Infectious Arthritides - Septic, Lyme, TB, Viral, HIV, Whipple's, ARF Flashcards
Diff between gonococcal and nongonococcal septic arthritis
Gonococcal:
–Healthy young (vs children/elderly/ immunocompromised)
–Migratory arthritis (vs monoarthritis)
–Common Rash and Tenosynovitis (vs rare)
–Rare + blood/joint Cx (vs common)
–Good outcome (vs bad)
Septic arthritis RF
-Impaired host defense, old (>80), young (<5)
– Neoplastic disease
– Chronic illness (EtOH, DM, cirrhosis, CKD, HIV, IVDU, hyposplenia from Sickle cell)
– Immunodef: hypogammaglobulinemia, complement def
– Skin infxn
– Drugs: GC, chemo, biologic
– Iatrogenic: prosthetic joint, IA GC
– Chronic arthritis (i.e., RA, hemarthrosis, osteoarthritis)
**MTP involvement DDX **
Septic, osteomyelitis, cellulitis,
-Diabetic osteolysis/Charcot,
-Intertarsal bursitis,
-Freiberg infarction (infarct of the MT head, often the 2nd),
-Sesamoiditis,
-CRPS,
-Stress fracture
** Septic arthritis likely organisms in DM**
In order of freq:
-Staph Aureus
-Streptococci
-Gram negative bacilli
-Polymicrobial
-Coagulase (-) Staph
-Culture negative
When is surgical drainage absolutely indicated for a septic joint?
-* Infected hip/ shoulder joints.
-* Vertebral OM with cord compression.
-* Anatomically difficult-to-drain (eg SC), loculated
-* Too thick to aspirate
-* Ongoing sx despite needle drainage
-* Prosthetic joints or foreign body
-* OM requiring surgical drainage.
-* Delayed onset of therapy (>7d)
Poor prognostic factors nongonococcal septic arthritis
-Old
-Late diagnosis
-On Immunosuppression
-Transplant, IHD, cirrhosis
-RA
-Multiple joints involved
-Bacteremia
-Gram negative
IVDU septic arthritis presentation
More gram neg, but S Aureus still MC
-More insidious w/ LONGER duration fo sx
-More AXIAL (L spine, SI joint, SC, symphysis pubis)
PJI RF
Distant site of infection,
-Impaired host defense
-RA, diabetes mellitus,
-Revision arthroplasty (5–10 times increased risk),
-Prolonged operative time
-Superficial joint replacements (i.e., knee, elbow, ankle)
Pseudoseptic arthritis causes
-RA
-Crystal
-Seroneg, Behcet’s
-SLE
-HA injection
-Prosthetic joints
-Renal transplant
RF for disseminated gonococcal infxn
Women, menstruation, preg, postpartum (cervical pH)
-Non-white, Urban residence, Low SES and educational status,
-High risk sex (multiple partner, prostitute)
-Previous gonococcal infection
-Complement deficiency
-Asplenia (SLE, Sickle cell)
** DGI Sx **
Papular/pustular skin rash
-Tenosynovitis (dorsum wrists, fingers, toes, ankles)
-Arthralgia
-
-GU symptoms eg PID
** DGI Tx **
Local cervicitis:CTX 250mg IM x1 + Azithro 1g x1
-DGI: CTX 1g IV daily x7d + azithro 1g PO x1
** DGI workup **
- Synovial cell count/culture/crystal/gram stain
– Blood culture
– urine NAAT testing for gonorrhea
– urethral/endocervical NAAT testing for gonorrhea
-
-**Test for syphilis and HIV
** DGI List 4 sites you want to culture?
-Give % positive synovial fluid culture?
-**
Genitourinary 80%
-Synovial fluid 50%
-Rectum 20%
-Pharynx 10%
-Blood <30%
-Skin Rare
** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Ask 4 other pertinent questions on history?**
Infectious history and exposures including sexual history
-Ocular symptoms (photophobia, red eye, pain)
-GI symptoms (diarrhea, weight loss)
-Other rashes?
** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 3 possible diagnoses?**
Behcet
-IBD with associated aphthous ulcers and peripheral arthritis
-HIV
-HSV
-?sarcoid
-?SLE
-gonococcal
** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 4 investigations?**
CBC
-Arthrocentesis (cell count, culture, microscopy)
-Swab of ulcer
-CXR (screen for PA aneurysms in Behcet)
-General STI testing including HIV testing, chlamydia
-?Pathergy testing
** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 3 therapies of most likely diagnosis? **
Topical corticosteroids (for ulcers)
-Colchicine titrate up to 0.6 TID
-Prednisone
-AZAthiorpine (for refractory ulcers, arthritis)
Syphilis presentation
-Fever, H/A, LN
-Mucosal ulcers, Sore throat
-Polyarthritis
-Maculopapular rash(palms and soles)
-Condyloma lata.
