Emergency arthritis in Rheumatic diseases
Div of Rheumatology Dept of Medicine Eulji University
Shim Seung Cheol, M.D., Ph.D.
Fistula development in RA Either sterile or septic
Connect the skin surface with a joint, soft tissue, or bursa.
The pathogenesis is difficult to understand because the rheumatoid process is centripetal, not centrifugal in nature.
On a Saturday morning
he was carrying a heavy box down a flight of stairs when he had an explosive pain in his proximal calf behind and below his knees.
By Monday morning he was unable to walk and had pitting edema of the lower leg and foot and marked tenderness on palpation of the calf.
Often confused with deep vein thrombosis (DVT) The diagnosis is best made with ultrasonography.
Treatment includes rest, elevation, needle puncture of the calf, knee joint aspiration, and referral.
Pain radiating up into the occiput.
Slowly progressive spastic quadriparesis, frequently with painless sensory loss in the hands.
Paresthesia in the shoulder or arms during movement of the head.
Degeneration of the transverse ligament can lead to instability at the C1-C2 level.
Exercise caution when evaluating patients with RA after minor falls, motor vehicle accidents (MVAs), or other injuries.
The earliest and M/C Sx of cervical subluxation is pain radiating up into the occiput.
less common Sxs are;
Transient episodes of medullary dysfunction associated with vertical penetration of the dens and vertebral artery compression.
When It Really Hurts: Case
A 39-year-old man
presents with severe pain in the forefoot and ankle that awakened him from sleep that morning.
He twisted his ankle the day before at work while welding at the Johnson Battery factory.
Past Hx: hypertension treated with hydrochlorothiazide for 5 years.
Over the past week, he has consumed 1 quart of whiskey per day.
BP 160/105, temperature 38.1oC
Septic (Infectious) Arthritis
:The most aggressive arthritis at quickly destroying a joint.
immunologic disorders (RA, SLE etc), joint prosthesis general population
2-10 cases
/per 100,000
30-70 cases X10
In gonococcal arthritis, women are approximately 3 times as likely as men to develop this disease.
Septic (Infectious) Arthritis
Most common cause: 80% of cases are caused by gram-positive aerobes
(60% S aureus;
15% beta-hemolytic streptococci;
5% Streptococcus pneumoniae), 20% of cases: gram-negative anaerobes.
Problem
Septic arthritis can quickly destroy a joint and can cause many complications, including osteomyelitis, bony erosions, fibrous ankylosis, sepsis, and even death.
Barriers to successful management include lack of clinical suspicion in the early phase of presentation, delay in definitive diagnostic needle aspiration, and failure to provide adequate drainage of the joint.
Despite advances in diagnostic studies, powerful antibiotics, and early drainage, significant joint destruction commonly occurs.
The most prevalent sites of infection include the following:
knee :40-50%
hip : 20-25%
ankle elbow wrist shoulder pelvis
Most infections affect only one joint.
In adults: knee; in children: hip joint.
What causes septic arthritis?
Bacteria may enter the joint directly as with trauma.
Infection may enter hematogenously (eg, intravenous [IV] drug injection).
Infection may enter from osteomyelitis that is adjacent to the capsule.
Infection also may enter from soft tissue infections (eg, cellulitis, abscess, bursitis, tenosynovitis).
Ear infections are the most common source of bacteria leading to septic arthritis in children.
Differentiation between gonococcal and nongonococcal
arthritis is important for the treatment
Gonococcal arthritis
In young sexually active patients with fever, tenosynovitis, migratory polyarthralgia, and dermatitis, suspect N gonorrhoeae. The rash may appear as papules over the trunk and extensor surfaces of distal extremities that eventually can turn into hemorrhagic pustules. Women are more likely to develop gonococcal arthritis than are men.
