articles Flashcards
predisposing factors for sepsis in unusual joints
(eg: sternoclavicular joint)
- IV drug use
- large vein catheterization
most common type of nontraumatic acute monoarthritis in young, sexually active people in the US
- gonococcal arthritis (3-4 x more common in women than men)
nongonocococal septic arthritis
- most destructive type of septic arthritis
- generally monoarticular (most often knees)
- S. aureus most common, also non group A beta hemolytic strep, gram negative, and S. pneuomoniae
(anaerobic and gram neg more common in IC people)
common cause of inflammation of a single large joint?
Lyme disease (mycobaterial, fungal and viral infections are rare)
what kinds of crystals can elicit acute monoarthritis?
- monosodium urate (gout)
- calcium pyrophosphate dihydrate (CPPD, pseudogout)
also: - calcium oxalate (renal dialysis)
- apatite
- lipid crystals
risk factors for spontaneous osteonecrosis
alcoholism
chronic corticosteroid use
clue: sudden onset of pain in seconds or minutes
potential dx: fracture, internal derangement, trauma, loose body
clue: onset of pain over several hours or one to two days
potential dx: infection, crystal deposition disease, other inflammatory arthritic condition
clue: insidious onset of pain over days to weeks
potential dx: indolent infection, osteoarthritis, infiltrative disease, tumor
clue: IV drug use, immunosuppression
potential dx: septi arthritis
clue: previous acute attacks in any joint, with spontaneous resolution
potential dx: crystal deposition disease, other inflammatory arthritic condition
recent prolonged course of corticosteroids
potential dx: infection, avascular necrosis
clue: coagulopathy, use of anticoagulants
potential dx: hemarthrosis
clue: urethritis, conjunctivitis, diarrhea, and rash
potential dx: reactive arthritis
clue: psoriatic patches or nail changes such as potting
potential dx: psoriatic arthritis
clue: use of diuretics, presence of tophi, history of renal stones or alcoholic binges
potential dx: gout
clue: eye inflammation, low back pain
potential dx: ankylosing spondylitis
clue: young adulthood, migratory polarthralgias, inflammation of the tendon sheaths of hands and feet, dermatitis
potential dx: gonococcal arthritis
clue: hilar adenopathy, erythema nodosum
potential dx: sarcoidosis
bulge sign
- the medial or lateral compartment is stroked and the fluid moves through the suprapatellar area into the opposite compartment, resulting in a visible bulge (indicates small effusion)
types of noninflammatory arthritis
( less than 2000 WBC)
- osteoarthritis, trauma, avascular necrosis, Charcot’s arthropathy, hemochromatosis, pigmented villonodular synovitis
types of inflammatory arthritis
( >2000 WBC)
- septic arthritis (>90% PMNs), crystal-induced monoarthritis (gout, pseudogout), RA, spondyloarthropathy, SLE, juvenile RA, lyme,
can crystals be present in a septic joint?
yes
is fever helpful in distinguishing infectious arthritis from others?
fever may be absent in patients with infectious monoarthritis but can be a presenting feature in acute attacks of gout or pseudogout
- fever may occur for other reasons in certain patients (eg: the IC)
does a normal serum uric acid level make gout less likely?
no, serum uric acid levels often are lowered in patents with acute gout
- conversely, there may be unrelated hyperuricemia in patients with other conditions
are gram staining and culture of synovial fluid sufficient to exclude infection?
no, cultures of blood, urine or another primary site of infection (eg: abscess) must be obtained and repeated as necessary if infection is strongly suspected clinically.