Lyme pathophys
Host’s inflammatory response to the spirochete (B. burgdorferi)
Lyme 1st stage manifestations
Early localized ECM
–Erythema migrans - annular lesion w/ central clearing
–Flu-like symptoms (H/A, arthralgia, fever, Regional LN)
** Lyme 2nd stage manifestations **
Disseminated infection:
–Neuro: CN palsy, meningitis, radiculoneuritis, sensorineural hearing loss
–iritis/keratitis
–Cardiac: AV block, myo/pancarditis, NO VALVE involvement
–Skin - satellite lesion
–MSK: migratory arthralgia,
–Other: LN, splenomegaly, hepatitis,
**Lyme 3rd stage manifestations **
Persistent infection (late disease):
–MSK: asymmetric oligoarthritis large joints (knees) w/ inflammatory fluid
–Neuro: encephalomyelitis, stroke like presentation, encephalopathy, polyneuropathy
** Name 5 non-MSK features in early disseminated Lyme disease **
Carditis
-Heart block
-Erythema migrans
-Cranial palsy, radiculoapthy, encephalopathy
-Keratitis
-SNHL
-Hepatitis, HSM
Lyme Diagnosis
1) Enzyme immunoassay (EIA) OR Immunofluorescence (IFA)
– Negative = consider alternate dx OR too early (<30d) → get Western Blog (WB)
– Positive/Equivocal = get IgG Western blot (IgM too if <30d)
-
-*if IgM + but NOT IgG likely false+ IgM
** Reasons for Lyme False + **
- Previously treated
– Subclinical past infxn bc in endemic area
– AB against other spirochetes, syphilis, leptospirosis (eg >1mo sx w/ +IgM ELISA and -IgG ELISA)
– Cross-reactivity with other diseases: IE, SLE, RA, MS, HPylori, EBV, CMV, malaria, non lyme spirochetes,
– Interpretation error of faint band
** Lyme Tx **
Early/Disseminated/Late:
-Doxycycline 100mg po BID x 14d
-
-*if CNS: CTX 2g daily
** Antibiotic-refractory Lyme arthritis pathophys and Tx **
HLADR4 and DR2 alleles bind B Burgdorferi and cross react w/ human protein → autoimmune inflamm
-Tx: No more abx
–NSAID
–IA GC
–HCQ
–Arthroscopic synovectomy
Post treatment Lyme disease syndrome (PTLDS) presentation
> 6mo of Fibro/ fatigue symptoms
-Cog dysfunction
-Widespread pain
-Sleep disturbance
-Faituge
Post treatment Lyme disease syndrome (PTLDS) Tx
Treat as Fibro
When to give Lyme PPX
OLDER than 8yo (ppx not effective)
-Endemic area
-Confirmed adult or nymph Ixodes tick
Attached for at least 36 hours
PPX can be given within 72 hours of tick removal
** Other bugs transmitted by ticks and their sx**
B miyamotoi: similar as lyme but NO RASH
-Babesiosis: thrombocytopenia, hemolysis, liver enzymes, intraerythrocytic org on smear
-Human granulocytic anaplasmosis - leukoepenia, thrombocytopenia
RF for osteoarticular TB
Female sex
-Old > 65yo
-Endemic country immigrant
-Immunosuppressed eg biologics, EtOH, IVDU, HIV
Osteoarticular TB MSK involvement
Spine (pott’s): disk narrowing, vertebral collapse, kyphosis, abscess ,neuro compromise
-Hip, SI joint, knee, ankle, hand/wrist
-OM (lytic lesion w/o periosteal rxn)
-Dactylitis
-Tenosynovitis
-Bursitis
What is Poncet’s disease
Culture negative polyarthritis (reactive/immune mediated) in TB of LN or pulmonary
-Tx w/ antiTB meds
** Osteoarticular TB Ix **
Synovial fluid smear, culture or adenosine deaminase
-Synovial biopsy: caseating granuloma
-Nucleic acid amplification tests (NAAT)
-CXR
-Bone biopsy
-Blood Cx
** Osteoarticular TB XR findings **
- Lytic lesions with little periosteal reaction
– Juxtaarticular osteoporosis
– Osteomyelitis
– Joint space narrowing
– Vertebral scalloping and collapse
– Paravertebral abscess
Osteoarticular TB Tx
RIPE x 6-9mo
-DC pyrazinamide after 2 mo
-DC ethambutol once TB confirmed sensitive to isoniazid
NTM risk factors
- Prior surgery/trauma.