S. epidermidis Direct inoculation
Intra-articular injection
Axial joints Recurrent bacteremia
IV drug user
S. aureus Impaired defense
Lupus
Always send for culture Joint disorganization
provides nidus for infection Osteoarthritis
Mimic sepsis Synovial fluid acidosis
Crystal induced arthritis
S. aureus Damaged joint is a good
nidus for infection RA
Clinical overview Possible mechanism
Lab Studies:
CBC count with differential - Often reveals leukocytosis with a left shift
Erythrocyte sedimentation rate and C-reactive protein - Helpful in monitoring treatment course
Blood cultures
– May be positive in up to 50% of S aureus infections – Very poor in detecting N gonorrhoeae (Approximately 10% of
cases prove positive.)
Urethral, cervical, pharyngeal, and rectal cultures - Much higher yield for N gonorrhoeae than in blood cultures
Synovial fluid analysis – Gram stain, culture, cell counts, and crystal analysis
Very decreased Decreased
~Blood
~Blood Glucose
Friable Friable Firm
Firm Mucin clot
Often positive*
Negative Negative Negative Culture result
>75%
>50%
<25%
<25%
PMN, %
Often
>100,000 2,000-75,000 200-2,000
<200 WBC, µL
Opaque Translucent Transparent Transparent Clarity
Variable Yellow
Straw-yellow Clear
Color
Variable Low
High High Viscosity
>3.5
>3.5
>3.5
<3.5 Volume, mL
Septic Inflammatory Non
inflammatory Reference
Range Quality
Treatment
In addition to drainage of the septic joint, rapid administration of IV antibiotics is paramount. It is important to obtain the synovial sample and blood cultures prior to commencement of IV antibiotic treatment. Certitude of final gram stain and/or culture should not preclude treatment. With this in mind, most patients respond to IV oxacillin or nafcillin in combination with IV ceftriaxone, cefotaxime, or ceftizoxime.
Joints infected with S aureus generally are treated with 4 weeks of antibiotics. Pseudomonal infections are treated for at least 3 weeks, whereas streptococcal infections and H influenzae are treated for approximately 2 weeks. Joints infected with N gonorrhoeae respond well to 1 week of IV Rocephin. If the patient responds quickly, a full 7-day regimen can be completed with oral antibiotics, such as ciprofloxacin 500 mg twice a day.
Prognosis
Despite proper and quick treatment of septic arthritis, prognosis remains poor. In a prospective 2-year study by Kaandorp et al with 154 patients (adults and children), 21% of cases resulted in poor patient outcome (death or severe functional deterioration), and 33% of cases resulted in poor joint outcome (amputation, arthrodesis, prosthetic surgery, or sever functional deterioration).
In retrospective review assessments of nongonococcal arthritis by Pioro et al, loss of joint function occurred in 34-50% of the general population without comorbidities. Mortality in this same population ranged from 2-14%.
Mortality figures in patients with polyarticular sepsis and rheumatoid arthritis ranged from 23-32% and 16-49%, respectively.
Rheumatoid flare
Pseudoseptic arthritis
Fever, chills, and grossly purulent synovial fluid Severe exacerbation of RA
Must be distinguished from infection.
24세 여자환자
3개월간의 고열을 주소로 입원.
열은 주로 밤에 심하였고 낮에는 없었다.
고열이 있을 때 주로 상부 앞가슴과 등에 피부발진이 동반.
sore throat와 arthritis, myalgia를 호소, 이학적 검사상 양측 경부 임파절이 촉지.
검사소견: WBC28800/mm3 (poly 88%, lymphocyte 12%, no blast cell), hemoglobin 10.3g/dl, platelet 255,000/mm3 , AST/ALT 88/120, ESR 63mm/hr, RF: negative, ANA: weakly positive, LDH 450 IU/dl, s-ferritin 5300ng/mL이었다.
virus, bacteria 검사: 모두 negative 혈액 및 뇨배양검사: 음성.
가장 가능성있는 진단명은?