- culture results may be negative in early infection
definition of polyarticular joint pain
pain in more than 4 joints
differential diagnosis of polyarticular joint pain (general)
viral infection, indirect bacterial infection (reactive arthritis), direct bacterial infection, other infections, crystal-induced synovitis, systemic rheumatic disease, systemic vasculitis disease, spondyloarthropathies, endocrine disorders, malinancy
types of polyarticular joint pain that can cause viral infection
parovirus b19, enterovirus, adenovirus, epstein-barr, coxsackievirus, cytomegalovirus, rubella, mumps, hep B, VZV, HIV
types of indirect bacterial infections that can cause polyarticular joint pain
eg: reactive arthritis
gonorrhea, bacterial endocarditis, campylobacter, chlamydia, salmonella, shigella, yersinia, whipple’s, group A strep
types of direct bacterial infections that can cause polyarticular joint pain
gonorrhea, s. aureus, gram negative bacilli, bacterial endocarditis
other types of infections that can cause polyarticular joint pain
lyme (borrelia burgdorferi), tuberculosis, fungi
crystal-induced synovitis that can cause polyarticular joint pain
gout, pseudogout, hydroxyapatite
types of systemic rheumatic disease that can cause polyarticular joint pain
rheumatoid arthritis, SLE, polymyositis/dermatomyositis, juvenile RA, scleroderma, Sjogren’s, Behcet’s, polymyalgia rheumatica
types of systemic vasculitis disease that can cause polyarticular joint pain
schlonlein-henoch purpura, hypersensitivity vasculitis, polyarteritis nodosa, Wegener’s granulomatosis, giant cell arteritis
types of spondyloarthropathies that can cause polyarticular joint pain
ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, reactive arthritis
types of endocrine disorders that can cause polyarticular joint pain
hyperparathyroidism, hyperthyroidism, hypothyroidism
types of malignancies that can cause polyarticular joint pain
metastatic cancer, multiple myeloma
other types of diseases that can cause polyarticular joint pain
osteoarthritis, hyperrmobility syndromes, sarcoidosis, fibromyalgia, osteomalacia, sweet’s syndrome, serum sickness
parvovirus b19 polyarticular infection
chronology, inflammation, distribution, other signs, gender ratio
acute yes small joints, symmetrical, no axial involvement lacy rash, malar rash 3:1 (F:M)
rheumatoid arthritis
chronology, inflammation, distribution, other signs, ratio
chronic
yes
small and large joints, symmetrical, cervical axial involvement
subcutaneous nodules, carpal tunnel syndrome
3:1
SLE
chronology, inflammation, distribution, other signs, ratio
chronic
yes
small joints, symmetrical, no axial involvement
malar rash, oral ulcers, serositis (pleuritis or pericarditis)
9:1
osteoarthritis
chronology, inflammation, distribution, other signs, ratio
chronic no lower extremity joints, proximal and distal IP joints, first carpometacarpal joint, sometimes symmetrical, cervical and lumbar involvement none 1:1
fibromyalgia
chronology, inflammation, distribution, other signs, ratio
chronic
no
diffuse pattern, symmetrical, axial involvement
myalgias, tender points, irritable bowel syndrome
9:1
ankylosing spondylitis
chronology, inflammation, distribution, other signs, ratio
chronic yes large joints, symmetrical, axial involvement iritis, tendonitis, aortic insuficiency 1:1 to 1:5
psoriatic arthritis
chronology, inflammation, distribution, other signs, ratio
chronic
inflammation
large and small joints, sometimes symmetrical + axial involvement
psoriasis, dactylitis (sausage digits), tendonitis, onychodystrophy
1:1
arthritis vs arthralgia
arthritis = joint pain w/ inflammation arthralgia = joint pain w/o inflammation
signs of inflammation
erythema, warmth, pain and swelling
fatigue, weight loss, fever
morning stiffness lasting longer than 1 hr
reticulated (lacy) rash, facial exanthem (slapped cheek)
parvovirus B19
malar rash
SLE, parvo b19, lyme, rosacea, seborrhea, dermatomyositis
plaques (scalp, navel, gluteal cleft)
psoriasis
heliotrope
dermatomyositis
erythema chronicum migrans
lyme
erythema marginatum rheumaticum
rheumatic fever
erythema nodosum
sarcoidosis, Crohns
pyoderma gangrenosum
IBD, RA, SLE, ankylosing spondylitis, sarcoidosis, Wegener’s granulomatosis
palpable purpura
hypersensitivity vasculitis, Schonlein-Henoch purpura, PAN
livedo reticularis
antiphospholipidd antibody syndrome, vasculitis, cholesterol emboli
keratoderma blennorrhagicum
reactive arthritis, psoriatic arthritis
discoid skin lesions
discoid lupus, SLE, sarcoidosis
Gottron’s papules or plaques
dermatomyositis
vesicopustule on erythematous base
gonococcal arthritis
iritis or uveitis
spondyloarthropathies, sarcoidosis, Wegener’s
conjunctivitis
spondyloarthropathies, SLE, Wegener’s
cytoid bodies (retinal exudates)
SLE
scleritis
RA, relapsing polychondritis
ischemic optic neuritis
GCA, Wegener’s
oral ulcers
SLE, Behcet’s, reactive arthritis, Wegener’s
