosis of knee septic arthritis from rheumatoid arthritis, osteoarthritis and gouty arthritis. Exp Ther Med 8:1075–1080.  https://doi.org/10.3892/etm.2014.1870 CrossRefGoogle Scholar
  41. 41.
    Martinot M, Sordet C, Soubrier M, Puéchal X, Saraux A, Lioté F, Guggenbuhl P, Lègre V, Jaulhac B, Maillefert JF, Zeisel M, Coumaros G, Sibilia J (2005) Diagnostic value of serum and synovial procalcitonin in acute arthritis: a prospective study of 42 patients. Clin Exp Rheumatol 23:303–310Google Scholar
  42. 42.
    Christ-Crain M, Müller B (2005) Procalcitonin in bacterial infections--hype, hope, more or less? Swiss Med Wkly 135:451–460. https://doi.org/2005/31/smw-11169

Copyright information

© International League of Associations for Rheumatology (ILAR) 2019

Authors and Affiliations

  • Mickaël Chouk
    • 1
    Email author
  • Frank Verhoeven
    • 1
  • Maxime Sondag
    • 1
  • Xavier Guillot
    • 2
  • Clément Prati
    • 1
  • Daniel Wendling
    • 1
  1. 1.CHRU Jean MinjozService de RhumatologieBesanconFrance
  2. 2.CHRU Félix GuyonService de RhumatologieSaint-DenisFrance

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