Download Monoarthritis - Bath Institute for Rheumatic Diseases

Monoarthritis
28th February 2012
Tehseen Ahmed
Aims and Objectives
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Aim
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To be able to manage the patient with an acute hot joint
Objectives
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By the end of this session you should be able to:
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Undertake a relevant history from a patient presenting with an
acute hot joint.
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Form a differential diagnosis for the patient.
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Appropriately further investigate / refer the patient.
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Institute initial treatment for your patient.
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Diagnostic approach
Case scenarios
Diagnostic clues
Investigation
Treatment
Picture quiz
Monoarthritis
• Inflammation of a single joint
• Can be acute or chronic.
Acute monoarthritis – Diagnostic
approach
• History
– review of symptoms
– previous joint disease or trauma
– concurrent illnesses
– family history
– medication use – e.g. diuretics, anticoagulants
– other risk factors
• travel, sexual history, diet, tick bites, occupational
history, alcohol and intravenous drug use
Acute monoarthritis – Diagnostic
approach
• Examination
– Focus on the involved and contralateral joint
and surrounding area
– General examination to look for other affected
joints
– Look for systemic manifestations of disease
Scenario 1
• A 35 year old man presents with a 1 day
history of an intensely painful and swollen
left knee. He is struggling to weight bear
and cannot bend his knee much.
• He is otherwise well except for
hypertension.
• Onset of pain
– “ I went to bed fine doctor. When I woke up I could hardly
bend my knee”
• Any previous similar episodes
– “Never in my knee doc. But I had something similar
affecting my foot last year. It lasted about two weeks.”
– “A&E treated me for a skin infection and gave me some
painkillers.”
• Medications
– “I take a tablet for my blood pressure when I remember
…… it don’t half make me pee a lot though doc.”
• Any alcohol?
– “No more than average like…… 6 pints a night say”
On examination
Diagnosis?
Gout
• Most common cause of inflammatory
arthritis in adults
• Usually men >40 years and postmenopausal women
• Initially acute monoarthritis
• Associated with hyperuricaemia, renal
impairment, diuretics, hypertension,
hyperlipidaemia, excess alcohol, obesity
• Family history in some
Gout
• 50-70% of first attacks affect the big toe.
• Other frequently affected joints include the midfoot,
ankle, knee, wrist, and elbow.
• Shoulders and hips rarely involved.
• Can have low grade temperature.
• Raised inflammatory markers (can be very high) with
neutrophilia.
• Majority of patients have further attacks.
• Tophi can develop in chronic disease.
Scenario 2
• A 35 year old American tourist presents
with a 2 day history of an intensely painful
and swollen left knee. He is struggling to
weight bear and cannot bend his knee
much.
• He reports feeling feverish.
• Onset of pain
– “ It has swollen up over a
few days and it feels hot”
• Any previous similar
episodes
– “First time I have had
anything like it”
• Medications
– “I don’t take anything”
• Any alcohol?
– “Very little”
• Associated symptoms
– “I felt feverish last night”
– “I noticed a couple of new
spots on my body ……….
….like acne”
• Anything else?
– “I had a one-night stand
last week …….. I didn’t use
any protection”
– “Could it be related?”
Diagnosis?
Gonococcal arthritis
• Gonococcal arthritis is caused by infection with the
gram-negative diplococcus neisseria gonorhhoeae.
• In the US, gonococcal arthritis is the most common form
of septic arthritis.
– This is in contrast to Western Europe, where gonococcal arthritis is
uncommon.
• Gonococcal arthritis is ultimately a consequence of
disseminated gonococcal infection.
• Haematogenous spread of the mucosal infection occurs
in up to 3% of cases.
– Time from initial infection to manifestations of disseminated infection
ranges from 1 day to 3 months.
• It manifests as either a bacteraemic infection (arthritisdermatitis syndrome; 60% of cases) or as a localized septic
arthritis (40%).
– Arthritis-dermatitis syndrome includes the classic triad of dermatitis,
tenosynovitis, and migratory polyarthritis.
• Septic arthritis form
– Joint symptoms begin within days to weeks of gonococcal infection.
– Usually affects one joint.
– Most commonly knees, wrists, ankles, elbows.
• Synovial fluid cultures can be positive in up to 50% of cases
– Cultures from likely sites of initial infection will increase the yield.
– Blood culture / Cervix / Rectum / Urethra / Pharynx.