-* Direct inoculation / environmental exposure (soil, water).
-* IA GC
-* Preexisting joint disease.
-* Open wounds
-* Immunosuppression: eg biologic
Positive TBST
PPD>5mm at 48h
-If negative, do IGRA (immunosuppressants can cause false negative)
Biologics highest risk for NTM/ TB
TNFi (especially Infliximab )
Biologics lowest risk for NTM/ TB
Abatacept , Ritux
-*ritux highest risk of hepatitis B reactivation
What to do w/ biologic start if latent MTB and normal CXR
1 month of latent TB Tx before biologic start
-Complete 9mo of isoniazid
What to do w/ biologic start if active TB
Complete TB tx before starting biologic
What to do w/ biologic start if previously treated NTM
Consult ID
-Can consider Ritux or Abatacept
-Avoid TNFi
Leprosy symptoms
Erythema nodosum 2/2 ReA
-Subcutaneous nodules
-Necrotizing vasculitis
-
-Symmetric small joint polyarthritis (can be RF+)
-Neuropathic acroosteolysis: Charcot, resorption distal metatarsals, aseptic necrosis, “claw” hands
-
-Infection of bone (distal phalanges)
Viral arthritis characteristics
Acute self-limited (weeks/months)
-Nonerosive,
-Inflammatory arthritis
-Can be RF and ANA+
Acute Hep B serology
Positive: HBcAb IgM, HBcAb IgG,HBsAg, HBeAg, HBV DNA
-Negative: Anti HBs, Anti HBe
Cleared Hep B serology
Positive: HBcAb IgG, Anti HBs, +/-Anti HBe
-Negative: HBcAb IgM, HBsAg, HBeAg, HBV DNA
Chronic HBV infection serology
Positive: HBcAb IgG, HBsAg, HBeAg, HBV DNA, Anti HBs, +/-Anti HBe
-Negative: HBcAb IgM
-*same as acute with negative HBcAb IgM
HBV Vaccine serology
Only Anti-HBs
RF chronic HBV
Male
-Immunocompromised
HBV rheum manifestations
Symmetric migratory polyarthralgia/itis (~RA) - resolves w/ jaundice onset
-Dermatitis - maculopapular, urticarial, petechial
-Membranous nephropathy
-HBV-associated polyarteritis nodosa
HBV PAN Tx
Immunosuppression
-PLEX
-Antiviral
HBV labs
Hep B serologies
-Positive RF
-Hypocomplementemia
-
When to give ppx antiviral for HBV with biologics
Chronic inactive with TNFi, Ritux, or other biologic
-Past resolved infxn with Ritux
** List 5 rheumatologic conditions that can accompany Hepatitis C.**
Nonerosive polyarthritis
-Cryo vasculitis
-Autoimmune conditions caused by interferon alpha (no longer used)
-Keratoconjunctivitis sicca
-Fibromyalgia
HCV serology
ANA, RF, Ro, La (if cryo: low complements and cryo+)
-Celiac
-Anticardiolipin
-Antithyroid, Antismooth, AntiLKM
Differentiate HCV arthritis from RA
HCV nonerosive and usually CCP negative
Differentiate HCV sicca from SS
Both hv Ro/La
-MSG biopsy shows CD8+T cells (vs CD4+ T cells in SS)
Treating Rheum pt w/ HBV or HCV infection
Use HCQ, SSZ, and AZA over MTX/LFN
-TNFi are safe
Parvovirus B19 sx & labs
Hydrops fetalis in infected mothers
-Erythema infectiosum (fifth disease) in children
-Aplastic crisis in adults
-pseudo rheumatoid inflammatory arthritis
-fever, rash, myalgia, arthritis (adults > children)
-Mimicking lupus: cytopenia, hypocomplementemia, a positive ANA, and transient aPL antibodies
Parvo B19 labs
Cytopenia,aplastic crisis
-Hypocomplementemia,
-Positive ANA, RF, dsDNA, ENA, APLA
Mech of viral arthritis eg Hep, Parvo
Immune complex deposition causing nonspecific inflammatory response
How to distinguish dengue fever from CHIK infection?
