Rheum E1 -Crystalline & Septic Arthritis

What is Gout?

painful form of arthritis that is caused by high uric acid levels in your blood (hyperuricemia)

What type of crystals are associated with gout?

Monosodium urate crystals

True or False: The majority of patients with hyperuricemia and gout are asymptomatic

True

The majority of patients with gout are due to (overproduction/undersecretion) of urid acid

Undersecretion

Why do humans have a higher level of uric acid when compared to other mammals?

Humans lack uricase which breaks down uric acid for urinary excretion

Who does gout predominantly effect?

men > 50 yo

What are the 3 clinical stages of Gout?

(in order)

1) asymptomatic hyperuricemia

2) acute intermittent

3) chronic tophaceous

Do you treat asymptomatic hyperuricemia (1st stage of gout)?

No

What meds can be favorable as uricosurics in the 1st stage of gout (asymptomatic hyperuricemia)?

Estrogen & high dose ASA

What are risk factors that should be removed in the 1st stage of gout (asymptomatic hyperuricemia)?

Thiazides, high fructose corn syrup, beer, low dose aspirin

What stage of gout is associated with the first attack?

Acute intermittent gout

Is acute intermittent gout usually monoarticular or polyarticular?

monoarticular

How long does acute intermittent gout last if untreated?

7-10 days

What is Chronic tophaceous gout associated with?

overproducers of urate and tophi

What is the most severe and destructive form of gout?

chronic tophaceous gout

What can chronic tophaceous gout lead to if untreated?

urate stone & nephropathy

What would aspiration of Gout show?

Negatively birefringent (yellow) needle-shaped crystals when lying parallel to the polarizer

What will be seen on an XR of gout?

Bite-like erosions

What is the 1st line tx for acute gouty flares?

(in order)

NSAIDs (Indocin), Colchicine, Steroids

What NSAID is preferred for tx of an acute gouty attack?

Indocin

What is the 1st line tx for chronic gout?

Xanthine oxidase inhibitors- Allopurinol or Febuoxstat

What is the goal serum uric acid level when tx chronic gout?

< 6 mg/dl

What should be started for preventative/bridging tx of gout?

Colchicine or NSAIDs x 6 months

*help avoid flares, while ULT take effect

What is the 2nd line tx for chronic gout?

add uricosurics: Lesinurad (Zurampic) & Probenecid

What is the 3rd line tx for chronic gout?

Uricase agent

What is the only FDA approved urolytic for tophaceous gout/refractory gout?

Pegloticase (Krystexxa) (Savient)

*given as an infusion

What is the goal serum uric acid when tx tophaceous gout?

< 5 mg/dl

What are the SE of Pegloticase (Krystexxa)?

Anaphylaxis, gouty flares

What type of crystals are associated with CPPD/pseudogout?

Calcium pyrophosphate dihydrate crystals

How does pseudogout present?

acute arthritis

What is seen on an XR of Pseudogout/CPPD?

Chondrocalcinosis

What is seen on an aspiration of Pseudogout/CPPD?

Positively birefringent (blue) short rod/rhomboid-shaped crystals

What are key distinguishing elements that aid in the dx of Pseudogout?

Chondrocalcinosis, + birefringent rod/rhomboid shaped crystals parallel to polarizer

What is the MC cause of secondary pseudogout/CPPD?

Osteoarthritis

What are other causes of secondary pseudogout/CPPD?

Hyperparathyroidism, Hemochromatosis, Hyperthyroidism

What degenerative changes are seen in finger joints affected by pseudogout/CPPD?

subchondral changes at 2nd & 3rd MCPs

Where does Chondrocalcinosis occur in Psuedogout?

wrists

What is the 1st line tx for pseudogout/CPPD?

*in order

NSAIDs, Colchicine, Steroids

What is Infectious/Septic arthritis?

arthritis due to causative pathogens documented by culture and/or Nucleic Acid Amplification Tests (NAAT)

What is the MC causative pathogen of nongonococcal bacterial arthritis?