• PCR testing of samples can also increase yield if cultures are
negative.
• Patients with gonococcal arthritis usually require initial IV abx.
– Unlike in Staph. aureus septic arthritis, joint destruction is rare.
Scenario 3
• An 80 year old woman with type 2 diabetes and
rheumatoid arthritis presents with a two week
history of increasing pain and swelling in her
right wrist.
• Her rheumatoid is well controlled on medication
but her wrist has been a problem and has been
injected with steroids recently.
• She is feeling feverish and unwell.
On examination
Diagnosis?
Septic arthritis
• More common in those with inflammatory arthropathies,
joint prostheses, impaired immunity.
• Any age affected but more commonly young and elderly.
• Systemic symptoms usually present but beware in
immunocompromised.
• Fever has poor sensitivity and specificity for septic
arthritis.
• Synovial fluid culture positive in 90%.
• More than one joint can be involved in up to 20% of
cases.
Scenario 4
• 85 year old woman
• RA, OA of the knees, Leg ulcers, Hypertension,
PPM
• Awaiting Right TKR
• 2 week history of marked swelling in her left
knee
– Started suddenly following some physiotherapy
• Not systemically unwell.
• On examination
– Large, warm effusion
left knee.
• Any further info?
Haemarthrosis
• Not always associated with a history of
trauma.
• Usually significant swelling.
• Traumatic causes include cruciate
ligament rupture and intra-articular
fracture.
• Other causes include pigmented
villonodular synovitis and bleeding
diatheses.
• In approximately 1/3 of cases of
monoarthritis no definitive diagnosis will be
identified even after appropriate
investigation.
Diagnostic clues
• Sudden onset of pain over seconds to minutes
– Trauma
• Onset of pain, swelling, tenderness maximal within 12
hours
– Crystal arthropathy
• Onset of pain over several hours or 1-2 days
– Crystal arthropathy
– Septic arthritis
– Monoarthritic presentation of other inflammatory
arthropathy
• Insidious onset of pain & swelling over days-weeks
– Low grade/atypical infection, OA, malignancy,
granulomatous disease
• DM, Cellulitis, Prosthetic joints, RA, IV drug abuse
– Septic arthritis
• Steroid exposure
– Septic arthritis
– Avascular necrosis
• Coagulopathy, Use of anticoagulants
– Haemarthrosis
Other causes of monoarthritis
Seronegative
spondyloarthropathies
Monoarthritic presentation of
polyarthritis
Pseudogout
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•
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More elderly age group.
Mean age early 70’s.
Acute monoarticular presentation.
In CPPD can also get oligoarticular and
occasionally polyarticular disease (can mimic
RA).
• Often affects the knee, wrist, or shoulder.
• Triggers include:
– Intercurrent illness
– Trauma
– Surgery
Investigations
•JOINT ASPIRATE !!!
– Gram stain
– M, C & S
– Crystal analysis
Investigations
• Blood cultures
• Bloods – ESR/CRP, FBC, U+E’s,
Clotting
• X-ray – affected and contralateral
joint
• Consider: serum urate, CXR, sputum
sample, urine culture, skin swabs
Treatment – depends on the
cause!
• Aspirate joint
• Analgesia – NSAIDs, Colchicine
• Rest / Ice / Elevation
• Antibiotics if indicated – 2 weeks IV, 4
weeks oral follow-on
• Intra-muscular/Intra-articular/Oral steroids
if indicated
Learning points
1. In acute inflammatory monoarthritis, symptoms reaching their
maximum within 6-12 hours are highly suggestive of a crystal
arthropathy.
2. Serum uric acid levels do not confirm or exclude gout.
3. Demonstration of urate crystals in synovial fluid or tophus
aspirates is diagnostic of gout.
4. Beware that gout and sepsis can co-exist.
5. Repeated culture of synovial fluid, blood and other sources of
sepsis may be needed if initial samples are negative but clinical
suspicion remains high.
6. In a young patient with a monoarthritis but no history of trauma,
refer to rheumatology NOT orthopaedics.
References
• Lingling M, Cranney A, Holroyd-Leduc JM. Acute monoarthritis:
What is the cause of my patient’s swollen joint? CMAJ. 2009
January 6; 180(1): 59–65
• Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult
patient have septic arthritis? JAMA 2007 Apr 4;297(13):1478-88