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Transcript
Acute Monoarthralgia Presentation Marilyn 67 y.o. woman Presents to GP with red painful right big toe which has kept her awake most of last night. She was well when she went to bed. No recent illnesses. Issues to consider. 1. How is arthritis described in terms of joint involvement? 2. What are the causes of acute monoarticular arthritis? 3. Can they be distinguished on history and examination? Joint involvement • • • • Number of joints – mono, oligo, poly arthritis Symmetrical or not Small or large joints Peripheral or axial Joint involvement Monoarthritis Oligoarthritis (≤5 joints) Symmetrical Polyarthritis Asymmetrical Polyarthritis Septic arthritis Crystal arthritis Rheumatoid arthritis Reactive arthritis Crystal arthritis (gout, CPPD) Psoriatic arthritis Osteoarthritis Trauma, eg haemarthrosis Psoriatic arthritis Osteoarthritis Reactive arthritis, eg Yersinia, Viruses (eg Salmonella, hepatitis A, B & Campylobacter C; mumps) Ankylosing spondylitis Osteoarthritis SLE, Sarcoidosis, leukaemia, endocarditis, haemochromatosis, sickle-cell anaemia, familial Mediterranean fever, Behçet’s. Acute monoarticular arthritis • • • • Trauma Bleed Infection (Danger!) Gout / pseudogout Septic arthritis • Uncommon but dangerous • Risk factors – Existing joint disease – Prosthetic joint – Immunosuppresed – Diabetes – Chronic renal disease – Skin infection, cutaneous ulcers – IV drug abuse, alcoholism – Previous intra-articular corticosteroid injection Septic arthritis • Joint pain, swelling, warmth, and restricted movement • Patient usually has a fever. Not always • Most common (>50%) in knee joint • Wrists, ankles, hips also common • 20% have infection in more than one joint. • Usually haematogenous, eg from endocarditis, UTI, or STD (particularly gonorrhea) Uptodate.com Haemarthrosis • Presents with considerable swelling • Trauma • Bleeding diatheses • Pigmented villonodular synovitis Crystal arthropathies Gout CPPD (Pseudogout) Others hyperucemia → uric acid crystals Calcium pyrophosphate dihydrate disease Basic calcium phosphate associated disease Can present similarly to gout, but less commonly Calcium oxalate arthritis Typically male >40yo 70% first in big toe Also in ankle, foot, knee, wrist, elbow Often in knee (olecranon bursa), and the small joints of the hands History Marilyn says she has had similar episodes twice in the past 18 months but never this severe and they have settled in 2 or 3 days with some Ibuprofen. She tried two doses over night with no relief. Examination On examination Marilyn is afebrile and is obviously in significant pain. Your examination of the toe shows a swelling which is localised to the first metatarsophangeal joint of the right great toe. It is red, slightly warm and exquisitely tender to palpation and painful with any attempted passive movement. She is completely unwilling to perform any active movement.