Rheuma Lecture 6 - misc.

gout

inflammatory disease (cristal arthropathy) caused by depots of monosodium urate crystals

most common form of inflammatory arthritis in men

gout

complications of gout

severe nephropathy, increased cv risk

clinical features gout

asymptomatic hyperuricemia

acute attacks w/ asymptomatic intervals

chronic gout

signs of an active gout attack

severe pain, swelling, erythema, tender, 6-12h

risk factors cristal arthropathies

alcohol, heavy meals, fasting, trauma

musculoskeletal manifestations cristal arthropathy

acute monoarthritis - podagra most common (1st MTP)

oligoarticular

pitting edmea

palpable tophi

urate arthropathy - manifestations on bone

subchondral bone erosions, osteophytes

dg cristal arthropathies

MSU crystal id, tophi, arthrocentesis, joint aspiration, ultrasound

causes primary gout

obesity, alchol, hta, DM2, obstructive sleep apnea, hypertriglyceridemia

causes secondary gout

diuretics, drugs in organ transplant, cylosporin

ttt acute attack cristal arthropathy

rest, ice, colchicine, nsaids, steroids

ttt cristal arthropathies

Il-1b, canakinumab, rilonacept

urate lowering drugs

allopurinol, febuxostat

calcium pyrophosphate crystal deposition disease (CPPD)

elderly disease, secondary to metabolic diseases or traumatized joints

clinical presentation CPPD

asymptomatic or pseudo-gout, brusque onset, limited

involvements of CPPD

destructive arthropathies, hemarthrosis, discitis of spine, tumoral deposits

dg CPPD

SF/joint biopsy

ttt CPPD

rest, ice, SF aspiration, colchine, NSAIDs

septic arthritis

presence of mostly staph aureus in joint, medical emergency

pyogenic bacterial arthritis

acute, painful mono-arthritis with fever leading to irreversible loss joint fxn or death

septic (purulent) arthritis - types

non and gonoccocal arthritis

non vs gonococcal arthritis in septic arthritis

non - age, n. meningitidis infection, monoarthritis, bad prognosis

gonoccocal - sexually active young menstruating women, gonorrhea infection, migratory polyarthritis, good prognosis

manifestations non-gonoccocal arthritis

acutely swollen joint, tender on palpation and very painful on movement

usually big joint

septic arthritis : possible infection related to patient w/ rheumatoid arthritis and osteoarthritis

staph aureus

septic arthritis : possible infection related to alcoholic

klebsiella

septic arthritis : possible infection related to patient w/ malignancy or ID drugs

gram - bacteria

septic arthritis : possible infection related to patient w/ IV drug abuse

pseudomonas, staph aureus

septic arthritis : possible infection related to patient w/ lupus

salmonella, n meningitidis, strep pneumoniae

septic arthritis : possible infection related to patient w/ complement deficiency

encapsulated microbes

what test is mandatory in non-gonococcal septic arthritis

arthrocentesis of joint →

gram stain, wbc (>50×10^9/L), culture

__________ may mimick a pseudo-septic pattern in septic arthritis

ca pyrophosphate deposition disease

lab tests for septic non-gonococcal arthritis

crp, esr, procalcitonin 0.5ng/ml

urine, blood, throat, wounds, skin blister cultures

imaging and results in non-gonococcal septic arthritids

chest xray

mri, US

results : chondrocalcinosis, osteomyelitis, juxta-articular osteoporosis, diffuse joint space narrowing, erosion

ttt septic arthritis (atb)

penicillin (cloxacillin)

if high risk gram - sepsis - 2/3 gen cephalo

MRSA risk - vancomycin

suspected gonococcus/meningococus - ceftriaxone

TB septic arthritis - types of invasions

1. direct 

2. secondary infection joints after inflammatory/degenerative changes

3. after intra-articular procedures or in prosthetic joints

4. reactive arthritis “Poncet’s disease”

