Arthropathies and Septic arthritis Flashcards by tcarlso 3

What are the s/sx of septic arthritis?

Hot, edematous joint that is painful and TTP

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What is the ddx for acute onset monoarthropathy?

Hemarthrosis
Septic arthritis
Infectious

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What is Pigmented villonodular synovitis? Presentation? Prognosis?

Idiopathic inflammation and overgrowth of the synovium in a joint that usually presents as an acute onset of focal joint pain and swelling. Usually recurs.

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Over what age is a risk factor for septic arthritis?

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What are the systemic diseases that predispose a patient to septic arthritis?

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What are some shx bits that predispose patients to septic arthritis?

Alcoholism

IV drug abuse

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What is the bacteria that more commonly causes septic arthritis in IV drug users? Which joint in particular?

Pseudomonas

Sternoclavicular joint

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What is the most common cause of a septic joint (how do bacteria get there)?

Hematogenous spread from drug abuse or catheters

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What is the most common joint that is affected with septic arthritis?

Knee

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What bacteria that, if found in a joint, should raise suspicion for endocarditis?

Staph Aureus

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What is the WBC level in a joint aspirate that is suggestive of a septic joint?

50,000-150,000

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What is the classic triad for gonococcal septic arthritis?

Tenosynovitis
Vesiculopustular skin lesions
Polyarthralgias

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What is the auger that is used to culture Neisseria?

Chocolate auger

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Where does sporotrichosis septic arthritis usually show up?

Finger joints

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What are the chances of causing a joint infection with steroid injections using proper technique?

Very low

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What is the most common joint infected with Lyme disease?

Knee

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What is the drug of choice for gram + cocci septic arthritis?

Vancomycin

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What is the drug of choice for gram - bacteria caused septic arthritis?

Third generation cephalosporin

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What are the three forms of joint drainage that can be done with septic arthritis?

Aspiration
Arthroscopy
Open drainage

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What are the non-diet precipitating factors of gout? (4)

Trauma
Surgery
Meds
cold exposure

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What are the dietary factors that can precipitate gout? (4)

EtOH
Fatty diet
Starvation
Dehydration

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What is the effect of ASA on gout?

Low dose increases uric acid, but high dose decreases

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What diuretic in particular increases uric acid levels?

HTZ

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What are the skin findings of the area over a gouty inflammation?

Cracked from the swelling

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What is the usual onset and duration (relative) for gouty attacks?

Fast onset, and quickly resolves

What is the role of estrogen/progesterone in gout?

Decreases uric acid levels

What is the effect of prolonged, untreated gout?

Increases frequency of attacks, and number of joints affected

What are tophi?

a deposit of crystalline uric acid and other substances at the surface of joints or in skin or cartilage, typically as a feature of gout.

When is synovial fluid analysis warranted with suspected gout attacks?

If first time to r/o septic joint

What is the birefringence findings with uric acid crystals?

If yellow in parallel plane of polarized light = uric acid ("ye-ll-ow in para-ll-el light") If perpendicular, then blue

What is the sensitivity of uric acid levels in gout flares?

Not that great

True or false: urate crystals always cause pain

False--only if cell is affected. This causes cytokine release.

What are the plain radiograph findings with an acute, new gouty attack?

Nothing

What are the plain radiograph findings with chronic gout?

- Subcortical bone cysts | - Bone erosions with overhanging edges

What are the US findings of chronic gout?

Hyperechoic linear density overlying the surface of joint cartilage

What if the definition of hyperuricemia?

Above 7%

What are the two major (very general) pathophysiological mechanism for gout?

Overproducer or underexcreter

What is the solubility or uric acid? What happens with decreased temperature?

7 mg/dL Decreased solubility with decreased temperature

What is the treatment for acute gout attacks? (4)

NSAIDs Glucocorticoids Colchicine TNF-alpha inhibitors

What is the MOA of colchicine?

Binds and stabilizes tubulin to inhibit microtubule polymerization, impairing leukocyte chemotaxis and degranulation

What should alway be checked for prior to administering TNF-alpha inhibitors? Why?

- Latent TB | - TNF-alpha needed to maintain granulomas

What are the three major TNF-alpha inhibitors?

INfliximab Etanercept Adalimumab

What is the MOA of infliximab? Use?

- Anti-TNF-alpha monoclonal ab | - IBD, RA, psoriasis, ankylosing spondylitis

What is the MOA of etanercept? Use?

- receptor for TNF-alpha + IgG1 Fc | - RA, psoriasis, ankylosing spondylitis

What is the MOA of adalimumab? Use?

- Anti-TNF-alpha monoclonal ab | - IBD, RA, psoriasis, ankylosing spondylitis

What is the MOA of allopurinol?

Inhibits xanthine oxidase to decrease the conversion of xanthine to uric acid

What is the MOA of febuxostat?

Xanthine oxidase inhibitor

What is the MOA of probenecid?

