Download Acute Arthropathies “I’ve got a painful, swollen knee doctor”

Acute Arthropathies
“I’ve got a painful, swollen knee
doctor”
By Dr Mahya Mirfattahi GP ST1
HDR LRCH
9th December 2009
What could it be?
•
•
•
•
•
•
•
•
•
Septic arthritis
Septic bursitis
Crystal arthropathies – gout, pseudogout
Acute exacerbation of osteoarthritis
Acute attack of rheumatoid arthritis
Trauma
Seronegative spondyloarthropathy
Viral infection
Lupus
Clinical assessment - History
• Patient demographics
– Age, gender, ethnicity, obese
• History
– Pain, swelling, stiffness, duration (short), site, preceding trauma,
other joints affected, previous episodes, systemic symptoms
• Past medical history
– Joint prosthesis, osteoarthritis, previous trauma, inflammatory
arthritis, psoriasis, recent episodes of illness, diabetes mellitus,
hypertension, recent corticosteroid joint injection, haemophilia
• Current medications
– Bendroflumethiazide, aspirin, immunosuppressant therapy
Clinical assessment - Examination
• Look
– Swelling, redness, scars, tophi, psoriatic plaques,
nails, nodules, joint deformities, ulcers
• Feel
– Warmth, effusion, swellings
• Move
– Restriction, crepitus, ability to weight bear, painful
movements
• Systemic features
Case 1
• 67 year old man
• Type 2 diabetic, suffers with ulcers on legs
dressed by district nurse. LT catheter.
• Presents with acute history of painful, hot,
swollen red knee
• Struggles to walk into surgery
• Feverish today
• Ulcers weeping
What would you like to do?
• History
– Further enquiries reveal recent corticosteroid
injection in knee for OA symptoms
• Examination
– Temp 37.8, tachycardic, red, hot, effusion,
unable to weight bear, restriction of movement
• Consider risk factors
• What is the mandatory investigation?
Joint aspiration
Septic arthritis
•
•
•
•
Overall mortality 10% in adults
Suppurative inflammation in joint space
Majority monoarticular
Large > small joints
– 50% knee, hip 20%, shoulder 8%, ankles 7%, elbow
& IPJ 1-4%
• Most commonly haematogenous spread
• Can be direct penetrating wound or neighbouring
infection
• Children, neonates, elderly & immunosuppressed
Pathogens
• 90% non-gonococcal
– staph aureus 50-80%, streptococcus 15-20%,
haemophilus influenzae b 20% (infants 6mo-2yrs),
anaerobes 5%
• Gonococcal
– young, sexually active
– Pustular skin lesions (dermatitis-arthritis syndrome)
– Tenosynovitis
– Migratory arthralgias
– Hand > knee, wrist, ankle, or elbow
Risk factors for septic arthritis
•
•
•
•
•
•
•
•
•
•
•
Previously damaged joints
Prosthetic joints
Immunocompromised states
Systemic drugs – corticosteroids, DMARDS, biological
agents
IV drug abuse
Alcohol abuse
Diabetes
Previous intra-articular corticosteroid injection
Cutaneous ulcers
Indwelling catheters
>65 yrs old
Management
• If confident, joint aspirate to dryness & urgent
gram stain
• Admit patient – discuss with orthopaedic on-call
SHO
• Blood tests
• Cultures – 3x blood, MSU, swabs
• Plain XR
• Start empirical antibiotics – 1st line flucloxacillin
IV 2g QDS
• Discuss with microbiologist
• Long duration of antibiotic therapy
Case 2
• 78 year old male
• Hypertensive, aspirin, osteoarthritis, renal
impairment, obese
• Complains of painful, hot swollen knee
• Noticed swellings on hands
• Previous episode of joint pain in big toe
6mo ago settled with OTC NSAIDs
What will you do next?
• History
– Further questioning reveals that had knee
arthroscopy last yr, likes alcohol
• Examination
• Investigations
– Joint fluid aspirate, blood tests, plain XR
• What are his risk factors?