Dengue
– Arthralgia WITHOUT synovitis
– Abdo pain
– Leukopenia
– Hemorrhagic manifestations
– Breakbone fever
What NOT to give in Zika infection
NSAIDs and ASA bc can cause bleeding in patietns with other flaviviridae infections
** Rheum Manifestations assoc’d w/ HIV **
Arthralgia/Arthritis
-Seroneg: ReA, PsA, undiff SpA bc CD8+
-Myalgia, PM, IBM
-Diffuse infiltrative lymphocytosis syndrome
-Vasculitis (all types: LVV, PAN, AAV, HSP, PVCNS, Behcets, Cryo2/3)
-Fibro
** Why test HIV in psoriasis **
As CD4 drops, can flare psoriasis
** Rheum Manifestations assoc’d w/ ART **
CD4 mediated: RA, Sjogren’s, SLE, SCLE, Sarcoid
-ReA
-Gout (hyperuricemia)
-Grave’s
-AVN, OP, osteomalacia
-OM
-Rhabdo, lipodystrophy, mitochondrial myopathy
Pathophys of HIV rheum syndromes
CD4 depletion = T reg cell depletion (for self tolerance and avoiding autoimmunity)
HIV autoimmune serologies
RF, ANA, Anticardiolipin, Cryo, ANCAs
HIV assoc’d arthritis manifestations and Tx
Seroneg oligoarticular knees/ankles
-Noninflammatory, culture neg, synovial fluid
-Normal XR
-Tx: NSAID, steroid, PT
-
-Prolonged:
– RA like erosions and joint space narrowing
–Jaccoud’s
-Tx: NSAIDs, HCQ, SSZ
Diff between HIV assoc’d arthritis and painful articular syndrome
Painful articular syndrome lasts <24h
– Occurs late in HIV
– Due to transient bone ischemia (no synovitis)
– Tx = narcotics
When to give DMARDs in pt w/ HIV
Adherence to ART
-Viral load is low
-CD4 T cell count >200/uL
HIV related wasting syndrome - sx and bx
Noninflamm necrotizing myopathy
-Bx: atrophy and necrosis WITHOUT inflamm
HIV associated PM vs PM
HIV assciated PM:
– Lower CK (can be normal)
– NO autoantibodies
-Otherwise, EMG, MRI, biopsy is the same
-
-Tx: Steroids+ART (2nd line = MTX)
AZT induced myopathy vs PM
AZT induced myopathy
– Biopsy shows AZT induced toxic mitochondrial myopathy with RAGGED RED FIBERS
-
-Tx: Hold AZT x4wks and monitor
** Diffuse infiltrative lymphocytosis syndrome vs Sjogren’s **
DILS:
– CD8+ predominant lymphocytic infiltration of salivary/lacrimal gland (vs CD4 in sjogrens)
– COMMON parotid swelling and extraglandular mx (less common in SS)
– RARE AB (RF, ANA, Ro/LA)
– Steroids help glandular (less helpful in SS)
-
** Name the rheumatic diseases that may improve in association with AIDS **
SLE and RA are CD4 driven, thus IMPROVE with AIDS
-Can worsen with ART
MoA of IRIS
Increasing CD4 counts w/ Tx exacerbates preexisting RA, SLE, Sarcoid
-CD4 and cytokines can cause new RA, SLE, Sarcoid, PM, ReA, SCLE, GBS, autoimmune thyroid
IRIS Tx
Self limited, continue ART unless ocular or CNS symptoms → then DC and give GC
When should screening for HIV be considered by the rheumatologist?
