LECTURE 10 Flashcards
What are the treatment goals for patients with arthritis?
- pain relief
- joint function maintenance or restoration
- prevention of joint damage
What do patients with acute monoarthritis usually present with
Patients usually present with a problem restricted to one anatomic region or joint e.g. shoulder or knee pain
What are some DDx for acute monoarthritis in adults
- OA - acute exacerbation
- Gout - especially the great toe often affects an already arthritic joint
- Septic arthritis
- Psoriatic arthropathy
- RA - acute attack
- Pseudogout - especially the knee; may affect an already arthritic joint
- Viral infection - especially rubella & parvovirus
- Reiter’s disease - typically in a young man, affecting the lower limb
What are some DDx for acute monoarthritis in children
- Septic arthritis
- Reactive arthritis
- Hemarthrosis
- Traumatic joint effusion
- Bone tumours and acute leukemia
- Juvenile arthritis systemic onset
How quickly do acute monoarthridities usually resolve?
2-6 weeks
What are some red flags that must be identified when assessing the seriousness of acute monoarthritis?
- severe pain
- febrile patients with systemic ssx
- patients with ssx of multiple organ involvement
- a history of associated significant trauma
In the diagnosis of acute monoarthridities, which 2 conditions are important to rule out first and why?
- Gout
- Septic arthritis
Both conditions can cause early and severe joint damage.
What is the gout diagnostic rule? Why was it developed? How do we interpret the scores??
Definition: The Gout Diagnostic Rule is a clinical predictive tool regarding how likely it is that a patient has gout
Reason for GDR development: To avoid joint aspiration and its attendant dangers (painful & risks infection)
- A high score implies a high likelihood of gout
- A low score implies that the dx is less certain, hence aspiration is required
In accordance with the GDR, what should patients with a score of greater than 8 do?
They should receive therapy for gout
In accordance with the GDR, what should patients with a score of 4-8 do?
They should undergo joint aspiration for:
MSU crystals
Infection
What needs to be considered if joint aspiration indicates non-inflammatory joint fluid in a clinically inflamed joint?
Nearby bone pathology e.g. stress fracture, osteomyelitis, avascular necrosis
Acute inflammation of periarticular structures e.g. gouty inflammation of tendon sheaths or bursae, septic bursitis
Subcutaneous inflammation or cellulitis e.g. ankle arthritis in erythema nodosum
What are the treatments for septic arthritis?
- IV Antibiotics
- Drainage of the infected synovial fluid
- Joint immobilisation for pain control
What manifestations of severe polyarthritis require hospitalisation?
- Ssx of significant, associated internal organ involvement
- Ssx of bacteraemia eg vesiculopustular skin lesions, Roth spots, rigors, splinter haemorrhages
- Systemic vasculitis
- Severe pain
- Severe systemic ssx
- Purulent synovial fluid in one or more joints
- Immunosuppression
In someone with acute polyarthritis, what should we do it they
a) do show ssx of septic arthritis
b) dont show signs of arthritis
a)
- obtain cultures e.g. blood, joint, cervix, urethra and pharynx
- IV Antibiotics and repeated joint drainage
b)
- conservative treatment
- repeated clinical examination for ssx of bacteraemia (fever, DIC etc)
What are initial treatment modalities for patients with acute polyarthritis?
SYSTEMIC ANTIBIOTICS
• for septic polyarthritis or bacteraemia with joint involvement (e.g. disseminated gonococcemia)
• Relevant cultures must be taken first
ANALGESICS
It is not usually possible to make an immediate definitive diagnosis in patients presenting with acute polyarthritis. The initial use of simple analgesics allows anti-inflammatory therapy to be delayed. This strategy increases the chance that further clinical ssx of the disease will occur, thereby aiding in the dx.
- Analgesics without anti-inflammatory properties are used initially in patients with mild arthritides e.g. acute rheumatic fever, viral arthritis
- Analgesics in patients with crystalline synovitis in whom NSAIDs or corticosteroids are C/I
ANTI-INFLAMMATORY DRUGS
• High-dose aspirin therapy can be used for acute rheumatic fever
• High-dose non-salicylate NSAID therapy is used to treat crystalline synovitis, acute viral arthritis, & RA, SLE & other connective-tissue disorders
Corticosteroids: Mainly used when: • High-dose NSAID therapy has failed • NSAID tx is C/I e.g. - renal insufficiency - active GI bleeding etc • High dose steroids are used with: - severe systemic ssx e.g. Still’s disease - concomitant major organ involvement - sx of systemic vasculitis e.g. acute SLE
Disease-specific treatments e.g. DMARDs* in RA