S. aureus

*followed by B-hemolytic streptococci & G- organisms

What is the causative pathogen of gonococcal bacterial arthritis?

Neisseria gonorrheae

What diagnostic test is preferred for diagnosis of bacterial arthritis?

Nucleic acid amplification test (NAAT)

What is used to culture gonorrhea?

chocolate agar (Thayer-martin media)

What is the MC joint affected by disseminated gonococcal infection?

Knee

What is the classic triad for Disseminated gonococcal infection?

Dermatitis, Migratory polyarthralgias/polyarthritis, Tenosynovitis

What is the preferred dx test for Disseminated gonoccoal infxn?

NAAT

What is the tx for disseminated gonococcal infection (arthritis)?

Ceftriaxone

True or False: You should always treat for chlamydia when treating a disseminated gonococcal infection

False

When should you treat for gonococcal infection AND chlamydia?

Only if NAAT is positive for chlamydia

What is the tx for chlamydia?

Doxy X 7 days or Azithromycin for kids/pregnancy

True or False: If NAAT is not available, then CDC recommends treating for coexisting chlamydia infection

True

What should you do when tx Gonorrhea or Chylamydia?

tx partners when possible

What pts are at risk for non-gonoccoal arthritis?

hospitalized, RA, hemodialysis pts, IVDA

What increases the risk/prevalence of MRSA & S. epidermidis infection of septic arthritis?

Prosthetic joints

What is the 1st line tx for non-gonoccocal arthritis (staph)?

Vancomycin

If non-gonococcal arthritis is NOT MRSA, what is the tx?

PCN or Cephalosporin x 4-6 weeks

What non-drug tx can you use for non-gonoccoal arthritis?

repeated joint aspiration

What are the two main causes of Osteomyelitis?

Hematogenous: IVDA, vertebral involvement d/t TB (Pott’s)

Contiguous: puncture wounds -nails, wood splints, injury

What is the best diagnostic study for osteomyelitis?

MRI

What joints are commonly affected in osteomyelitis due to IVDA?

Sternoclavicular, SI, or pubic symphysis

What is the tx for Osteomyelitis?

IV abs (Vanco) x 6 weeks, surgical debridement

What is shown on an XR of Osteomyelitis?

periosteal elevation along w/ bony erosions and destruction of the cortex

What are the most common viral pathogens causing viral arthritis?

Human parvovirus B-19, Hep B & C, HIV

How long does viral arthritis last?

2-4 weeks (not chronic/non-destructive)

What is the most common form of viral arthritis?

Human Parvovirus B-19

Patient with viral arthritis due to human parvovirus B-19 will have high titers of what abs?

Anti-IgM

How does viral arthritis d/t Parvovirus present?

abrupt symmetrical, malaise, flu-like; resolves 2-4 weeks (self-limiting)

What agent causes Lyme disease?

Borrelia burgdorferi

What are sx of early lyme disease?

erythema migrans, constitution sx, GI sx, meningeal irritation

What are sx of acute disseminated lyme infection?

cutaneous, neurological manifestations, cardiac manifestations

What are sx of Late lyme disease?

neurological manifestations, arthritis

What is erythema migrans?

erythematous wheal w/ central clearing

*seen in Lyme

What are the diagnostic studies for Lyme disease?

(2 step approach)

1. ELISA

2. Western blot (confirmatory)

What is the tx for stage 1 Lyme disease?

Oral Abx (doxy, amoxicillin, erythromycin) x 21 days

*pregnant → Erythromycin

What is the tx for stage 2 & 3 Lyme disease?

Try: Doxy x 28 days

If fails: IV Abx (ceftriaxone, pen G, cefotaxime) x 3-4 weeks

What med do you use for neuro & cardio manifestations of Lyme disease?

IV ceftriaxone

How many times can you repeat IV ceftriaxone for tx of Lyme disease?

No more than twice