Inhibits reabsorption of uric acid in PCT (also inhibits the secretion of PCN)

What is the MOA of rasburicase?

a recombinant version of urate oxidase, an enzyme that metabolizes uric acid to allantoin, which is much more water soluble

What are the drugs that predispose patients to gout?

- ASA - Diuretics - ACEIs

What are the drugs to prevent recurrent attacks of gout? (3)

- Allopurinol - Febuxostat - Probenecid

What is the role of EtOH in gout?

Predisposes

What is the role of cherries in gout?

Preventative

What is the role of vitamin C in gout?

Preventative

What is the uric acid goal for preventing gout?

Below 6 mg/dL

What organ is involved in the clearance of febuxostat?

Hepatic

What are the ethnicities in which allopurinol is more toxic?

Korean Thai Han chinese

How is allopurinol excreted?

Renally

When are uricosuric agents contraindicated? Why?

If CrCl is less than 50 (will not work if not excreting enough)

What diuretic has uricosuric activity?

Losartan

What is uricase? Use?

Same MOA as rasburicase, but can be extremely toxic, so only use if severe cases

What are the NSAIDs of choice for gout?

Naproxen | Indomethacin

What is the steroid of choice for gout? High or low dose?

Low dose prednisone

What color are uric acid crystals in parallel light? Calcium pyrophosphate crystals?

Uric acid = yellow | Ca = blue

Who usually gets calcium pyrophosphate crystal deposits (pseudogout)?

Older people

What are three major diseases that are associated with pseudogout?

- Hemochromatosis - Hyper/hypoparathyroidism - Thyroid disease

What is the treatment for pseudogout?

NSAIDs Colchicine Steroids

Which gender is more affected by acute attacks of pseudogout?

Men

Which gender is more affected by osteoarthritis with chondrocalcinosis of pseudogout?

Women

What is the classic shape of pseudogout crystals?

Rhomboid

What is crowned dens syndrome?

n inflammatory condition resulting from crystal deposition in cruciform and alar ligaments surrounding the dens, appearing as a radiopaque 'crown' surrounding the top of the dens. It typically presents with pain and increased inflammatory markers.

What are some of the different presentations of CPPD? (4)

- Acute - Asymptomatic - Pseudo RA - Pseudo OA

What are the plain film findings of CPPD?

Chondrocalcinosis / degenerative changes in the wrist, knee, pubic symphysis

What are spondyloarthropathies?

Inflammation of the axial joints, asymmetrical oligoarthritis,

What are the four diseases associated with HLA-B27?

- Psoriasis - Ankylosing spondylitis - IBD - Reactive arthritis

What are the s/sx of spondyloarthropathies?

-Low back pain present when lying still for long periods, but resolves with movement

What is enthesopathy?

a disorder involving the attachment of a tendon or ligament to a bone

What is dactylitis?

Dactylitis or sausage digit is inflammation of an entire digit

What will an x-ray show with ankylosing spondylitis?

Fusion of the vertebrae ("bamboo spine")

What are the three major nonpharmacologic treatments for spondyloarthropathies?

- Smoking cessation - Exercise - Education

What are the three major pharmacotherapies for spondyloarthropathies?

NSAIDs Analgesics DMARDs

What are the 5 major NSAIDs, besides ASA?

- IBU - naproxen - indomethacin - ketorolac - diclofenac

What is the MOA and use of celecoxib?

- Reversibly inhibits COX-2 (spares good COX-1). | - RA, OA

Why does celecoxib spare platelet function?

No effect of TXA2

What is the metabolite that causes the toxicity associated with acetaminophen? Treatment and MOA?

NAPQI N-acetylcysteine is antidote regenerates glutathione

What is the MOA of bisphosphonates?

Pyrophosphate analog; binds hydroxyapatite in bone, to inhibit osteoclast activity

What is the MOA of alendronate?

bisphosphonate

What is the suffix common to bisphosphonate drugs?

"-dronate"

What is the classic toxicity associated with bisphosphonates?

Corrosive esophagitis

Which TNF-alpha inhibitor does not affect the uveitis common to ankylosing spondylitis?

Etanercept

What are the five different patterns of involvement for arthritis?

- Distal oligoarthritis - Asymmetric polyarthritis - Symmetric polyarthritis - Arthritis mutilans - Spondyloarthritis

What is Arthritis mutilans?

Arthritis mutilans, is a rare arthropathy originally described as affecting the hands, feet, fingers, and/or toes, but refers in general to severe derangement of any joint ("mortar in a pestle")

What are the post enteric causative pathogens of reactive arthritis?

Campylobacter Salmonella Shigella Yersinia

What are the s/sx of reactive arthritis, besides the classic triad?

LBP Dactylitis Enthesitis

What is the classic skin manifestation of reactive arthritis?

- Keratoderma Blennorrhagicum | - rash on the soles of the feet

Where is the associated arthritis found with IBD?

Sacro Iliac, spine, or peripheral joints

What is the difference between type I and type II IBD arthritis?

Type I = peripheral, self limiting Type II = polyarticular, peripheral, frequent recurrences