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MSK block > Crystal Arthropathies and Septic Arthritis (R6) > Flashcards

Crystal Arthropathies and Septic Arthritis (R6) Flashcards

1
Q

List the 2 main cystal related arthropathies (Incl the composition of each)

A
  1. Gouty arthropathy ➞ monosodium urate (MSU)
  2. Calcium pyrophosphate dihydrate disease (CPPD) ie. Pseudogout
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2
Q

What is gout?

A

An inflammatory and destructive arthritis which results from the deposition of urate crystals from extracellular fluids

(Urate is the final degradation product of purine metabolism)

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3
Q

Typical presentation of gout?

A

A single acute hot, swollen and painful joint

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4
Q

Compare acute gout vs gouty arthritis in terms of:

  • presentation and onset
  • resolutions yes/no?
  • physical impairments
  • affected joints
A
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5
Q

What defines hyperuricemia (gout)?

A

Serum urate > 6.8 mg/dl

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6
Q

List 3 groups of people who are at an increased risk of gout

A
  1. Boys with unusual enzymatic defects
  2. Men after puberty
  3. Women after menopause
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7
Q

Explain the pathway of gout development

Explain how drugs act in this pathway for treatment

A
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8
Q

List 4 risk factors for gout

A
  1. Male
  2. Obesity
  3. High purine diet (e.g. meat and seafood)
  4. Alcohol
  5. Diuretics
  6. Existing cardiovascular or kidney disease
  7. Family history
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9
Q

List 3 joints which tend to be affected in gout?

A
  1. Base of the big toe (MTP joint)
  2. Wrists
  3. Base of thumb (CMC joint)

Can also affects large joints like the knee and ankle

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10
Q

Clinical sign indicative of gout?

A

Gouty tophi

Subcutaneous deposits of uric acid in the hands (DIP), elbows and ears

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11
Q

How is gout diagnosed?

A
  1. Clinically History, Exam, CRP and ESR
  2. Joint aspiration (polarized Light Microscopy) = gold standard
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12
Q

List 4 findings on microscopy of fluid aspiration in gout

A
  1. No bacterial growth (excl septic arthritis)
  2. Needle shaped crystals
  3. Negatively birefringent of polarised light
  4. Monosodium urate crystals
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13
Q

How is gout managed during an acute flare?

A
  1. NSAIDs (eg. ibuprofen) are first-line
  2. Colchicine second-line
  3. Steroids can be considered third-line
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14
Q

Gout Prophylaxis?

A
  1. Allopurinol (xanthine oxidase inhibitor) → reduces uric acid
  2. Lifestyle changes → wt loss, hydration, and minimising alcohol
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15
Q

Should allopurinol prophylaxis be initiated during or after an acute flare of gout?

A

Initiated after acute attack is settled

Once treatment of allopurinol has been started then it can be continued during an acute attack

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16
Q

List 4 findings on X-ray indicative of gout.

A
  1. Space between the joint is maintained
  2. Lytic lesions
  3. Punched out erosions
  4. Erosions can have sclerotic borders with overhanging edges
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17
Q

What is calcium pyrophosphate crystal deposition disease?

A

Precipitation of calcium pyrophosphate dihydrate (CPPD) crystals in connective tissues

Short term for CPPD is Pyrophosphate arthropathy

18
Q

List the 4 clinical presentations of CPPD

A
  1. Asymptomatic CPPD
  2. Pseudogout ➞ acute CPP
  3. Pseudo - RA ➞ chronic CPP
  4. Pseudo-OA ➞ OA with CPPD
19
Q

What age group and sex does CPPD most commonly affect?

A

Older adults ➞ increasingly common in both men and women with advancing age

20
Q

What is Pseudogout?

A

Calcium pyrophosphate crystals are deposited in the joint causing joint problems

Also known as chondrocalcinosis

21
Q

List 4 risk factors for pseudogout

A
  1. Advanced age
  2. Injury or previous joint surgery
  3. Hyperparathyroidism
  4. Haemochromatosis
  5. Hypomagnesaemia
  6. Hypophosphataemia
22
Q

Typical presentation of pseudogout?