Risk factors for gout
•
•
•
•
•
•
•
•
•
Low dose aspirin
Diuretic
Increasing age, male
Family history
Hypertension
Central obesity
Alcohol consumption
Renal insufficiency
Haematological disorders
Precipitants of attack
•
•
•
•
•
Dehydration
Injury
Concurrent illness
Dental extraction
Excess foods/alcohol
Management
• Investigations
– Joint aspiration –ve birefringent needle-shaped
– Blood tests
•
•
•
•
•
•
Rest joint
NSAID or if unable or not responding colchicine
Consider PPI
Caution use of colchicine in IHD,CCF
Give until pain relieved
Side effects – diarrhoea, abdominal cramps
Prevention
•
•
•
•
•
Review medications
Advise patients – diet, lifestyle, weight loss
Prophylaxis
– Indications: uncomplicated gout >2 attacks/yr, tophi, renal insufficiency,
uric acid stones, need to continue diuretics
Allopurinol
– Start at 100mg od, gradually increase, monitor uric acid levels 4 weekly
until normal
– Delay until 2/52 after intial attack settled
– Monitor creatinine
– SE: rash – stop & reintroduce lower dose
– Interactions
– Give colchicine/NSAID first 3-6mo
– Continue allopurinol in attacks if pt already taking
Referral to rheumatology if no improvement
Case 3
• 17 year old male
• Recent travel to Ibiza, playing football
yesterday, bad tackle, able to continue
game.
• Painful, swollen knee
• No past medical history
• Able to weight bear, but sore
• Differential?
What would you do next?
• History
– Recent illness, STI, family history of bleeding
disorders
• Examination
• Investigations
– Joint fluid aspirate, blood tests, plain XR
Haemarthrosis
• Plain XR – fat/blood interface
• Common cause
– Ligament injury (cruciates in sports)
– Intra-articular #
• Inherited haemophilias
– APTT, assays for factors VIII, IX
Lipohaemarthrosis
Case 4 – a real story!
•
•
•
•
•
52 year old lady
Presents with confusion
Osteoarthritis, TKR 6 wks ago, obese
Fever, ache in knee, coughing
Husband very concerned requests GP
home visit
Assessment
• Confused to time, place & person
• Smelly urine
• Coughing, complains of back pain,
breathless
• Temp 38.6, tachycardic, consolidation
lower lobe, urine dip positive
• Knee – scar clean, dry, healed well. No
effusion. Not red. Slight warmth. Tender
ROM, but no restriction.
What will you do next?
• Admit to AMU
• Orthopaedic review?
– Yes, needs assessment
• Investigations
– Blood tests
– Cultures – 3x blood, MSU
– CXR
– Plain XR Knee
Management
• Needs joint aspiration in theatre, washout
of knee
• May need removal of prosthesis
• Empirical antibiotics intravenous long term
• Discuss with microbiologist
• Monitor inflammatory markers
Pseudogout
•
•
•
•
•
•
Consider when intermittent attacks
Monoarticular – knee, wrist, hip
Can simulate bacterial infection – severe inflammation & fever
Can be symmetrical
Joint damage can be severe
Investigations
– Joint aspiration = calcium pyrophosphate dehydrate crystals
(CPPD), rhomboid shaped, +ve birefringent
– Plain XR – chondrocalcinosis
– Causes – must screen for hyperparathyroidism,
haemachromatosis, hyphosphataemia, hypomagnesiaemia
• Treatment
– Rest, ice, NSAIDs, colchicine, intra-articular steroid injection
Reactive arthritis
• Aseptic arthritis
• Occurs 2-6wks after bacterial infection elsewhere
– Gastroenteritis (salmonella, campylobacter)
– GU infection (chlamydia, gonorrhoea)
• Can be HLA B27 +ve
• Treatment – NSAIDs, physiotherapy, steroid joint
injections
• Reiter’s syndrome
– Polyarthropathy, urethritis, irits, psoriaform rash
– Follows GU/GI infection
– Joint & eye changes often severe
Diagnosis?
What are these?
Diagnosis?
Diagnosis?
Useful Resources
• GP notebook
• Doctors.net e-module on acute swollen
joint
• ARC (www.arc.org.uk)
• Patient uk
• www.ukgoutsociety.org
• www.arthritiscare.org.uk