Acute Arthropathies “I’ve got a painful, swollen knee doctor” By Dr Mahya Mirfattahi GP ST1 HDR LRCH 9th December 2009

What could it be? Septic arthritis Septic bursitis Crystal arthropathies – gout, pseudogout Acute exacerbation of osteoarthritis Acute attack of rheumatoid arthritis Trauma Seronegative spondyloarthropathy Viral infection Lupus

Clinical assessment - History Patient demographics Age, gender, ethnicity, obese History Pain, swelling, stiffness, duration (short), site, preceding trauma, other joints affected, previous episodes, systemic symptoms Past medical history Joint prosthesis, osteoarthritis, previous trauma, inflammatory arthritis, psoriasis, recent episodes of illness, diabetes mellitus, hypertension, recent corticosteroid joint injection, haemophilia Current medications Bendroflumethiazide, aspirin, immunosuppressant therapy

Clinical assessment - Examination Look Swelling, redness, scars, tophi, psoriatic plaques, nails, nodules, joint deformities, ulcers Feel Warmth, effusion, swellings Move Restriction, crepitus, ability to weight bear, painful movements Systemic features

Case 1 67 year old man Type 2 diabetic, suffers with ulcers on legs dressed by district nurse. LT catheter. Presents with acute history of painful, hot, swollen red knee Struggles to walk into surgery Feverish today Ulcers weeping

What would you like to do? History Further enquiries reveal recent corticosteroid injection in knee for OA symptoms Examination Temp 37.8, tachycardic, red, hot, effusion, unable to weight bear, restriction of movement Consider risk factors What is the mandatory investigation?

Joint aspiration

Septic arthritis Overall mortality 10% in adults Suppurative inflammation in joint space Majority monoarticular Large > small joints 50% knee, hip 20%, shoulder 8%, ankles 7%, elbow & IPJ 1-4% Most commonly haematogenous spread Can be direct penetrating wound or neighbouring infection Children, neonates, elderly & immunosuppressed

Pathogens 90% non-gonococcal staph aureus 50-80%, streptococcus 15-20%, haemophilus influenzae b 20% (infants 6mo-2yrs), anaerobes 5% Gonococcal young, sexually active Pustular skin lesions (dermatitis-arthritis syndrome) Tenosynovitis Migratory arthralgias Hand > knee, wrist, ankle, or elbow

Risk factors for septic arthritis Previously damaged joints Prosthetic joints Immunocompromised states Systemic drugs – corticosteroids, DMARDS, biological agents IV drug abuse Alcohol abuse Diabetes Previous intra-articular corticosteroid injection Cutaneous ulcers Indwelling catheters >65 yrs old

Management If confident, joint aspirate to dryness & urgent gram stain Admit patient – discuss with orthopaedic on-call SHO Blood tests Cultures – 3x blood, MSU, swabs Plain XR Start empirical antibiotics – 1st line flucloxacillin IV 2g QDS Discuss with microbiologist Long duration of antibiotic therapy

Case 2 78 year old male Hypertensive, aspirin, osteoarthritis, renal impairment, obese Complains of painful, hot swollen knee Noticed swellings on hands Previous episode of joint pain in big toe 6mo ago settled with OTC NSAIDs

What will you do next? History Examination Investigations Further questioning reveals that had knee arthroscopy last yr, likes alcohol Examination Investigations Joint fluid aspirate, blood tests, plain XR What are his risk factors?

Risk factors for gout Low dose aspirin Diuretic Increasing age, male Family history Hypertension Central obesity Alcohol consumption Renal insufficiency Haematological disorders

Precipitants of attack Dehydration Injury Concurrent illness Dental extraction Excess foods/alcohol

Management Investigations Rest joint Joint aspiration –ve birefringent needle-shaped Blood tests Rest joint NSAID or if unable or not responding colchicine Consider PPI Caution use of colchicine in IHD,CCF Give until pain relieved Side effects – diarrhoea, abdominal cramps

Prevention Review medications Advise patients – diet, lifestyle, weight loss Prophylaxis Indications: uncomplicated gout >2 attacks/yr, tophi, renal insufficiency, uric acid stones, need to continue diuretics Allopurinol Start at 100mg od, gradually increase, monitor uric acid levels 4 weekly until normal Delay until 2/52 after intial attack settled Monitor creatinine SE: rash – stop & reintroduce lower dose Interactions Give colchicine/NSAID first 3-6mo Continue allopurinol in attacks if pt already taking Referral to rheumatology if no improvement

Case 3 17 year old male Recent travel to Ibiza, playing football yesterday, bad tackle, able to continue game. Painful, swollen knee No past medical history Able to weight bear, but sore Differential?

What would you do next? History Examination Investigations Recent illness, STI, family history of bleeding disorders Examination Investigations Joint fluid aspirate, blood tests, plain XR

Haemarthrosis Plain XR – fat/blood interface Common cause Ligament injury (cruciates in sports) Intra-articular # Inherited haemophilias APTT, assays for factors VIII, IX

Lipohaemarthrosis

Case 4 – a real story! 52 year old lady Presents with confusion Osteoarthritis, TKR 6 wks ago, obese Fever, ache in knee, coughing Husband very concerned requests GP home visit

Assessment Confused to time, place & person Smelly urine Coughing, complains of back pain, breathless Temp 38.6, tachycardic, consolidation lower lobe, urine dip positive Knee – scar clean, dry, healed well. No effusion. Not red. Slight warmth. Tender ROM, but no restriction.

What will you do next? Admit to AMU Orthopaedic review? Investigations Yes, needs assessment Investigations Blood tests Cultures – 3x blood, MSU CXR Plain XR Knee

Management Needs joint aspiration in theatre, washout of knee May need removal of prosthesis Empirical antibiotics intravenous long term Discuss with microbiologist Monitor inflammatory markers

Pseudogout Treatment Consider when intermittent attacks Monoarticular – knee, wrist, hip Can simulate bacterial infection – severe inflammation & fever Can be symmetrical Joint damage can be severe Investigations Joint aspiration = calcium pyrophosphate dehydrate crystals (CPPD), rhomboid shaped, +ve birefringent Plain XR – chondrocalcinosis Causes – must screen for hyperparathyroidism, haemachromatosis, hyphosphataemia, hypomagnesiaemia Treatment Rest, ice, NSAIDs, colchicine, intra-articular steroid injection

Reactive arthritis Aseptic arthritis Occurs 2-6wks after bacterial infection elsewhere Gastroenteritis (salmonella, campylobacter) GU infection (chlamydia, gonorrhoea) Can be HLA B27 +ve Treatment – NSAIDs, physiotherapy, steroid joint injections Reiter’s syndrome Polyarthropathy, urethritis, irits, psoriaform rash Follows GU/GI infection Joint & eye changes often severe

Diagnosis?

What are these?

Diagnosis?

Diagnosis?

Useful Resources GP notebook Doctors.net e-module on acute swollen joint ARC (www.arc.org.uk) Patient uk www.ukgoutsociety.org www.arthritiscare.org.uk