What I will cover today Newly presenting monoarthritis Newly presently polyarthritis What to do with a pt who has an RA flare (in brief) Initial management of pt with known lupus (in brief)
Case 1 P/C: 65 year old woman presents with 1/52 painful warm and swollen right knee. HPC: Diabetic GP injected right knee 1/52 ago swollen, warm and extremely painful, unable to move and bear weight on it. O/E: T-37.4 C, BP-100/60, P-100,RR-18,Sa02- 100% air Warm, swollen tender right knee and restricted range of movements. Systemic examination unremarkable
Differential diagnosis Look at age, activities, medication and comorbidities WHAT DIAGNOSIS IF MISSED WILL SIGNIFICANTLY MATTER IN THE LONG TERM?
Differential diagnosis SEPTIC ARTHRITIS (case fatality of ~11%) Trauma- should be a history unless pt has dementia Crystals: Gout/ pseudogout/ steroid Haemarthrosis (warfarin- check INR level) New onset of inflammatory arthritis Bursitis
Septic arthritis Usually symptoms develop over days Risk factors?
Risk factors –pre-existing joint disease, RA, OA –prosthetic joints –low socio-economic status –IV drug abuse –alcoholism –DM –previous intra-articular corticosteroid injection and –ulcerated skin
Investigations FBC, LFT, U and E, CRP, ESR Blood cultures MSU Asepticknee aspiration- can be done by anyone who feels confident of technique- medics, surgeons, orthopaedics, rheumatologists- but beware high INR –M C and S- universal bottle and put in blood cultures bottles if you have enough aspirate –Crystals (biochemistry)
Treatment As per hospital guidelines Usually at least 2 weeks IV antibiotics and 4 weeks oral AB tailored to infecting bug Thromboprophylaxis Early orthopaedic referral for consideration of wash out
Infecting organism Most common-Staphylococcus aureus or Streptococci Young adults- significant incidence of Gonococcal arthritis Gram negative- elderly and the immunocompromised Anaerobic organisms-penetrating trauma
Treatment Try maximum dose of whichever NSAID your ward stocks (ask nurses) If contraindicated, or ineffective, use colchicine 500ug tds (NOT BNF dose) If NOT respond, oral pred 20mg od for 5 days or intra articular steroids Please DON’T start allopurinol or worry about normal uric acid level- dips in acute attack Give pt gout info (patient.co.uk arthritisresearchuk.org)
Reactive arthritis More common in younger pts Can be a result of chlamydia, ureaplasma, samonella, shigella and campylobacter infection Uveitis, conjunctivitis, circinate balanitis May affect more than one large joint Diagnosis of exclusion ASPIRATE JOINT (gonoccocal)
Refer to rheumatology and GUM Appropriate microbiology including HIV and hep serology if GUM related infection NSAIDs thromboprophylaxis
CASE 4 42 yr old factory worker, presents to A & E with 3 week history of worsening jt pain, stiffness and swelling. Told by work manager to attend as unable to operate machinery today No FH O/E multiple swollen joints, skin and nails normal
Management Ensure no history of infection ANYWHERE Look hard for psoriasis (scalp) Investigations?
FBC, U and E, LFT, CRP, ESR CCP Uric acid if gout possible ANA/ ANCA Hands feet and chest xr Initial treatment?
Regular paracetomol NSAIDs if no contraindications PHONE a rheumatologist for either inpt review or rapid OPA- please do NOT start steroids unless you at least attempt to discuss with a rheumatologist first
Attend hospital due to flare Flare whilst inpt for another reason
Attend A and E due to flare ~40% of pts who have had 1 years stable RA will flare annually, most self manage Those that don’t self manage- –Severe flare, unusual presentation of jt pains, inadequate home support, clinic cancellations, poor adherence to medication, infections and other concomitant health problems
Management Ask why have they presented NOW Look very hard for infection- if only 1 jt swollen then ASPIRATE plus usual bloods Consider blood cultures even if apyrexial (steroids, immunosuppressives, biologics- TB) Be realistic about whether the pt is likely to be able to ‘rise up and walk’ Phone Rheumatologist
What we do with these pts Ensure no infection (again) Optimise DMARDS/ biologics Steroids- often IM to ensure they are short term only Possibly keep in for physio/ OT/ social/ medical input
Inpts with RA who flare Significant comorbidity- increased CVD with 10yr reduced life expectancy mainly due to IHD, but also infection Joint replacement surgery So why do these pts flare?
Medication stopped accidently or on purpose on admission –PREDNISOLONE (usually accident) –DMARDs/ biologics- anti TNF (usually deliberate) Usual pains may feel worse when ill with other medical problems Infection Flares may just happen
Try and exclude infection If prednisolone omitted then reinstate and consider higher dose If active infection then temporarily stop methotrexate, leflunomide, cyclosporin, biologics PHONE RHEUMATOLOGIST
Pts admitted with possible flare of SLE symptoms Try not to panic or ignore but seek advice early Look for usual pathology that can cause similar symptoms Infection screen- lupus flares frequently triggered by infection
Usual bloods plus complement levels (can fall in flare) and nuclear antibodies unless done in past month- new or rising dsDNA antibodies can indicate flare Keep on DMARDs unless severe blood dyscrasias (which may in any case be due to SLE) PHONE RHEUMATOLOGIST