Download Rheumatologic Emergencies - Calgary Emergency Medicine

Rheumatologic Emergencies
Sarah McPherson
May1, 2002
MONOARTICULAR ARTHRITIS
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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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Common joints involved:
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Adult: Knee, wrist, ankle
Children: Knee, Hip
IVDU: axial skeleton (vertebral, SI, sternoclav)
Risk Factors:
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Very old and young
Chronic debilitating disease
IVDU
Immunosuppressive therapy
Prosthetic joint or post arthrocentesis
Septic Arthritis
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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
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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
Septic Arthritis
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Management:
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Non-prosthetic joint:
Daily aspiration
 Iv Ancef for 3 weeks
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Prosthetic joint
Daily aspiration or I&D
 IV vancomycin and po Ciprofloxacin
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Gout
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Risk factors:
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Obesity
Hypertension
Diabetes
Alcohol consumption
Loop diuretics
Lead exposure
Gout
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Management:
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NSAIDs:
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Indomethacin 50 mg tid X 3-5 days
Colchicine:
0.6 mg q1h until pain subsides max 4-6 mg
 Side Effects: GI upset,
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Steroids
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If resistant to above; 40 mg qd X 3-5 days
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.
Gonnococcal Arthritis
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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)
Gonococcal Arthritis
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Diagnosis: initially clinical diagnosis
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Confirm with C&S from urethral, rectal and
pharyngeal swabs
Treatment:
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Ceftriaxone 1 gr iv X 24-48 hr
Follow with Cefixime 400mg bid or Cipro
500mg bid to complete 7 days antibx
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.
Lyme disease
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From tick bites in areas where Borrelia
burdorferi is endemic
~ 50% of people remember bite
Presentation:
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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
Lyme disease
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Treatment:
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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)
Reiter’s Syndrome
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Reactive arthritis from GI/GU infections
(Chlamydia, Shigella, Salmonella,
Yersinia, Campylobacter)
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Asymmetric polyarthritis mainly of weight
bearing joints ~ 2-6 weeks post urethritis
or dysentery
Reiter’s Syndrome
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Physical exam:
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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
Reiter’s syndrome
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Management:
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Indomethacin up to 250 mg/d
If Chlamydial tetracylines may shorten
duration
Will last 4-7 months
May be recurrent
Bursitis & Tendinitits
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Shoulder – major causes of pain:
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Elbow
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Lateral epicondylitis, olecranonbursitis
Hip
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Subacromial bursitis, supraspinatuns
tendinitits, bicipital tendinitis, rotator cuff
Trochanteric, ischial, iliopsoas bursitis
Knee
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Prepatellar, infrapatellar, anserine bursitis
Bursitis & Tendinitis
MANAGEMENT
 Conservative
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Ice, rest, NSAID’s
Early ROM exercises for shoulder and elbow
Olecranon and prepatellar bursitis
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Aspirate
Cefazolin 1g iv q8hr
SLE – the diagnosis (need > 4)
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Malar rash
Discoid rash
Photosensitivity
Oral ulcers
Arthritis
Serositis
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Pleuritis
Percarditis
Renal disorder
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Neurologic disorder
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Hematologic disorder
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Seizures
Psychosis
Anemia
Leukopenia
Thrombocytopenia
Blood tests
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ANA, anti-Sm Ab, antiDNA Ab, False +
VDRL/RPR
SLE - treatment
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NSAID’s : first line (don’t use if low
platelets, GI involvement, renal disease)
Corticosteroids:
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Minor: Prednisone 0.5 mg/kg/d
Major: Prednisone 1g/kg/d
Cerebritis or worsening glomerulonephritis:
methylprednisolone 1 g iv
Antimalarial
Immunosuppression agents
SLE – complications of
immunosuppressive agents
Cyclophosphamide
 Hemorragic cystitis
 Bladder carcinoma
 SIADH
 GI distress
 Alopecia
 Myelosuppression
 Neoplasia
 Infection
Azathioprine
 GI distress
 Myelosuppression
 Hepatitis
 Pancreatitis
 Aseptic meningitis
 Neoplasia
 Infection
Drugs that can cause a Lupuslike Syndrome
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Procainamide
Quinidine
Hydralazine
Isoniazid
Penecillin
Sulphonamides
Tetracycline
Dilantin
And the list goes on…..
Vasculides
Wegener’s
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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
Vasculides
Henoch-Schonlein Purpura
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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