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RMSK > 01a: Acute Arthritis > Flashcards

01a: Acute Arthritis Flashcards

1
Q

How is acute defined for acute arthritis?

A

Less than 6 weeks duration

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2
Q

What is arthritis?

A

Inflammation localized to articular structures; accompanied by swelling (synovitis and/or effusion), warmth, discomfort and redness.

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3
Q

What is arthralgia?

A

Subjective term of non-inflammatory joint pain

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4
Q

What does rapid onset suggest?

A

Traumatic, septic or crystalline etiology

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5
Q

What does slow/insidious onset suggest?

A

Systemic rheumatic disease or non-inflammatory process (such as osteoarthritis)

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6
Q

What do worse-in-the-morning symptoms suggest?

A

Systemic rheumatic disease (improves with mobility)

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7
Q

What do worse-at-night symptoms suggest?

A

Sprain/strain/non-inflammatory process

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8
Q

What do worse-with-activity symptoms suggest?

A

Tendinitis/bursitis/non-inflammatory process

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9
Q

What do worse-with-rest symptoms suggest?

A

Systemic rheumatic disease

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10
Q

What does joint localization suggest?

A

Arthritis or arthralgia

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11
Q

What does inter-articular localization suggest?

A

Diffuse pain syndromes (e.g., fibromyalgia)

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12
Q

What condition is uncommon with polyarticular symptoms?

A

Septic arthritis

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13
Q

Can monoarticular symptoms be present with systemic rheumatic disease?

A

Yes; may be an early presentation

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14
Q

What rheumatic condition is often preceded by trauma?

A

Calcium pyrophosphate deposition disease (CPPD); AKA pseudogout

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15
Q

What do hot-to-touch joints suggest?

A

Septic or crystalline etiology

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16
Q

What do cool-to-touch joints suggest?

A

Non-inflammatory etiology

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17
Q

What is”touch-me-not” pain, and what does it suggest?

A

Painful for even bedsheets/clothes to touch; seen in septic or crystalline arthritis

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18
Q

In what disease is stiffness > pain?

A

Systemic rheumatic disease

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19
Q

What diseases present with vague, deep aches?

A

Hyperparathyroidism, osteomalacia, bone lesions (night pain)

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20
Q

What diseases present with burning/numbness/tingling?

A

Neurogenic

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21
Q

What diseases present with claudication?

A

Vascular and spinal stenosis

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22
Q

What disease often presents with symmetry?

A

Systemic rheumatic diseases

23
Q

What diseases often present with constitutional/prodromal symptoms (e.g., fever, malaise, flu-like symptoms)?

A

Infection, systemic rheumatic diseases, occasionally crystalline arthritis

24
Q

What does intercritical return to complete normalcy suggest?

A

Crystalline arthritis

25
Q

What are specific indicators of systemic rheumatic diseases?

A
  • Cutaneous manifestations (psoriasis, photosensitivity, purpura, skin thickening, erythema nodosum, nodules)
  • Swollen glands
  • Raynaud’s (excessively reduced blood flow in response to cold or emotional stress, causing discoloration of the fingers, toes, and occasionally other areas)
  • Oral/nasal ulcers
  • Pleurisy/pericarditis
  • Eye inflammation
  • Nail changes
  • Dry eyes/mouth
  • Proximal muscle weakness
  • Sinusitis
  • Hearing loss
26
Q

What are the following findings in tendinitis/bursitis?

  1. Symmetry
  2. Inflammation
  3. Tenderness
  4. Instability
  5. Locking
  6. Multi-system disease
A
  1. Uncommon
  2. Over tendon/bursa
  3. Focal
  4. Uncommon
  5. Unusual except with tears
  6. No
27
Q

What are the following findings in **non-inflammatory **joint disease?

  1. Symmetry
  2. Inflammation
  3. Tenderness
  4. Instability
  5. Locking
  6. Multi-system disease
A
  1. Occasional
  2. Unusual
  3. Unusual (variable)
  4. Occasional
  5. Possible (implies loose body/internal derangement)
  6. No
28
Q

What are the following findings in systemic rheumatic disease?

  1. Symmetry
  2. Inflammation
  3. Tenderness
  4. Instability
  5. Locking
  6. Multi-system disease
A
  1. Common
  2. Common
  3. Over entire joint space
  4. Uncommon
  5. Uncommon
  6. Often
29
Q

What are the common etiologies of acute monoarthritis?

A
  • Infection
    • Bacterial (gonococcal vs. non-gonococcal)
    • Viruses (although often polyarticular)
    • Fungi/spirochetes/mycobacteria
  • Crystal-induced (gout, pseudogout [CPPD])
  • Trauma
  • Hemarthrosis
  • Osteonecrosis
  • Early monoarticular presentation of polyarticular disease
30
Q

What synovial fluid findings suggest monoarthritis?

A
  1. Cell count + differential w/ WBC >2K or >75%PMN (suggests inflammatory etiology)
  2. Gram stain (+) culture (negative studies do not r/o septic joint)
  3. Crystal assessment using polarized light microscopy
31
Q

What is the differential for non-inflammatory joint fluid (<2K WBC/uL)?

A
  • Osteoarthritis
  • Trauma
  • Charcot’s joint
  • Pancreatitis
  • Hemochromatosis
  • Acromegaly
  • Glucocorticoid withdrawal
  • Hypertrophic osteoarthropathy
  • Avascular necrosis
  • Pigmented villonodular synovitis
  • Systemic lupus erythematous
32
Q

What is the differential for inflammatory joint fluid (>2K WBC/uL)?