presentation TB septic arthritis

slow onset of monoarthritis of weightbearing joint

diffuse joint space narrowing, bony erosions

phemister triad

low grade fever, asthenia, low appetit, weight loss, night chills

risk factors TB septic arthritis

avdanced age, tb in past, chronic immunosuppression

TB septic arthritis - synovial biopsy results

chronic caseating granulomatous inflammation

Poncet’s disease

extrapul TB - non-suppurative reactive arthritis, erythema nodosum

• symmetrical, oligo-polyarthritis of big joints of lower limbs

• resolves within weeks of anti tb therapy

characteristics of atypical mycobacterial (mycobacterium) septic arthritis

tenosynovitis, bursiits, periarticular discharging sinus, polyarthritis, ID

mycobacterium leprae septic arthritis

acid-fast bacilli in joints, explosive onset, acute symmetric polyarthritis of small joints of extremities OR tenosynivitis alone

brucellosis septic arthritis

febrile illness from contaminated dairy, hepatosplenomegaly, lymphadenopathy, leukopenia, pancytopenia → acute unilat sacroiliitis, peripheral arthritis of lower limbs

diagnostic test for brucellosis septic arthritis

brucella dna in synovial fluid or tissue - PCR

fungal septic arthritis

insidous onset, neutropenia, affecting lung, skin, synovial fluid/bone

risk factors fungal septic arthritis

neutropenia, steroids, central v catheter, atb, history candida, IV drug abuse

leading cause of septic arthritis among young adults

gonococcal septic arthritis

presentation gonococcal arthritis

polyarthralgia, fever, chills, tiny papules/pustules, tenosynovitis, purulent arthritis

findings culture gonococcal septic arthritis

joint fluid +

blood culture -

tests to ask for if gonococcal septic arthritis

crp, esr, pcr, uroenital samples, prostatic massage fluid, first void urine, synovial samples

ttt gonococcal septic arthritis

3rd gen cephalosporin

nsaids, analgesics, physio

prosthetic joint septic arthritis is caused by which infection

coag - staph

after 3m - staph areus, strep or gram - bacilli

causes of spondylodiscitis septic arthritis

staph aureus, strep, pyogenic (lumbar first), tb (thoracic), enterobacteria

mri results septic spondylodiscitis arthritis

subchondral radiolucency, erosions, loss endplate definition, loss disc height

ttt spondylodiscitis septic arthritis

isoniazid and rifampicin

bed rest 2w, immobilisation in corset

acute onset polyarthritis - viral - whic viruses?

parvoviruses, rubella, hep b and c

viral arthritis by parvovirus - entry routes

resp, blood products, vertically

presentation viral arthritis by parvovirus

fifth disease - erythema, oligoarthritis in kids

aplastic anemia, thrombocytopenia, pancytopenia, hepatits, myocarditis, myositis

viral arthritis by rubella

rash preceded by lymphadenopathy

symmetrical polyarthritis

anti rubella atb present

ttt viral arhtritis by rubella

nsaids, iv Igs

routes of hep b causing a viral arthritis

vertical, sexual, blood-borne contact

viral arthritis by hep b - presentation

symmetrical polyarthritis lasting days-months, cryoglobulinemia and polyarteritis nodosa

markers in viral arthritis caused by hep b

HBsAg, anti-HBc, RF

hep c viral arthritis - causes

blood borne, poor sterilization medical devices, unscreened blood products

vertival, sexual

presentation hep c viral arthritis

mono/oligo or polyarticular, less aggressive

paresthesias, myalgias, pruritus, sicca symptoms, fibro

marker in hep c viral arthritis

RF

ttt hep c viral arthritis

NSAIDs, low dose CT

HTLV-1 associated viral arthritis

peripheral, symmetrical polyarthritis

predisposed to t cell leukemia

RF+

presentation of HIV arthritis

oligoarticular, in lower limbs <6 weeks, synovial fluid is non inflammatory and sterile