1) Diagnosis of ReA with sexual or unknown mode of acquisition,
-2) IVDU
-3) Septic arhtiris/pyomositis
-4) PsA w/ refractory or atypical rash
-5) atypical SLE or unexplained autoantibody
-6) Sicca without Ro/La
-7) Autoimmune dz refractory to usual tx
HTLV1 (human T lymphotropic virus type 1) disease association
-T cell leukemia and NHL - hyperCa, skin involvement
-Chronic inflamm syndrome - seroneg oligo/polyarthritis w/ tenosynovitis and nodules w/ fibrinoid necrosis
HTLV1 smear cells
Flower cells
** Whipple’s pathogen**
Tropheryma whipplei
** Whipple’s symptoms**
-Wasting/weight loss, abdo pain, Steatorrhea, diarrhea, malabsorption
-Arthritis (seroneg palindromic rheumatism of knees, ankles, wrists, SI joints, spine)
-Eye inflammation (Panuveitis, keratitis, retinitis, optic neuritis, orbital pseudotumor) , Supranuclear ophthalmoplegia
-Hyperpigmentation of skin, skin lesions
- Encephalopathy, Psychiatric symptoms
-Interstitial nephritis
-Pancytopenia, Lymphadenopathy
-Endocarditis (cultre negative)
Whipple’s CNS sx
Dementia
-Psych
-Myoclonus
-Oculomasticatory or oculofacial-skeletal myorhythmia (pathognomonic)
Whiples triad
Dementia,
-Supranuclear ophthalmoplegia
-Myoclonus
Whipples Dx
Biopsy showing organism in one involved tissue by 2 methods (PAS stain, PCR, immunohistochemical stain OR
-PCR testing in 2 involved sites (eg synovial fluid and CSF)
-*always test CNS regardless of neuro symptoms
** Whipple’s Tx **
CTX 2g x14d (up to 28d for neuro or IE) then longer term Septra DS BID fora year
-*can cause IRIS (esp if CNS involved or previous immunosuppression)
** Rxn when taking abx for Whipple **
Jarisch-Herxheimer reaction within 24h (in pt w/ spirochete infxn): fever, chills, headache, hypotension, severe abdominal or pleuritic chest pain.
-IRIS- Immune reconstitution syndrome within weeks: disease symptoms and high fever
Rheumatic fever symptoms
J—joints (migratory NONEROSIVE arthritis)
-♥—carditis (peri/myocardium, valves - MV, AoV, CHF, heart block)
-N—nodules (subcutaneous)
-E—erythema marginatum (irreg serpignous nonpruritic rash sparing face)
-S—Sydenham’s chorea (asymmetric movement face/hands/feet)
-Fever
Rheumatic fever Jones criteria
Initial ARF = 2 major or 1 major + 2 minor
-Recurrent ARF = 2 majr or 1 maj + 2 minor or 3 minor
-Major
Carditis
-Arthritis
Chorea
-EM
-Subcutaneous nodule
-Minor
-Arthralgia
-Fever
-ESR >60, CRP >3
-Prolonged PR (unless carditis is present already)
Situations in which a diagnosis of ARF might be made without strict adherence to the Jones criteria
- Isolated chorea months after initial strept infxn & negative serology
- Indolent carditis and/or typical mitral/aortic valve lesion as only manifestation
- Previous rheumatic heart disease
GAS Lab tests
Throat cx for GAS
-Rapid Strep Ag test
-*neither tell you if carrier vs active infxn and can be negative if in latent period
-
-Preferred:
-Antistreptolysin test or antideoxyribnuclease B test
How does GAS cause ARF
Molecular mimicry
– Ig against GAS peptidoglycans cross react w/ cardiac myosin
-
-GAS protein can also bind collagens to create immune rxn
ARF exam test
Milkmaid grip = involuntary grasp/release when trying to hold constant grip (pathognomonic)
-Jaccoud’s if recurrent ARF
ARF prevention
-ABX PPX 5y (or 10Y if mild cardiac sx) from last attack or until age 21
-Severe carditis w damage = PPX for 10 years or until age 40 (can consider lifelong ppx
-Abx PPX for ARF pt if frequent exposure to children until exposure ends
Complications of Strep infxn
ARF
-PANDAS (pediatric autoimmune neuropsych d/o assoc’d w/ strep) eg OCD, Tic
ARF Tx
Azithro, Clinda
-Penicillin G or V or Amox if carditis/neuro
-Arthritis: ASA or Naproxen
List the main type/pattern of arthritis and 1 skin manifestation for each of the following infections
-Lyme
-Gonorrhea
-Parvo
-Mycobacterium
-
Lyme: early migratory arthralgia, late mono>oligoarhtritis
– erythema migrans
-
-Gonorrhea: tenosynovitis and migratory polyarthralgia
– pustular dermatitis
-
-Parvo: symmetric polyarthalgia/arthritis
– facial erythema (slapped cheek)
-
-Mycobacterium: Tenosynovitis, OM, dactylitis, septic arthritis
– Subcutaneous nodules
** How does HIV, syphilis, and lyme arthritis present with **
HIV: Seronegative, oligoarticular, non-destructive, lower extremity predominant arthritis
-Syphilis: symmetric polyarthritis involving knees/ankles > small joints of hands
-Lyme: migratory arthralgia → late asymmetric oligoarticular arthritis of large joints (knees)