parotid enlargement
Sjogrens, sarcoidosis
macroglossia
amyloidosis
scalp tenderness
GCA
bloody or severe sinusitis
Wegener’s
inflammation of ear lobe
relapsing polychondirits
onycholysis
psoriatic arthritis, hyperthyroidism
pitting nails
psoriatic arthritis
nail clubbing
IBD, whipple’s, hyperthyroidism
nodules
RA, gout, whipple’s, rheumatic fever, amyloidosis, sarcoidosis
tophi
gout
jaundice
hepatitis, hemochromatosis
hyperpigmentation
whipple’s, hemochromatosis
telangiectasia
scleroderma
thickened skin
scleroderma, amyloidosis, eosinophilic fasciitis
hair thinning
hypothyroidism, SLE
tender points
fibromyalgia
tender points
fibromyalgia
heberden’s nodes
DIP joints
OA
Bouchard’s nodes
PIP joints
OA
Boutonniere and swan-neck deformities
RA SLE, Ehlers-Danlos
dactylitis
spondyloarthropathies
bursitis and enthesitis
spondyloarthropathies
mitral regurg and stenosis
rheumatic fever
aortic regurg
anklosing spondylitis, rheumatic fever, relapsing polychondritis, reactive arthritis, Marfan syndrome, Takayasu’s arteritis
cardiomyopathies
viral infection, amyloidosis, sarcoidosis, SLE, polymyositis
new murmur, fever
bacterial endocarditis, rheumatic fever
diminished peripheral pulses
GCA, Takayasu’s arteritis
hepatomegaly
whipple’s, hemochromatosis, amyloidosis, Wilson’s
positive fecal occult blood test
IBD
prostatitis
reactive arthritis, ankylosing spondylitis
urethritis or cervicitis
reactive arthritis, gonococcal arthritis
scrotal or vulvar ulcers
Behcet’s
hypogonadism
hemochromatosis
balanitis circinata
reactive arthritis
entrapment neuropathies
RA, hypothyroidism, hyperparathyroidism
facial palsy
lyme
peripheral neuropathy
SLE, amyloidosis
chorea
antiphospholipid antibody syndrome, SL, rheumatic fever
mononeuritis multiplex
RA, SLE, lyme, vasculitis
seizures
SLE
most important risk factors for septic arthritis
- prosthetic hip or knee joint
- skin infection
- joint surgery
- rheumatoid arthritis
- age >80 yrs
- diabetes mellitus
examples of large vessel vasculitis
takayasu arteritis
giant cell arteritis
examples of medium vessel vasculitis
polyarteritis nodosa
kawasaki disease
examples of ANCA-associated small vessel vasculitis
microscopic polyangiitis
granulomatosis with polyangitis (wegener’s)
eosinophilic granulomatosis (churg-strauss)
examples of immune complex small vessel vasculitis
cryoglobulinemia vasculitis
IgA vasculitis (Henoch-Schonlein)
hypocomplemenemic urticarial vasculitis (anti-C1q vasculitis)
anti-GBM disease
examples of variable vessel vasculitis
Behcet’s disease
Cogan’s syndrome
examples of vasculitis associated w/ systemic disease
lupus vasculitis
rheumatoid vasculitis
sarcoid vasculitis
Takayasu arteritis
often granulomatous
affects aorta and/or major branches
onset usually
GCA
often granulomatous affects aorta/or major branches, usually carotid and vertebral arteries often involves temporal artery onset usually >50 yrs often ass. w/ polymyalgia rheumatica
polyarteritis nodosa
necrotizing arterities of medium or small arteries w/o glomerulonephritis. not ass/ with ANCA
Kawasaki disease
arteritis ass. w/ mucocutaneous LN syndrome and predominately affecting medium and small arteries.
coronary arteries often involved.
usually affects children
ANCA-associated vasculitis
necrotizing vasculitis affecting small vessels.
ass. w/ MPO, ANCA or proteinase 3
microscopic polyangiitis
necrotizing vasculitis affecting small vessels.
necrotizing glomerulonephritis very common
pulmonary capillaritis often occurs
granulomatosis w/ polyangiitis (wegener’s, GPA)
necrotizing granulomatous inflammation usually involving upper + lower resp tract (small vessels)
necrotizing glomerulonephritis is common
eosinophilic granulomatosis w/ polyangiitis (Churg Strauss)
eosinophil-rich and necrotizing granulomatous inflammation often involving resp tract
ass. w/ asthma and eosinophilia
ANCA more frequent when glomerulonephritis is present
immune complex vasculitis
small vessels
glomerulonephritis is frequent
anti-glomerular basement membrane disease
affects glomerular capillaries (glomerulonephritis) and pulmonary capillaries (pulmonary hemorrhage)
cryoglobulinemic vasculitis
ass. w/ serum cryoglobulins
skin, glomeruli and peripheral nerves often involved
IgA vasculitis (henoch-schonlein)
small vessels
often involves skin and GI tract
often causes arthritis
hypocomplementemic urticarial vasculitis (anti-C1Q vasculitis)
urticaria, hypocomplementemia
glomerulonephritis, arthritis, obstructive pulmonary disease and ocular inflammation are common
Behcet’s disease
recurrent oral and/or genital aphthous ulcers, w/ cutaneous, ocular, articular, GI and/or CNS inflammatory lesions
Cogan’s syndrome
ocular inflammatory lesions (interstitial keratitis, uveitis, episcleritis), and inner ear disease (sensorineural hearing loss, vestibular dysfunction)
vasculitic signs: arteritis, aortitis, aortic aneurysms, and aortic and mitral valvulitis
