1. INPATIENT’S RHEUMATOLOGICAL PROBLEMS Dr Tanya Potter Consultant Rheumatologist UHCW

2. To cover Patients that junior Drs refer to us Plus a little of what you may feel wary of…

3. Referral Review 135 referrals 2009-2010 seen by SpR (some others seen directly by Consultant) 116 medicine 10 surgical 3 ED 2 paediatric 2 ITU 1 Obs and Gynae 1 psychiatry

4. Diagnosis

5. Subsequent diagnosis of ‘others’

6. What I will cover today Newly presenting monoarthritis Newly presently polyarthritis What to do with a pt who has an RA flare (in brief) Initial management of pt with known lupus (in brief)

7. Case 1 P/C: 65 year old woman presents with 1/52 painful warm and swollen right knee. HPC: Diabetic GP injected right knee 1/52 ago swollen, warm and extremely painful, unable to move and bear weight on it. O/E: T-37.4 C, BP-100/60, P-100,RR-18,Sa02- 100% air Warm, swollen tender right knee and restricted range of movements. Systemic examination unremarkable

9. Differential diagnosis Look at age, activities, medication and comorbidities WHAT DIAGNOSIS IF MISSED WILL SIGNIFICANTLY MATTER IN THE LONG TERM?

10. Differential diagnosis SEPTIC ARTHRITIS (case fatality of ~11%) Trauma- should be a history unless pt has dementia Crystals: Gout/ pseudogout/ steroid Haemarthrosis (warfarin- check INR level) New onset of inflammatory arthritis Bursitis

11. Septic arthritis Usually symptoms develop over days Risk factors?

12. Risk factors –pre-existing joint disease, RA, OA –prosthetic joints –low socio-economic status –IV drug abuse –alcoholism –DM –previous intra-articular corticosteroid injection and –ulcerated skin

13. Investigations?

14. Investigations FBC, LFT, U and E, CRP, ESR Blood cultures MSU Asepticknee aspiration- can be done by anyone who feels confident of technique- medics, surgeons, orthopaedics, rheumatologists- but beware high INR –M C and S- universal bottle and put in blood cultures bottles if you have enough aspirate –Crystals (biochemistry)

15. xray

16. Treatment As per hospital guidelines Usually at least 2 weeks IV antibiotics and 4 weeks oral AB tailored to infecting bug Thromboprophylaxis Early orthopaedic referral for consideration of wash out

17. Infecting organism Most common-Staphylococcus aureus or Streptococci Young adults- significant incidence of Gonococcal arthritis Gram negative- elderly and the immunocompromised Anaerobic organisms-penetrating trauma

18. Treat early…

19. Questions?

20. CASE 2 56 year old man presents having woken with incredibly painful swollen knee PMH hypertension only SH ~ 20 pints beer a week DH bendrofluathiazide O/E temp 37.2, swollen left knee Diagnosis?

21. Gout Incredibly severe pain developing over few hours Swollen red hot joint May have history of similar attacks (ASK) Risk factors?

22. Risk factors Dehydration Sepsis Recent surgery Drugs- which? Increasing age Men or post menopausal women XS purine intake- beer/ red wine/ red meat/ offal Investigations?

23. Investigations FBC, U & E, CRP, blood cultures Unless it 1 st MTP, or history of very similar attacks, then ASPIRATE JOINT

24. Crystal arthritis (may affect more than one joint) Usually uric acidOccasionally calcium pyrophosphate

25. Steroid crystals

26. Treatment?

27. Treatment Try maximum dose of whichever NSAID your ward stocks (ask nurses) If contraindicated, or ineffective, use colchicine 500ug tds (NOT BNF dose) If NOT respond, oral pred 20mg od for 5 days or intra articular steroids Please DON’T start allopurinol or worry about normal uric acid level- dips in acute attack Give pt gout info (patient.co.uk arthritisresearchuk.org)

28. Questions?

29. CASE 3 26 year old male presents with 2 week history of sore eyes and swollen knee No history of IV drug use Unprotected sex with more than one partner in past month (YOU MUST ASK)

31. Reactive arthritis More common in younger pts Can be a result of chlamydia, ureaplasma, samonella, shigella and campylobacter infection Uveitis, conjunctivitis, circinate balanitis May affect more than one large joint Diagnosis of exclusion ASPIRATE JOINT (gonoccocal)

32. Refer to rheumatology and GUM Appropriate microbiology including HIV and hep serology if GUM related infection NSAIDs thromboprophylaxis

33. Questions?

34. CASE 4 42 yr old factory worker, presents to A & E with 3 week history of worsening jt pain, stiffness and swelling. Told by work manager to attend as unable to operate machinery today No FH O/E multiple swollen joints, skin and nails normal

35. New polyarthritis

36. Management Ensure no history of infection ANYWHERE Look hard for psoriasis (scalp) Investigations?

37. FBC, U and E, LFT, CRP, ESR CCP Uric acid if gout possible ANA/ ANCA Hands feet and chest xr Initial treatment?

38. Regular paracetomol NSAIDs if no contraindications PHONE a rheumatologist for either inpt review or rapid OPA- please do NOT start steroids unless you at least attempt to discuss with a rheumatologist first

39. Questions?

40. RA in-pts who flare

41. Attend hospital due to flare Flare whilst inpt for another reason

42. Attend A and E due to flare ~40% of pts who have had 1 years stable RA will flare annually, most self manage Those that don’t self manage- –Severe flare, unusual presentation of jt pains, inadequate home support, clinic cancellations, poor adherence to medication, infections and other concomitant health problems

43. What will you do?

44. Management Ask why have they presented NOW Look very hard for infection- if only 1 jt swollen then ASPIRATE plus usual bloods Consider blood cultures even if apyrexial (steroids, immunosuppressives, biologics- TB) Be realistic about whether the pt is likely to be able to ‘rise up and walk’ Phone Rheumatologist

45. What we do with these pts Ensure no infection (again) Optimise DMARDS/ biologics Steroids- often IM to ensure they are short term only Possibly keep in for physio/ OT/ social/ medical input

47. Inpts with RA who flare Significant comorbidity- increased CVD with 10yr reduced life expectancy mainly due to IHD, but also infection Joint replacement surgery So why do these pts flare?

48. Medication stopped accidently or on purpose on admission –PREDNISOLONE (usually accident) –DMARDs/ biologics- anti TNF (usually deliberate) Usual pains may feel worse when ill with other medical problems Infection Flares may just happen

49. Try and exclude infection If prednisolone omitted then reinstate and consider higher dose If active infection then temporarily stop methotrexate, leflunomide, cyclosporin, biologics PHONE RHEUMATOLOGIST

50. Questions?

51. Pts admitted with possible flare of SLE symptoms Try not to panic or ignore but seek advice early Look for usual pathology that can cause similar symptoms Infection screen- lupus flares frequently triggered by infection

52. Usual bloods plus complement levels (can fall in flare) and nuclear antibodies unless done in past month- new or rising dsDNA antibodies can indicate flare Keep on DMARDs unless severe blood dyscrasias (which may in any case be due to SLE) PHONE RHEUMATOLOGIST

53. Questions?

54. Summary Rheumatological problems extremely common in hospital in-pts Symptoms frequently very treatable Phone for advice rather than just sending an internal referral slip