A

An older adult with a hot, swollen, stiff, painful knee

Can affect the shoulders, wrists and hips and can be asymptomatic

23
Q

How is pseudogout diagnosed?

A

Joint aspiration of synovial fluid

Clinically tends to be milder in presentation than gout or septic arthritis

24
Q

List 4 findings on microscopy of fluid aspiration in psuedogout

A
  1. No bacterial growth
  2. Calcium pyrophosphate crystals
  3. Rhomboid shaped crystals
  4. Positive birefringent of polarised light
25
Q

What is the classic pathognomonic X-ray change seen in pseudogout?

A

Chondrocalcinosis - diganostic

Thin white line in the middle of the joint space caused by the calcium deposition

26
Q

List 4 other X-ray changes which may be seen in pseudogout

A

Similar to OA

  • loss of joint space
  • osteophytes
  • subarticular sclerosis
  • subchondral cysts
27
Q

Management of Pseudogout?

A

Usually self-resolve but symptomatic management involves:

  • NSAIDs
  • Colchicine
  • Joint aspiration
  • Steroid injections
  • Oral steroids

Joint washout (arthrocentesis) is an option in severe cases

28
Q

List 4 ways CPPD crystals differ from MSU crystals

A

I. More difficult to detect

II. Smaller (0.5 to 10 microns)

III. Weakly positively birefringent or not birefringent

IV. More polymorphic with rod-shaped and cuboid crystals in addition to the usual rhomboidal form

29
Q

What is Septic Arthritis?

A

Infection inside a joint

Medical emergency, as infection can destroy the joint and cause serious systemic illness

30
Q

In what age group is Septic Arthritis most common?

A

Children under 4 years

31
Q

List 4 risk factors for Septic Arthritis

A
  1. Joint replacement
  2. RA
  3. CKD
  4. Immunosuppression
32
Q

How does septic arthritis present?

A
  1. Hot, red, swollen and painful joint
  2. Refusing to weight bear
  3. Stiffness and reduced range of motion
  4. Systemic symptoms ie. fever, lethargy and sepsis
33
Q

Most common joint(s) affected by septic arthritis in

  1. Adults
  2. Children
A

Usually only affects a single joint

  1. knee
  2. hip, knee or ankle
34
Q

Most common causative organism in septic arthritis?

A

Staphylococcus aureus

Others incl:

  • Neisseria gonorrhoea
  • Group A strep (Strep pyogenes)
  • Haemophilus influenza
  • E. coli.
35
Q

According to the BNF how long should antibiotic treatment of septic arthritis continue for?

A

6-12 weeks

36
Q

List 4 important ddx for septic arthritis

A
  1. Transient sinovitis
  2. Perthes disease
  3. Slipped upper femoral epiphysis
  4. Juvenile idiopathic arthritis
37
Q

Investigations for Septic Arthritis

A
  1. Joint aspiration for gram staining, crystal microscopy, culture and antibiotic sensitivities
  2. Bloods: high WCC, ESR/CRP
  3. Blood cultures
  4. X-ray of joint
38
Q

What criteria is used to diagnose Septic Arthritis in children?

Explain

A

The Kocher criteria

  • fever >38.5 degrees C
  • non-weight bearing
  • raised ESR
  • raised WCC
39
Q

Management of Septic Arthritis

A
  1. IV antibiotics
  2. Consider joint washout under GA in severe cases
  3. Physiotherapy after acute infection resolves
40
Q

List 3 complications of Septic Arthritis

A
  • Osteomyelitis
  • Arthritis
  • Ankylosis fusion
41
Q

Antibiotics for septic arthritis:

  1. First line
  2. If penicillin-allergic
  3. MRSA suspected
  4. Gonococcal arthritis or Gram-negative infection suspected
A
  1. Flucloxacillin
  2. Clindamycin
  3. Vancomycin
  4. Cefotaxime
42
Q

How is septic arthritis most commonly spread?

A

Hematogenous spread

Eg. spread from abscesses

MSK block (30 decks)

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