- Camille N Kotton, MD
Camille N Kotton, MD
- Associate Professor
- Harvard Medical School
- Jonathan Kay, MD
Jonathan Kay, MD
- Timothy S. and Elaine L. Peterson Chair in Rheumatology
- Professor of Medicine and Director of Clinical Research, Rheumatology
- University of Massachusetts Medical School
Bursitis is an inflammation or degeneration of the sac-like structures that protect the soft tissues from underlying bony prominences . Septic bursitis refers to inflammation of the bursa that is due to infection, typically resulting from bacterial inoculation that is direct (eg, puncture wound), spread from nearby soft tissues (eg, cellulitis), or hematogenous (eg, bacterial endocarditis).
Nonseptic bursitis due to trauma, repetitive injury, crystal diseases, and other systemic disorders are discussed separately. (See "Bursitis: An overview of clinical manifestations, diagnosis, and management".)
ETIOLOGY AND PATHOGENESIS
There are more than 150 bursae in the human body. Bursae may be divided by location into those that are superficial or deep. Superficial bursae are subcutaneous and separate skin from deeper tissues such as periosteum or ligaments. Deep bursae serve to reduce friction between fibrous structures, such as tendons, from adjacent bone. Bursae are lined by synovial cells, which under ordinary circumstances produce a small amount of lubricating fluid.
Factors that increase the risk of septic bursitis include loss of skin integrity, impaired response to infection (eg, diabetes mellitus, alcohol abuse), and host factors that lead to an increased amount of bursal fluid or tissue (such as rheumatoid arthritis or tophaceous gout) [2-4]. One study of septic olecranon bursitis found that one-third of patients had at least one comorbid illness . It is unclear whether immunosuppressed states such as HIV/AIDS increase the risk of septic bursitis [6,7].
Superficial bursae — The superficial or subcutaneous bursae are predisposed to infection as a result of skin trauma. The most common mechanisms involved in septic superficial bursitis consist of direct inoculation due to puncture of the overlying skin or contiguous spread from cellulitis [2,6]. The majority of reported cases have been in men [5,8-10]. Trauma to the skin and bursa may be occupational, due to recreational activities, or related to concomitant disease. Among these the following are notable [6,11-13]:
- Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, Prevention, 3rd ed, Williams & Wilkins, Baltimore 1996.
- Valeriano-Marcet J, Carter JD, Vasey FB. Soft tissue disease. Rheum Dis Clin North Am 2003; 29:77.
- Ho G Jr, Tice AD, Kaplan SR. Septic bursitis in the prepatellar and olecranon bursae: an analysis of 25 cases. Ann Intern Med 1978; 89:21.
- Canoso JJ, Yood RA. Reaction of superficial bursae in response to specific disease stimuli. Arthritis Rheum 1979; 22:1361.
- Laupland KB, Davies HD, Calgary Home Parenteral Therapy Program Study Group. Olecranon septic bursitis managed in an ambulatory setting. The Calgary Home Parenteral Therapy Program Study Group. Clin Invest Med 2001; 24:171.
- Zimmermann B 3rd, Mikolich DJ, Ho G Jr. Septic bursitis. Semin Arthritis Rheum 1995; 24:391.
- Söderquist B, Hedström SA. Predisposing factors, bacteriology and antibiotic therapy in 35 cases of septic bursitis. Scand J Infect Dis 1986; 18:305.
- Cea-Pereiro JC, Garcia-Meijide J, Mera-Varela A, Gomez-Reino JJ. A comparison between septic bursitis caused by Staphylococcus aureus and those caused by other organisms. Clin Rheumatol 2001; 20:10.
- García-Porrúa C, González-Gay MA, Ibañez D, García-País MJ. The clinical spectrum of severe septic bursitis in northwestern Spain: a 10 year study. J Rheumatol 1999; 26:663.
- Stell IM, Gransden WR. Simple tests for septic bursitis: comparative study. BMJ 1998; 316:1877.
- Enzenauer RJ, Pluss JL. Septic olecranon bursitis in patients with chronic obstructive pulmonary disease. Am J Med 1996; 100:479.
- Rubayi S, Montgomerie JZ. Septic ischial bursitis in patients with spinal cord injury. Paraplegia 1992; 30:200.
- Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am 2005; 19:991.
- Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis 1984; 43:44.
- Burke CC, Martel-Laferriere V, Dieterich DT. Septic bursitis, a potential complication of protease inhibitor use in hepatitis C virus. Clin Infect Dis 2013; 56:1507.
- Drezner JA, Sennett BJ. Subacromial/subdeltoid septic bursitis associated with isotretinoin therapy and corticosteroid injection. J Am Board Fam Pract 2004; 17:299.
- Ho G Jr, Tice AD. Comparison of nonseptic and septic bursitis. Further observations on the treatment of septic bursitis. Arch Intern Med 1979; 139:1269.
- Smith DL, McAfee JH, Lucas LM, et al. Septic and nonseptic olecranon bursitis. Utility of the surface temperature probe in the early differentiation of septic and nonseptic cases. Arch Intern Med 1989; 149:1581.
- Reilly D, Kamineni S. Olecranon bursitis. J Shoulder Elbow Surg 2016; 25:158.
- Perez C, Huttner A, Assal M, et al. Infectious olecranon and patellar bursitis: short-course adjuvant antibiotic therapy is not a risk factor for recurrence in adult hospitalized patients. J Antimicrob Chemother 2010; 65:1008.
- Sayegh ET, Strauch RJ. Treatment of olecranon bursitis: a systematic review. Arch Orthop Trauma Surg 2014; 134:1517.
