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Acute monoarthropathy

Acute monoarthropathy. Jaya Ravindran Rheumatologist. Aims. an approach to the investigation and differential diagnosis of acute monoarticular pain focus on septic and crystal arthritis. Acute Monoarthritis - differential diagnosis. Septic arthritis Crystal arthritis Gout (uric acid)

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Acute monoarthropathy

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  1. Acute monoarthropathy Jaya Ravindran Rheumatologist

  2. Aims • an approach to the investigation and differential diagnosis of acute monoarticular pain • focus on septic and crystal arthritis

  3. Acute Monoarthritis - differential diagnosis • Septic arthritis • Crystal arthritis • Gout (uric acid) • Pseudogout/calcium pyrophosphate deposition disease (CPPD)

  4. What are other differentials for acute monoarticular pain?

  5. Monoarthritis - differential diagnosis Psoriatic arthritis • Onycholysis • Subungual hyperkeratosis • Pitting • Extensor surfaces, scalp, natal cleft, umbilicus • Other associated features eg uveitis, inflammatory bowel disease, enthesitis, Ankylosing spondylitis

  6. Monoarthritis - differential diagnosis Reactive arthritis • Prodromal GI /GU Infection eg campylobacter, salmonella, shigella, Yersinia,chlamydia • Pustular psoriasis and circinate balanitis

  7. Monoarthritis - differential diagnosis • Trauma - # and haemarthroses (warfarin, bleeding disorders) • Palindromic rheumatism – 24-48 hours inflammatory monoarthritis, can evolve into polyarthritis eg RA

  8. Others to think about • Osteonecrosis/AVN (steroids/alcohol) • Severe pain but good ROM • Monoarticular RA • Monoarticular OA • Prosthetic joint - loosening, # or infection • Periarticular pathology

  9. Articular vs periarticular?

  10. Is it an articular or extra-articular problem? • ARTICULAR PERI-ARTICULAR • pain all planes pain in plane of tendon • active = passive active > passive • capsular swelling/effusion linear swelling • joint line tenderness localised tenderness • diffuse erythema/heat localised erythema/heat

  11. Olecranon bursitis

  12. Septic arthritis • 15-30 per 100,000 population • Fatal in 11% of cases in UK • Delayed or inadequate treatment leads to irreversible joint damage

  13. How do you get septic arthritis?

  14. Pathogenesis

  15. Who gets septic arthritis?

  16. common organisms Staphylococci or Streptococcus young adults, significant incidence gonococcal arthritis Elderly & immunocompromised gram -ve organisms Anaerobes more common with penetrating trauma Who gets septic arthritis?

  17. Who gets septic arthritis? • pre-existing joint disease • prosthetic joints • low SE status, IV drug abuse, alcoholism • diabetes, steroids, immunosuppression • previous intra-articular steroid injection

  18. Who gets septic arthritis? • Skin lesions e.g. ulcers, particularly in context RA often source of infection • poor prognostic features: older, pre-existing joint disease & presence of synthetic material within joint

  19. What are the signs and symptoms of septic arthritis?

  20. Symptoms & signs of septic arthritis • Typically hot, swollen, red tender joint with reduced range of movement, difficulty weight bearing • Systemic upset • Night and rest pain • Symptoms usually present for < 2/52 • Large joints more commonly affected than small • majority of joint sepsis in hip or knee

  21. Symptoms & signs of septic arthritis • In pre-existing inflammatory joint disease symptoms in affected joint(s), out of proportion to disease activity in other joints. • 10-15% of cases, > one joint - so polyarticular presentation does not exclude sepsis • presence of fever not reliable indicator- if clinical suspicion high - treat

  22. What investigations are useful in septic arthritis?

  23. Investigations • Synovial fluid aspiration • volume/viscosity/cellularity/appearance • gram stain/culture • Absence of organism does not exclude septic arthritis • polarised light microscopy (crystals) • NB suspected prosthetic joint sepsis should ALWAYS be referred to orthopaedics

  24. Investigations • Always blood cultures • significant proportion blood cultures + ve in absence of + ve synovial fluid cultures • FBC ESR & CRP • BUT absence of raised WBC, ESR or CRP not exclude diagnosis of sepsis - if clinical suspicion high always treat

  25. Other investigations • CRP useful for monitoring response to treatment • Urate may be normal in acute gout and of no diagnostic value in acute gout or sepsis • Measure urea, electrolytes & liver function for end organ damage (poor prognostic feature) • Renal function may influence antibiotic choice

  26. Other tests? • If skin pustule is present, suggestive of gonococcal infection, then skin swab should be taken • If history suggests possibility of genitourinary or respiratory tract infection then culture sputum (and CXR) & urine & take anogenital & throat swabs where appropriate • If periarticular sepsis – appropriate swabs and cultures

  27. Imaging • Plain X rays no benefit in diagnosis but form baseline for any future joint damage. May show chondrocalcinosis. • MRI useful in distinguishing sepsis from OA but less good between sepsis & inflammation • MRI sensitive for osteomyelitis

  28. Imaging • Ultrasound useful in guiding needle aspiration eg hip • White cell scanning helpful in diagnosing prosthetic sepsis

  29. Antibiotic treatment of septic arthritis • Local and national guidelines • Liaise with micro. guided by gram stain • Conventionally given iv for 2 weeks or until signs improve, then orally for around 4 weeks

  30. Joint drainage & surgical options • medical aspiration, surgical aspiration via arthroscopy or open arthrotomy • Suspected hip sepsis – early orthopaedic referral – may need urgent open debridement

  31. Recommendations specific to 1o care & emergency department • commonest hot joint to present in 1o care is 1st MTP gout • usually diagnosed on clinical grounds without needle aspiration or referral to hospital. (Make referral if inadequate recovery) • Some GPs aspirate & inject joints for inflammatory arthritis or osteoarthritis. If withdraw pus/unexpected cloudy fluid should send sample with patient to local emergency department

  32. Recommendations specific to 1o care & emergency department • GPs & doctors in EAU should refer patients with suspected septic arthritis to specialist with expertise to aspirate joint. May be orthopaedic surgeon or rheumatologist • Admit if sepsis is suspected or confirmed.

  33. Summary • with a short history of a hot, swollen, tender joint (or joints) plus restriction of movement; septic arthritis until proven otherwise • If clinical suspicion high investigate & treat as septic arthritis even in absence of fever

  34. THANK-YOU

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