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Rheumatologic Emergencies

Rheumatologic Emergencies. Sarah McPherson May1, 2002. MONOARTICULAR ARTHRITIS. Case: 70 year old man presents with a red hot swollen knee x 24 hr. He tells you that the affected knee is a prosthetic joint. What is the likely diagnosis? How should you manage this case?. Septic Arthritis.

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Rheumatologic Emergencies

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  1. Rheumatologic Emergencies Sarah McPherson May1, 2002

  2. MONOARTICULAR ARTHRITIS • Case: 70 year old man presents with a red hot swollen knee x 24 hr. He tells you that the affected knee is a prosthetic joint. What is the likely diagnosis? How should you manage this case?

  3. Septic Arthritis • Common joints involved: • Adult: Knee, wrist, ankle • Children: Knee, Hip • IVDU: axial skeleton (vertebral, SI, sternoclav) • Risk Factors: • Very old and young • Chronic debilitating disease • IVDU • Immunosuppressive therapy • Prosthetic joint or post arthrocentesis

  4. Septic Arthritis • Joint aspiration: • A must do!!!! KNEE: Extend knee, insert needle from the medial side between posterior surface of the patella and intercondylar femoral notch at midpoint to superior pole of the patella WRIST: Flex wrist with ulnar deviation. Insert needle distal to Lister’s tubercle ulnar to extensor pollicus longus

  5. Septic Arthritis ELBOW Flex elbow . Insert needle from lateral side distal to lateral epicondyle and direct medially ANKLE Plantar flex foot. Insert needle into hollow at anterior edge of the medial malleolus medial to anterior tibial tendon. Will have to insert needle 2-3 cm NORMAL SYNOVIAL FLUID ANALYSIS Clear < 200 WBC/mm3 < 25 PMN no crystals

  6. Septic Arthritis • Management: • Non-prosthetic joint: • Daily aspiration • Iv Ancef for 3 weeks • Prosthetic joint • Daily aspiration or I&D • IV vancomycin and po Ciprofloxacin

  7. Gout • Risk factors: • Obesity • Hypertension • Diabetes • Alcohol consumption • Loop diuretics • Lead exposure

  8. Gout • Management: • NSAIDs: • Indomethacin 50 mg tid X 3-5 days • Colchicine: • 0.6 mg q1h until pain subsides max 4-6 mg • Side Effects: GI upset, • Steroids • If resistant to above; 40 mg qd X 3-5 days

  9. POLYARTHRITIS Case: 26 yr old woman presents with myalgias and arthritis of the right wrist and left knee X 1 wk. She notes that 2 days ago she also had pain in her left hand but that had resolved. On exam she is febrile and you notice red pustular lesions on the sides of her fingers.

  10. Gonnococcal Arthritis • Fever, chills, arthralgia progressing to arthritis • Wrist, knee, and ankle most commonly affected • 2/3 will have characteristic rash (necrotic pustules on distal extremities & fingers)

  11. Gonococcal Arthritis • Diagnosis: initially clinical diagnosis • Confirm with C&S from urethral, rectal and pharyngeal swabs • Treatment: • Ceftriaxone 1 gr iv X 24-48 hr • Follow with Cefixime 400mg bid or Cipro 500mg bid to complete 7 days antibx

  12. Case: 65 yr old man presents with a headache and achy joints for just over 24 hrs. He describes a red lesion on his thigh that has been growing in size for the past 3 days.

  13. Lyme disease • From tick bites in areas where Borrelia burdorferi is endemic • ~ 50% of people remember bite Presentation: • Lesion at bite site that rapidly grows in size and multiplies • Red boarder with central clearing • Fever, migratory tenosynovitis, polyarthrits, headache • At 4 weeks may have neurologic and cardiac abnormalities • 50-60% arthritis at 6 months, may be recurrent

  14. Lyme disease • Treatment: • Shortens duration of symptoms and prevents later disease • Doxycycline 100mg bid X 2-4 weeks • Amoxicillin 500mg tid X 2-4 weeks (pregnant and lactating women, children < 5 yrs)

  15. Reiter’s Syndrome • Reactive arthritis from GI/GU infections (Chlamydia, Shigella, Salmonella, Yersinia, Campylobacter) • Asymmetric polyarthritis mainly of weight bearing joints ~ 2-6 weeks post urethritis or dysentery

  16. Reiter’s Syndrome • Physical exam: • Polyarthritis • Ocular findings (conjuntivitis, uveitis, corneal ulcers) • Oral ulcers (10% of patients) • Sores on glans penis (20% patients) • Saugelike fingers and toes • Low back pain

  17. Reiter’s syndrome • Management: • Indomethacin up to 250 mg/d • If Chlamydial tetracylines may shorten duration • Will last 4-7 months • May be recurrent

  18. Bursitis & Tendinitits • Shoulder – major causes of pain: • Subacromial bursitis, supraspinatuns tendinitits, bicipital tendinitis, rotator cuff • Elbow • Lateral epicondylitis, olecranonbursitis • Hip • Trochanteric, ischial, iliopsoas bursitis • Knee • Prepatellar, infrapatellar, anserine bursitis

  19. Bursitis & Tendinitis MANAGEMENT • Conservative • Ice, rest, NSAID’s • Early ROM exercises for shoulder and elbow • Olecranon and prepatellar bursitis • Aspirate • Cefazolin 1g iv q8hr

  20. Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis Pleuritis Percarditis Renal disorder Neurologic disorder Seizures Psychosis Hematologic disorder Anemia Leukopenia Thrombocytopenia Blood tests ANA, anti-Sm Ab, anti-DNA Ab, False + VDRL/RPR SLE – the diagnosis (need > 4)

  21. SLE - treatment • NSAID’s : first line (don’t use if low platelets, GI involvement, renal disease) • Corticosteroids: • Minor: Prednisone 0.5 mg/kg/d • Major: Prednisone 1g/kg/d • Cerebritis or worsening glomerulonephritis: methylprednisolone 1 g iv • Antimalarial • Immunosuppression agents

  22. Cyclophosphamide Hemorragic cystitis Bladder carcinoma SIADH GI distress Alopecia Myelosuppression Neoplasia Infection Azathioprine GI distress Myelosuppression Hepatitis Pancreatitis Aseptic meningitis Neoplasia Infection SLE – complications of immunosuppressive agents

  23. Drugs that can cause a Lupus-like Syndrome • Procainamide • Quinidine • Hydralazine • Isoniazid • Penecillin • Sulphonamides • Tetracycline • Dilantin • And the list goes on…..

  24. Vasculides Wegener’s • Medium vessel disease • Upper resp tract, Lower resp tract, then glomerulonephritis (85%), ocular findings and cerebral vasculitis (33%) • Diagnosis: elevated ESR, + c-ANCA, - ANA, hematuria, active urine sediment • CXR: sharply demarcated pulmonary nodules • Management: steroids & cyclophosphamide, iv steroid for flares of glomerulonephritis

  25. Vasculides Henoch-Schonlein Purpura • Usually affects children • Triggers: viral infections, insect stings, drugs • Presentation: purpuric rash, lower limb arthralgia, GI complaints (80%), gomerulonephritis (50%) • Management: conservative, severe arthralgia or abdo pain give 1mg/kg/d prednisone, admit with iv steroids if renal involvement

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