Acute hot swollen joint. Dr Edward Roddy Senior Lecturer in Rheumatology and Consultant Rheumatologist

Transcription

1 Acute hot swollen joint Dr Edward Roddy Senior Lecturer in Rheumatology and Consultant Rheumatologist

2 Acute monoarthritis: differential diagnosis Septic arthritis Crystal arthritis (gout, pseudogout) Haemarthrosis Reactive arthritis Monoarticular presentation of inflammatory arthritis Traumatic synovitis

3 Acute monoarthritis: differential diagnosis Septic arthritis Crystal arthritis (gout, pseudogout) Haemarthrosis Reactive arthritis Monoarticular presentation of inflammatory arthritis Traumatic synovitis

4 Weston Ann Rheum Dis 1999 Septic arthritis The most serious cause of monoarthritis A medical emergency Mortality 10% Persistent pain, joint damage, functional impairment 30%

5 Septic arthritis: risk factors Extremes of age Low socioeconomic status Immunosuppression alcoholism, diabetes mellitus Any joint pathology (esp RA) Joint prosthesis Previous ia steroid injection Cutaneous ulcers iv drug abuse Mathews Ann Rheum Dis 2007 Mathews Lancet 2010

6 Septic arthritis: clinical features Sub-acute onset over 1-2 weeks Painful, swollen, red, tender joint(s) 85% present as monoarthritis Knee most common Fever absent in 50% Features of infection elsewhere? Mathews Ann Rheum Dis 2007 Mathews Lancet 2010

7 Weston Ann Rheum Dis 1999 Septic arthritis: which joint? %

8 Septic arthritis: diagnosis Refer prosthetic joints to orthopaedics Aspirate the (native) joint frank pus, Gram stain, WCC, culture & sensitivity as soon as possible prior to starting antibiotics Blood cultures Markers of infection may be absent X-rays of limited value acutely Coakley Rheumatology 2006 Mathews Ann Rheum Dis 2007

9 Markers of infection % Fever Elevated WCC ESR>20mm/hr CRP>20mg/l SF WCC > 50000/mm3 Weston Ann Rheum Dis 1999 Coutlakis J Clin Rheumatol 2002

10 Septic arthritis: organisms Staph aureus MRSA Staph epidermidis Strep spp Gram negative spp Gupta Rheumatology 2001

11 Septic arthritis: management Medical resuscitation iv antibiotics following joint aspiration according to local guidelines modify with results of Gram stain & cultures typically 2 weeks iv, then 4 weeks oral Analgesia!! Daily aspiration/arthroscopic washout Surgical removal of implant Coakley Rheumatology 2006 Mathews Ann Rheum Dis 2007

12 Acute gout

13 Acute arthritis [Na] + [Urate] Tophi Chronic gouty arthritis Male gender Family history Alcohol excess Dietary purines Metabolic syndrome Obesity BP Renal impairment Diuretics Osteoarthritis

14 Acute gout: clinical features Typical features of crystal inflammation Rapid onset (<24 hours) Severe pain, heat, swelling, (erythema) Exquisite tenderness Skin desquamation May be systemic upset 1st attack 1st MTPJ in 50-70% 1 st MTPJ = gout likely Zhang Ann Rheum Dis 2006 Roddy J Foot Ankle Res 2011

15 The patient goes to bed and sleeps quietly till about two in the morning, when he is awakened by a pain which usually seizes the great toe The pain resembles that of a dislocated bone and this is immediately succeeded by a chillness, shivering and a slight fever. The pain grows gradually more violent every hour, and comes to a height towards evening becomes so exquisitely painful as not to endure the weight of the clothes nor shaking of the room from a person s walking briskly therein Thomas Sydenham ( )

16 Acute gout - other sites Roddy J Foot Ankle Res 2011

17 Acute gout: diagnosis Crystal identification is the gold standard Not necessary when classical podagra Consider when: presentation atypical affects joints other than 1 st MTPJ Zhang Ann Rheum Dis 2006

18 Acute gout: lab tests Serum uric acid: Acute phase reactant: normal during attack in 25-49% Hyperuricaemia does not equal gout But useful for monitoring therapy WCC/ESR/CRP may well be elevated Zhang Ann Rheum Dis 2006

19 Acute gout: management Aim: rapid relief of pain and inflammation Main options: NSAIDs Colchicine Corticosteroids

20 Acute gout: NSAIDs No evidence for any particular NSAID Any fast-acting NSAID at full dose eg naproxen, diclofenac Indomethacin best avoided Gastrointestinal concerns: PPI as indicated etoricoxib 120mg daily Schumacher BMJ 2002 Sutaria Rheumatology 2006 Zhang Ann Rheum Dis 2006 Janssens Lancet 2008 Khanna Semin Arthritis Rheum 2014

21 Acute gout: colchicine Traditional dosing regime 1mg initially then 500mcg every 2-3 hours until pain abates or diarrhoea/vomiting occurs BNF since November 2008: 500mcg two to four times daily until symptoms relieved Ahern Aust NZ J Med 1987 Morris BMJ 2003 Sutaria Rheumatology 2006 Zhang Ann Rheum Dis 2006 Terkeltaub Arthritis Rheum 2010 Khanna Semin Arthritis Rheum 2014

22 Acute gout: other options Joint aspiration/injection Oral/intramuscular steroids eg prednisolone 20mg daily when NSAIDs/colchicine inappropriate AND joint injection not possible (site of attack, expertise, multiple joints) Local application of ice-packs Schlesinger J Rheumatol 2002 Sutaria Rheumatology 2006 Zhang Ann Rheum Dis 2006 Janssens Lancet 2008 Khanna Semin Arthritis Rheum 2014

23 What to do with allopurinol? Not normally started during attack But not stopped if attack occurs attack = successful treatment not a side-effect

24 Don t reinforce the myths Gout is: Not funny Not self-inflicted Not a rich man s disease Commonly nothing to do with diet or alcohol

25 Acute pseudogout

26 Calcium pyrophosphate crystal deposition Common age-related phenomenon Very rare under 50 years Most common cause of cartilage calcification Acute pseudogout

27 Zhang Ann Rheum Dis 2011 Acute pseudogout: clinical features Acute attack of synovitis at a single joint Typical features of crystal inflammation Rapid onset (<24 hours) Severe pain, heat, swelling, (erythema) Exquisite tenderness Systemic upset common Knee most common site Most likely cause of acute arthritis of knee, wrist or shoulder >65 years

28 Acute pseudogout: diagnosis Crystal identification is the gold standard Radiographic chondrocalcinosis Common at the knee, wrist, symphysis pubis Does not confirm acute pseudogout Can be caused by other crystals too Insensitive may miss small deposits Diagnosis should be crystal-proven

29 Zhang Ann Rheum Dis 2011 Acute pseudogout: management Aims for rapid relief of joint pain/swelling Joint aspiration/injection is treatment of choice NSAID caution in elderly, consider PPI Low-dose colchicine 500mcg bd-qds im/oral steroid if: joint difficult to inject eg mid-foot oligo/polyarticular attacks Topical ice therapy

30 Sepsis or crystals? History: speed of onset Crystals: rapid (<24 hours) Septic arthritis: sub-acute 1-2 weeks Gout very likely if 1 st MTPJ Knee over 65 years suggests CPPD; less certain Can t rely on fever/wcc/esr/crp Serum uric acid often normal in acute gout Joint aspiration is the investigation of choice

31 When not to aspirate? Prosthetic joints Overlying skin infection Difficult joints hip, mid-foot Anticoagulation Image courtesy of Prof M Doherty Rapid onset of severe pain and tenderness at 1 st MTPJ: aspiration probably not needed

32 Key messages Fever, WCC, ESR, CRP, uric acid are poor discriminators Septic arthritis: aspirate ASAP but before antibiotics high-dose iv antibiotics Joint aspiration is the single investigation of choice Acute gout: NSAID or low-dose colchicine first-line don t stop allopurinol Acute pseudogout: acute arthritis of knee, wrist, shoulder in over 65s CC not reliable: aspiration needed Low-dose colchicine/steroids first-line