Presentation is loading. Please wait.

Presentation is loading. Please wait.

Clinical Approach to Acute Arthritis

Similar presentations


Presentation on theme: "Clinical Approach to Acute Arthritis"— Presentation transcript:

1 Clinical Approach to Acute Arthritis
DR.AFSAR SAYEEDA MRCP(UK) CONSULTANT INTERNIST & RHEUMATOLOGIST HEAD CTU DIVISION,DEPT OF MEDICINE KING KHALID UNIVERSITY HOSPITAL

2 Normal Joint..

3 ARTHRALGIA / ARTHRITIS
INTRAARTICULAR / PERIARTICULAR /NONARTICULAR MONOARTHRITIS/ POLYARTHRITIS INFLAMMATORY / NONINFLAMMATORY

4 Monoarthritis Inflammation of a single joint Can be acute or chronic.

5 Diagnostic approach Case scenarios Diagnostic clues Investigation Treatment Picture quiz

6 Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER: INFECTION ! SEPTIC(gonococcal/nongonococcal) CRYSTAL INDUCED(gout, pseudogout) TRAUMATIC (fracture, internal derangement) Other (hemarthrosis, osteonecrosis, presentation of polyarticular disorders)

7 Acute monoarthritis – Diagnostic approach
History review of symptoms previous joint disease or trauma concurrent illnesses family history medication use – e.g. diuretics, anticoagulants other risk factors travel, sexual history, diet, tick bites, occupational history, alcohol and intravenous drug use

8 Examination Focus on the involved and contralateral joint and surrounding area General examination to look for other affected joints Look for systemic manifestations of disease

9 Scenario 1 A 35 year old man presents with a 1 day history of an intensely painful and swollen left knee. He is struggling to weight bear and cannot bend his knee much. He is otherwise well except for hypertension.

10 Any previous similar episodes
Onset of pain “ I went to bed fine doctor. When I woke up I could hardly bend my knee” Any previous similar episodes “Never in my knee doc. But I had something similar affecting my foot last year. It lasted about two weeks.” “A&E treated me for a skin infection and gave me some painkillers.” Medications “I take a tablet for my blood pressure.” Any alcohol? “No more than average like…… 6 pints a night say”

11 On examination

12 Diagnosis?

13 Acute Gouty Arthritis

14 Gout Most common cause of inflammatory arthritis in adults
Usually men >40 years and post-menopausal women Initially acute monoarthritis Risk Factors -Primary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis. Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure. Family history in some

15 Caused by monosodium urate crystals.
50-70% of first attacks affect the big toe. Other frequently affected joints include the midfoot, ankle, knee, wrist, and elbow. Shoulders and hips rarely involved.

16 Gout Can have low grade temperature.(mimics infection)
Raised inflammatory markers (can be very high) with neutrophilia. The cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis. Majority of patients have further attacks. Tophi can develop in chronic disease.

17 Urate Crystals Needle-shaped Strongly negative birefringent

18 Scenario 2 A 35 year old American tourist presents
with a 2 day history of an intensely painful and swollen left knee. He is unable to bear weight and has marked difficulty in bending his knee. He reports feeling feverish.

19 Any previous similar episodes
Onset of pain “ It has swollen up over a few days and it feels hot” Any previous similar episodes “First time I have had anything like it” Medications “I don’t take anything” Any alcohol? “Very little” Associated symptoms “I felt feverish last night” “I noticed a couple of new spots on my body ………. ….like acne” Anything else? “I had a one-night stand last week …….. I didn’t use any protection” “Could it be related?”

20

21

22 Diagnosis?

23 Gonococcal arthritis Gonococcal arthritis is caused by infection with the gram- negative diplococcus neisseria gonorhhoeae. In the US, gonococcal arthritis is the most common form of septic arthritis. a consequence of disseminated gonococcal infection. Haematogenous spread of the mucosal infection occurs in up to 3% of cases. Time from initial infection to manifestations of disseminated infection ranges from 1 day to 3 months.

24 It manifests as either a bacteraemic infection (arthritis-dermatitis syndrome.tenosynovitis; 60% of cases) or as a localized septic arthritis (40%). Synovial fluid cultures can be positive in up to 50% of cases Cultures from likely sites of initial infection will increase the yield. Blood culture / Cervix / Rectum / Urethra / Pharynx. PCR testing of samples can also increase yield if cultures are negative. Unlike in Staph. aureus septic arthritis, joint destruction is rare.

25 Scenario 3 An 80 year old woman with type 2 diabetes and rheumatoid arthritis presents with a two week history of increasing pain and swelling in her right wrist. Her rheumatoid is well controlled on medication but her wrist has been a problem and has been injected with steroids recently. She is feeling feverish and unwell.

26 On examination

27 Diagnosis?

28 Septic arthritis More common in those with inflammatory arthropathies, joint prostheses, impaired immunity.(DM,Cancer) Any age affected but more commonly young and elderly. Systemic symptoms usually present but not in immunocompromised. Fever has poor sensitivity and specificity for septic arthritis. Synovial fluid culture positive in 90%. Knee joint - commonest .(others-Hip, shoulder) Most develop from hematogenous spread. Monoarticular-80% Polyarticular- 20%.

29 Viral – HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus
SEPTIC ARTHRITIS Bacterial Gonococcal Non-gonococcal -Gram positive aerobes (80%) (Staphylococcus aureus(60%) , non­group-A beta-hemolytic streptococci, gram-negative bacteria(18%), & Streptococcus pneumoniae) Viral – HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus Fungal

30 Scenario 4 85 year old woman
RA, OA of the knees, Leg ulcers, Hypertension, PPM Awaiting Right TKR 2 week history of marked swelling in her left knee Started suddenly following some physiotherapy Not systemically unwell.