A
  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Spondyloarthropathies
  • Juvenile chronic arthritis
  • Gout
  • Pseudogout
  • Systemic lupus erythematous
  • Septic arthritis
33
Q

When is it appropriate to get a CT or MRI for joint pain?

A

Suspected osteomyelitis as focus, or soft-tissue abscess

34
Q

Bacterial septic arthritis

A
  • Sepsis, extensive joint damage, mortality
    • Mortality ~10% overall; 19-33% in elderly or with comorbidities
    • 40% with permanent loss of joint function
  • Broken down into gonococcal or non-gonococcal
35
Q

Gonococcal septic arthritis

A
  • Epidemiology:
    • Incidence ↓ over past 2 decades
    • Seen in sexually active YAs
    • F > M
  • Other clinical features
    • Polyarthralgia can precede (but mono in 50%)
    • Constitutional sx
    • Tenosynovitis, especially wrist (68%)
    • Skin lesions (75%): erythematous papules progress to vesicles or pustules on extremities and trunk
    • Anogenital infx often asx!
36
Q

Non-gonococcal septic arthritis

A
  • Etiology:
    • Gram (+) in 80% of cases
      • S Aureus in 60% of non-G cases
    • Gram (-) in 10-20% of cases
      • E. Coli, Proteus, Klebsiella, Enterobacter
      • Seen in v. young, elderly, injection drug use, immunocomp’d
  • Diabetes is a risk factor
  • Presentation:
    • Prodrome of malaise & fever (often mild)
    • Large joint preference (knees/hips > shoulders > wrist/ankles)
  • Management:
    • Aggressive
    • Serial aspiration to dryness vs. open surgical drainage w/ lavage
    • Parenteral abx
    • Splinting & physical therapy to prevent contractures and muscle atrophy
37
Q

What is a contracture?

A

Condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.

38
Q

Crystal arthritis types

A

Gout vs. calcium pyrophosphate deposition (CPPD)

39
Q

Gout

A
  • Intense articular inflammation
  • “Touch-me-not” tenderness
  • Minimal to no prodrome
  • Joint predilection: 1st metatarsophalangeal, midfood, ankle, knee, wrist, elbow, distal interphalangeal
40
Q

Calcium pyrophosphate deposition (CPPD)

A
  • Mono-, oligo-, or polyarticular
  • Knee most commonly affected, followed by wrist (MTP uncommon)
  • Preceding minor joint trauma often reported
  • Associated w/ hemochromatosis, hyperparathyroidism, hypophosphatasia, hypomagnesemia
41
Q

What is joint effusion?

A

Presence of increased intra-articular fluid

42
Q

Lyme Arthritis

A

Features dependent on phase of disease

  • Early disseminated:
    • Poly-arthralgia
    • ELISA may be negative early (but occurs prior to development of bullseye rash)
  • Late:
    • Weeks - months after primary infx
    • Positive ELISA
    • Mono, oligo, occasionally polyarthritis
    • Asymmetric
    • Large/medium joints
    • Large effusion in single knee in most
43
Q

Polyarthritis differential

A
  • Infection
    • Gonococcal
    • Meningococcal
    • Lyme disease
    • Rheumatic fever
    • Bacterial endocarditis
    • Viral (rubella, parvovirus, HBV, HCV)
    • Fungal (histoplasmosis, diseminated coccidiodomycosis)
    • Mycobacterial
  • Systemic rheumatic
    • RA
    • SLE
    • Sjogren’s syndrome
    • Reactive arthritis
    • Psoriatic arthritis
    • Polyarticular gout
    • Sarcoid arthritis
    • Vasculitis
    • Polymyalgia rheumatica
    • Inflammatory neuropathies
44
Q

What polyarthritic diseases progress in a migratory pattern?

A
  • Rheumatic fever
  • Gonococcal (disseminated gonococcemia)
  • Early phase of Lyme disease
45
Q

What polyarthritic diseases progress in an additive pattern?

A
  • RA
  • SLE
  • Psoriasis
46
Q

What polyarthritic diseases occur in an intermittent pattern?

A
  • Gout
  • Reactive arthritis
47
Q

Viral arthitis

A
  • Patho: direct invasion of synovium by virus –> immune complex mediated synovitis –> virus acts as antigenic target for immune system
  • Tx: Usually self-limited; requires no specific therapy
48
Q

Most common virus causing chronic polyarthralgia/itis?

49
Q

Common viruses causing self-limited polyarthralgia/itis?

A
  • HBV
  • Parvovirus
  • Alphavirus
  • Dengue (uncommon, but causes v. intense sx)
50
Q

Viruses less likely to cause polyarthralgia/itis?

A
  • EBV
  • CMV
  • Mumps
  • Coxsackie
  • HSV
  • Adenovirus
51
Q

Emerging cause of chronic viral polyarthritis (especially in WaHi)?

A

Chikungunya (immigration from DR)

52
Q

What common symptoms are seen in chikungunya infection?

A
  • Days to weeks: “saddle back fever”
    • Fever
    • H/A
  • Weeks
    • Fatigue
    • Myalgias
  • Weeks to months
    • Arthralgia/arthritis
    • Rash
    • Insomnia
53
Q

What symptoms of chikungunya infection are sometimes seen in children (but rare in adults)?

A
  • Photophobia
  • Retro-orbital pain
  • Vomiting/diarrhea
  • Acute encephalopathy
  • Acute meningitis

RMSK (16 decks)

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