- Fischer PA, Kopp A, Massarotti EM. Anaerobic septic bursitis: case report and review. Clin Infect Dis 1996; 22:879.
- Mathew SD, Tully CC, Borra H, et al. Septic subacromial bursitis caused by Mycobacterium kansasii in an immunocompromised host. Mil Med 2012; 177:617.
- Gertner E. Chronic septic bursitis caused by dematiaceous fungi. Am J Orthop (Belle Mead NJ) 2007; 36:E10.
- Ramírez I, Nieto-Ríos JF, Ocampo-Kohn C, et al. Protothecal bursitis after simultaneous kidney/liver transplantation: a case report and review. Transpl Infect Dis 2016; 18:266.
- Ramos-Pascua LR, Carro-Fernández JA, Santos-Sánchez JA, et al. Bursectomy, Curettage, and Chemotherapy in Tuberculous Trochanteric Bursitis. Clin Orthop Surg 2016; 8:106.
- Davis JM, Broughton SJ. Prepatellar bursitis caused by Brucella abortus. Med J Aust 1996; 165:460.
- Guiral J, Reverte D, Carrero P. Iliopsoas bursitis due to Brucella melitensis infection--a case report. Acta Orthop Scand 1999; 70:523.
- McDermott M, O'Connell B, Mulvihill TE, Sweeney EC. Chronic Brucella infection of the supra-patellar bursa with sinus formation. J Clin Pathol 1994; 47:764.
- Friedman ND, Sexton DJ. Bursitis due to Mycobacterium goodii, a recently described, rapidly growing mycobacterium. J Clin Microbiol 2001; 39:404.
- Crespo M, Pigrau C, Flores X, et al. Tuberculous trochanteric bursitis: report of 5 cases and literature review. Scand J Infect Dis 2004; 36:552.
- Ornvold K, Paepke J. Aspergillus terreus as a cause of septic olecranon bursitis. Am J Clin Pathol 1992; 97:114.
- Wall BA, Weinblatt ME, Darnall JT, Muss H. Candida tropicalis arthritis and bursitis. JAMA 1982; 248:1098.
- Torres HA, Bodey GP, Tarrand JJ, Kontoyiannis DP. Protothecosis in patients with cancer: case series and literature review. Clin Microbiol Infect 2003; 9:786.
- Samuel S, Boopalan PR, Alexander M, et al. Tuberculosis of and around the ankle. J Foot Ankle Surg 2011; 50:466.
- Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Omawi M. Tuberculosis of the hand. J Hand Surg Am 2011; 36:1413.
- Garrigues GE, Aldridge JM 3rd, Toth AP, Stout JE. Nontuberculous mycobacterial olecranon bursitis: case reports and literature review. J Shoulder Elbow Surg 2009; 18:e1.
- Leth S, Jensen-Fangel S. Infrapatellar bursitis with Mycobacterium malmoense related to immune reconstitution inflammatory syndrome in an HIV-positive patient. BMJ Case Rep 2012; 2012.
- Ahbel DE, Alexander AH, Kleine ML, Lichtman DM. Protothecal olecranon bursitis. A case report and review of the literature. J Bone Joint Surg Am 1980; 62:835.
- Ginesty E, Dromer C, Galy-Fourcade D, et al. Iliopsoas bursopathies. A review of twelve cases. Rev Rhum Engl Ed 1998; 65:181.
- Goldin DS, Stangler DA, Canoso JJ. Rheumatoid subcutaneous bursitis. J Rheumatol 1981; 8:974.
- Beltran J. MR imaging of soft-tissue infection. Magn Reson Imaging Clin N Am 1995; 3:743.
- Manueddu CA, Hoogewoud HM, Balague F, Waldeburger M. Infective iliopsoas bursitis. A case report. Int Orthop 1991; 15:135.
- Coste N, Perceau G, Léone J, et al. Osteoarticular complications of erysipelas. J Am Acad Dermatol 2004; 50:203.
- Choi HR. Patellar osteomyelitis presenting as prepatellar bursitis. Knee 2007; 14:333.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
- Frazee BW, Fee C, Lambert L. How common is MRSA in adult septic arthritis? Ann Emerg Med 2009; 54:695.
- Roschmann RA, Bell CL. Septic bursitis in immunocompromised patients. Am J Med 1987; 83:661.
- Ho G Jr, Su EY. Antibiotic therapy of septic bursitis. Its implication in the treatment of septic arthritis. Arthritis Rheum 1981; 24:905.
- Martinez-Taboada VM, Cabeza R, Cacho PM, et al. Cloxacillin-based therapy in severe septic bursitis: retrospective study of 82 cases. Joint Bone Spine 2009; 76:665.
- Baumbach SF, Lobo CM, Badyine I, et al. Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg 2014; 134:359.
- Uçkay I, von Dach E, Perez C, et al. One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial. Mayo Clin Proc 2017; 92:1061.
- Gendernalik JD, Sechriest VF 2nd. Prepatellar septic bursitis: a case report of skin necrosis associated with open bursectomy. Mil Med 2009; 174:666.
- Dillon JP, Freedman I, Tan JS, et al. Endoscopic bursectomy for the treatment of septic pre-patellar bursitis: a case series. Arch Orthop Trauma Surg 2012; 132:921.
- ETIOLOGY AND PATHOGENESIS
- Superficial bursae
- Deep bursae
- CLINICAL PRESENTATION
- Bursa aspiration
- Imaging studies
- Additional studies
- DIFFERENTIAL DIAGNOSIS
- Initial antibiotic therapy
- - Duration of therapy
- Indications for surgery
- Recurrent infection
- Preventing recurrence
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS