Presentation on theme: "28th February 2012 Tehseen Ahmed"— Presentation transcript:
128th February 2012 Tehseen Ahmed Monoarthritis28th February 2012Tehseen Ahmed
2Aims and Objectives Aim Objectives To be able to manage the patient with an acute hot jointObjectivesBy the end of this session you should be able to:Undertake a relevant history from a patient presenting with an acute hot joint.Form a differential diagnosis for the patient.Appropriately further investigate / refer the patient.Institute initial treatment for your patient.
4MonoarthritisInflammation of a single jointCan be acute or chronic.
5Acute monoarthritis – Diagnostic approach Historyreview of symptomsprevious joint disease or traumaconcurrent illnessesfamily historymedication use – e.g. diuretics, anticoagulantsother risk factorstravel, sexual history, diet, tick bites, occupational history, alcohol and intravenous drug use
6Acute monoarthritis – Diagnostic approach ExaminationFocus on the involved and contralateral joint and surrounding areaGeneral examination to look for other affected jointsLook for systemic manifestations of disease
7Scenario 1A 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.
8Medications Any alcohol? Onset of pain Any previous similar episodes “ 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”
11Gout Most common cause of inflammatory arthritis in adults Usually men >40 years and post-menopausal womenInitially acute monoarthritisAssociated with hyperuricaemia, renal impairment, diuretics, hypertension, hyperlipidaemia, excess alcohol, obesityFamily history in some
12Gout 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.
13Scenario 2A 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.
14Any previous similar episodes 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?”
18Gonococcal arthritisGonococcal 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.
19Synovial fluid cultures can be positive in up to 50% of cases It manifests as either a bacteraemic infection (arthritis-dermatitis 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 formJoint 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 casesCultures 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.
20Scenario 3An 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.
23Septic arthritisMore 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.
24Scenario 4 85 year old woman RA, OA of the knees, Leg ulcers, Hypertension, PPMAwaiting Right TKR2 week history of marked swelling in her left kneeStarted suddenly following some physiotherapyNot systemically unwell.
25On examinationLarge, warm effusion left knee.Any further info?
28Haemarthrosis 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.
29In approximately 1/3 of cases of monoarthritis no definitive diagnosis will be identified even after appropriate investigation.
31Sudden onset of pain over seconds to minutes TraumaOnset of pain, swelling, tenderness maximal within 12 hoursCrystal arthropathyOnset of pain over several hours or 1-2 daysSeptic arthritisMonoarthritic presentation of other inflammatory arthropathy
32Insidious onset of pain & swelling over days-weeks Low grade/atypical infection, OA, malignancy, granulomatous diseaseDM, Cellulitis, Prosthetic joints, RA, IV drug abuseSeptic arthritisSteroid exposureAvascular necrosisCoagulopathy, Use of anticoagulantsHaemarthrosis
37Pseudogout 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 illnessTraumaSurgery
38InvestigationsJOINT ASPIRATE !!!Gram stainM, C & SCrystal analysis
40Treatment – depends on the cause! Aspirate jointAnalgesia – NSAIDs, ColchicineRest / Ice / ElevationAntibiotics if indicated – 2 weeks IV, 4 weeks oral follow-onIntra-muscular/Intra-articular/Oral steroids if indicated
41Learning pointsIn acute inflammatory monoarthritis, symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy.Serum uric acid levels do not confirm or exclude gout.Demonstration of urate crystals in synovial fluid or tophus aspirates is diagnostic of gout.Beware that gout and sepsis can co-exist.Repeated culture of synovial fluid, blood and other sources of sepsis may be needed if initial samples are negative but clinical suspicion remains high.In a young patient with a monoarthritis but no history of trauma, refer to rheumatology NOT orthopaedics.
42ReferencesLingling M, Cranney A, Holroyd-Leduc JM. Acute monoarthritis: What is the cause of my patient’s swollen joint? CMAJ January 6; 180(1): 59–65Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA 2007 Apr 4;297(13):