Fever rarely occurs in adult RA.
Later in course, if vasculitis or serositis or intense exacerbations of disease.
AOSD usually presents with fever.
Fever
30-40 decade
Similar to juvenile onset arthritis with fever.
F:M=1:1
Fever can develop before arthritis
Fever pattern :quotidian(normal level at least once each day) salmon colored macules on trunk and extremities, more prominent when patients are febrile.
The cervical spine is involved, and loss of neck motion may be striking.
Pericarditis, pleural effusion, abnormal LFT.
Systemic infection, lymphoma, vasculitis should be ruled out.
When It Really Hurts: Case
A 39-year-old man
presents with severe pain in the forefoot and ankle that awakened him from sleep that morning.
He twisted his ankle the day before at work while welding at the Johnson Battery factory.
Past Hx: hypertension treated with hydrochlorothiazide for 5 years.
Over the past week, he has consumed 1 quart of whiskey per day.
V/S: BP 160/105, temperature 38.1oC
Question: What Is Differential Dx?
A. Reiter’s syndrome B. Rheumatoid arthritis C. Infection D. Trauma E. Crystalline arthritis
Initial Test Results
• Creatinine 1.8 mg/dL
• Synovial fluid analysis
• WBC 50,000, 90% PMNs
• Gram stain: No organisms
• Culture sent
• Compensated polarizing microscopy
Many crystals
Gout
The Best Understood Form of Arthritis Rational and effective therapy is available
Solubility of urate ion as a function of temperature in the presence of 140mM Na +
6.8 6.0
? 4.5
? 3.3 2.5 1.8 1.2 37
35 32(knee)
30 29(ankle)
25 20 15 10
Maximal equilibium Con. of urate in the presence of 14mM Na+ (mg/dl)
Temperature(oC)
Joint involve in RA
The joints with the highest ratio of synovium to articular cartilage are preferentially involved.
Definitive diagnosis: made by examining either synovial fluid or tophaceous deposits for the characteristic needle-like MSU crystals which show strong negative bifringence by compensated polarized light microscopy.
The common practice relying on the less specific findings of the classic gouty triad----acute monoarthritis+ hyperuricemia+ symptomatic improvement on colchicine
Differential diagnosis of acute monoarticular gout
--septic arthritis( especially secondary to N.gonorrheoa)
--other crystal-induced arthropathies(pseudogout) --palindromic rhuematism and rheuamtoid arthritis --traumatic arthritis
--sarcoid arthritis
Almost all acute attacks occur before 50 years of age
60-yo female
Sudden onset of knee pain?
CPPD
Major cause of acute monarthritis in the elderly population.
Attacks usually involve a large joint (Knee:M/C, wrist, ankle) Sudden onset of severe pain, swelling, redness, and increased warmth.
Succesive polyarticular involvement with a migratory pattern mimicking RA.
Polyarticular involvement is most commonly observed in familial forms
Pathogenesis
Pyrophosphate crystalline deposits in the midzone of hyaline cartilage in association with hypertrophic chondrocytes.
Rarely in tendon and bursae.
Pyrophosphate level is elevated in synovial fluid, and normal in serum and urine.
Precipitated by Trauma Surgery
Medical illness: MI, stroke, pneumonia, pregnancy, pamidronate IV, hyaluronate intraarticular injetion.
Acute attacks may be associated with high fever, chills, leukocytosis, elevated ESR mimicking infectious arthritis.
Diagnosis
Rod or rhomboid shaped, weakly birefringent
Tx - NSAID
intraarticular steroid
colchicine prophylactic treatment :helpful
Gout & RA
12 of 160 seropositive RA: hyperuricemia 11 of 12: quiet disease
The onset of hyperuriemia: the improvement of RA In patient with fluctuations in uric acid level,
correlation between an increase in uric acid level and improvement in disese activity.
Hypothesis:
The hyperuricemic state may be anti-inflammatory.