31 On examination Large, warm effusion left knee. Any further info?

32 Haemarthrosis history of trauma. Not always associated
Usually significant swelling. Traumatic causes include cruciate ligament rupture and intra-articular fracture. Other causes include pigmented villonodular synovitis and bleeding diatheses.

33 Pseudogout More elderly age group. Mean age early 70’s.
Acute monoarticular presentation. Occ polyarticular- . Often affects the knee, wrist, or shoulder. Triggers include: Intercurrent illness Trauma Surgery CPPD disease may be asymptomatic (deposition of CPP in cartilage).

34 CPPD Crystals Rod or rhomboid-shaped Weakly positive birefringent

35 In approximately 1/3 of cases of monoarthritis no definitive diagnosis will be identified even after appropriate investigation.

36 Diagnostic clues

37 Sudden onset of pain over seconds to minutes
Trauma Onset of pain, swelling, tenderness maximal within 12 hours Crystal arthropathy Onset of pain over several hours or 1-2 days Septic arthritis Monoarthritic presentation of other inflammatory arthropathy

38 Insidious onset of pain & swelling over days-weeks
Low grade/atypical infection, OA, malignancy, granulomatous disease. Previous similar attacks?,drugs-diuretics – crystals or inflammatory arthritis. DM, Cellulitis, Prosthetic joints, RA, IV drug abuse,a recent infection Septic arthritis Steroid exposure Avascular necrosis Coagulopathy, Use of anticoagulants Haemarthrosis

39 Other causes of monoarthritis

40 Seronegative spondyloarthropathies

41 Monoarthritic presentation of polyarthritis

42 JOINT ASPIRATE !!! Investigations Gram stain C & S Total leucocyte
count Polarising microscopy (Crystal analysis)

43 Investigations Blood cultures Bloods – ESR/CRP, FBC, U+E’s, Clotting
X-ray – affected and contralateral joint Consider: serum urate, CXR, sputum sample, urine culture, skin swabs

44 Treatment – depends on the cause!
Aspirate joint Analgesia – NSAIDs, Colchicine Rest / Ice / Elevation Antibiotics if indicated – 2 weeks IV, 4 weeks oral follow-on Intra-muscular/Intra-articular/Oral steroids if indicated

45 Learning points In acute inflammatory monoarthritis, symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy. Serum uric acid levels do not confirm or exclude gout. Demonstration of urate crystals in synovial fluid or tophus aspirates is diagnostic of gout. Beware that gout and sepsis can co-exist. Repeated culture of synovial fluid, blood and other sources of sepsis may be needed if initial samples are negative but clinical suspicion remains high. In a young patient with a monoarthritis but no history of trauma, refer to rheumatology NOT orthopaedics.

46 Polyarthritis Definite inflammation (swelling, tenderness, warmth of > 5 joints A patient with 2-4 joints is said to have pauci- or oligoarticular arthritis

47 Inflammatory Vs. Noninflammatory
Feature Inflammatory Mechanical Morning stiffness >1 h Swelling Warmth Erythema Effusion < 30 min

48 Approach to Inflammatory Arthritis
Main Diagnostic Groupings – 3 RA, SPA, SLE Crystalline arthritis Infectious arthritis

49 Temporal Patterns in Polyarthritis
Migratory: Rheumatic fever Additive : RA, SLE, psoriasis Intermittent: Gout, reactive arthritis

50 Patterns of Joint Involvement
Symmetric: viral, RA, SLE, psoriasis. Asymmetric, : reactive arthritis, psoriasis, enteropathic arthritis. DIP joints: Psoriatic.

51 Phy. Examination.. General Examination:
LAP, parotid enlargement, oral ulceration, heart murmurs, pericardial or pleural friction rubs, crackle…= systemic disease. Fever= infection, reactive arthritis, RA, SLE, Crystal induced arthritis Subcutaneous nodules= RA, RHD, Gout (tophi) Skin manifestations= psoriasis, RA, SLE… Eye disease (keratoconjunctivitis sicca, uveitis. Conjunctivitis, episcleritis…)

52 Viral Arthritis Younger patients Usually presents with prodrome, rash
Causes: Parvovirus B-19, Rubella, Hep B and C, Acute HIV infection, E-B virus, mumps Prognosis good; self-limited

53 Rheumatoid Arthritis Symmetric, inflammatory polyarthritis, involving large and small joints Acute, severe onset %; subacute 20% Hand characteristically involved Acute hand deformity: fusiform swelling of fingers due to synovitis of PIPs RF may be negative at onset and may remain negative in 15-20%! RA is a clinical diagnosis, no laboratory test is diagnostic, just supportive!

54 Acute Polyarthritis - RA

55 Arthritis Of SLE Musculoskeletal manifestation 90%.
Most have arthralgia. May have acute inflammatory synovitis RA-like. Do not develop erosions. Other clinical features help with DD: malar rash, photosensitivity, rashes, alopecia, oral ulceration.

56 Butterfly Rash – SLE

57 Photosensitivity

58 Alopecia - SLE

59 Arthritis of Rheumatic Fever
Etiology: Streptococcus pyogenes (group A); immune response to antecedent infection Migratory polyarthritis, large joints: knees, ankles, elbows, wrists. Major manifestations: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules.

60 Key Points Distinguish arthralgia from arthritis
Distinguish arthritis from soft tissue non articular syndromes (discrepancy between “active” and “passive” ROM suggests periarticular/soft tissue). If the problem is articular distinguish single joint from multiple joint involvement. Traumatic or nontraumatic. Inflammatory or non-inflammatory disease. Always consider septic arthritis!

61 THANK YOU


Download ppt "Clinical Approach to Acute Arthritis"

Similar presentations


Ads by Google