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A 48 year old woman is seen for two days of severe pain in her right elbow. She has a long standing history of rheumatoid arthritis involving her hands, wrists, elbows, ankles and spine. She often gets flares of pain after overuse of the computer, or with significant changes in the weather. Her most recent flare was three weeks ago, at which time she was placed on prednisone. She is currently tapering the dose. She now describes severe pain in the elbow and markedly diminished range of motion. She denies shortness of breath, chest pain, fevers, sweats or weight loss. • She has no other medical problems.. • Medications include 1000 mg of naprosyn daily, 10 mg of prednisone daily, and 20 mg of omeprazole. • Family history is unremarkable. • She does not drink alcohol, and has never smoked. • ROS is entirely negative.
Physical exam: • Vital signs: 104/68 70 14 38.2 C • Alert, oriented • Cardiac, pulmonary, abdominal exams normal • Decreased ROM of both wrists, both ankles, and both elbows, with the right elbow worse than the left. There is mild warmth and edema over all joints, but notably increased over the right elbow, with some redness. • Joint aspirate is done, which is sent for analysis. You perform a gram stain, which shows many WBCs but no organisms
Which of the following is the most appropriate therapy for this patient? A) Increase prednisone to 60 mg daily B) Depo-medrol, 80 mg IM C) Depo-medrol, 80 mg intraarticular D) Cefotaxime + vancomycin, IV E) Toradol, 60 mg IM
Which of the following is the most appropriate therapy for this patient? A) Increase prednisone to 60 mg daily B) Depo-medrol, 80 mg IM C) Depo-medrol, 80 mg intraarticular D) Cefotaxime + vancomycin, IV E) Toradol, 60 mg IM
Septic arthritis • Synovial fluid analysis should be performed in the febrile patient with an acute flare of established arthritis to rule out superimposed septic arthritis • Unexplained inflammatory fluid, particularly in a febrile patient, is assumed to be infected until proven otherwise by appropriate culture • Infected fluid is usually purulent with an average leukocyte count (most of which are neutrophils) of 50,000 to 150,000 cells/mm3. However, lower cell counts may be observed among immunocompromised patients and in infections due to mycobacterial, some Neisserial, and several gram positive organisms.
Septic arthritis in RA • Although rheumatoid arthritis (RA) is typically a symmetrical, chronic polyarthritis, an acute or subacute exacerbation of one or a few joints is common. It is important to differentiate such an exacerbation from concurrent bacterial arthritis. However, the correct diagnosis may be difficult to establish because the clinical findings may be somewhat atypical. As an example, many RA patients present indolently (rather than acutely) with bacterial arthritis, often with little fever or peripheral blood leukocytosis. Conversely, RA alone may present with a "pseudoseptic arthritis" picture, including an explosive acute synovitis with a marked synovial fluid leukocytosis. Thus, Gram stain and culture of synovial fluid are essential when evaluating the new onset of synovitis in these patients.
Septic arthritis - therapy • Gram + • Cefazolin • Vancomycin • Gram – • Ceftazidine • Ceftriaxone • Cefotaxime • Repeat joint aspiration may be necessary • **Intraarticular steroids may cause rapid deterioration in patients with bacterial arthritis, leading to joint destruction.** OBJECTIVE: recall that a severe flare in a single joint of a patient with rheumatoid arthritis may indicate the joint is septic
