List I - Act Core Conditions

Question 1

What is septic arthritis?

Answer 1

• Refers to the infection of a joint

* Requires a high index of suspicion and can affect both native and prosthetic joints

Question 2

What are the risk factors for septic arthritis?

Answer 2

• Age >80 yrs
• Any pre-existing joint disease e.g. RA
• Diabetes mellitus
• Chronic renal failure
  Hip or knee joint prosthesis
• IV drug use

Question 3

What are the main causative organisms that can lead to septic arthritis?

Answer 3

• Staphylococcus aureus
• Streptococcus
• Gonorrhoea (in sexually active patients)
• Salmonella (especially in sickle cell)
• MRSA
• Staphylococcus epidermis

Question 4

How does septic arthritis happen?

Answer 4

• Bacteria will seed to the joint from:
• Bacteraemia e.g. recent cellulitis, UTI, chest infection
• Direct inoculation
• Spreading from adjacent osteomyelitis

Question 5

What are the presenting features of septic arthritis?

Answer 5

• Single swollen joint causing severe pain (although absence of pain does not rule it out)
• Examination will reveal a red, hot swollen joint causing pain on active and passive movements
• Effusion may be present
• Often the joint is rigid and the patient will not tolerate any passive movement at all, and will be unable to weight bear
• Symptoms are more florid and obvious in native joint injection, in prosthetic joint infections, the features can be more subtle

Question 6

What are the differential diagnoses for septic arthritis?

Answer 6

• Flare of osteoarthritis
• Haemarthrosis
• Crystal arthropathies (gout and pseudogout)
• Rheumatoid arthritis and other inflammatory arthropathies
• Reactive arthritis
• Lyme disease (infection with Borrella burgdoferi)

Question 7

What investigations need to be done for septic arthritis?

Answer 7

• FBC
• CRP
• ESR
• Urate levels
• Blood cultures (at least two separate samples) especially those with evidence of sepsis
• Joint aspiration is essential and needs to be done before antibiotics are given (for patients with a prosthetic joint, this should be done in the operating room
• Joint fluid analysis should also be sent for Gram stain, leucocyte count, polarising microscopy and fluid culture
• Cell count with WBC > 50, 000 is considered diagnostic for septic arthritis, however lower counts may still indicate infection
• Prosthetic joint with WBC >1100 is considered septic

Question 8

Which imaging is useful in the management and investigation of septic arthritis?

Answer 8

• Plain radiograph - may be normal in early stages but may progress to demonstrate capsule and soft tissue swelling, fat pad shift, or joint space widening
• USS can be useful to guide joint aspiration and for drainage particularly at the hip
• CT/MRI imaging is sensitive for assessing joint damage, therefore typically used if there is uncertainty in the diagnosis

Question 9

What are the risk factors for septic arthritis?

Answer 9

• Age >80 years
• Diabetes
• Rheumatoid arthritis
• Cirrhosis
• HIV
• History of crystal arthropathy
• Endocarditis or recent bacteraemia
• IVDU
• Recent joint surgery

Question 10

What is the definitive treatment and management for septic arthritis?

Answer 10

Considered an orthopaedic emergency

• IV antibiotics, operative irrigation and drainage of the joint
• Initiate empirical therapy prior to definitive cultures based on patient age and or risk factors (usually flucloxacillin or clindamycin if penicillin allergic)
• Transition to organism specific antibiotic therapy based once culture sensitivities are obtained
• Treatment can be monitored by following serum WBC, ESR and CRP levels during treatment

Question 11

How is irrigation and drainage of the joint performed in a patient with septic arthritis?

Answer 11

• Approach - can be performed open or arthroscopically (joint dependent)
• Irrigation - remove all purulent fluid and irrigate joint
• Debridement - synovectomy can be performed as needed
• Cultures - obtain joint fluid and tissue for culture

Question 12

Which location is most common for septic arthritis (in adults)?

Answer 12

• Knee

Question 13

Which criteria are used for the diagnosis of septic arthritis?

Answer 13

• Kocher criteria - used for diagnosis
• Fever >38.5 c
• Non-weight bearing
• Raised ESR
• Raised WCC

Paediatrics only

Question 14

What is temporal arteritis?

Answer 14

• AKA giant cell arteritis
• Systemic granulomatous arteritis that usually affects large and medium sized vessels
• Females > Males
• Temporal arteritis is commonest type
• Granulomatous lesions may be seen on biopsy (although 50% are normal)

Question 15

How common is temporal arteritis?

Answer 15

• 20/100,000 in the UK per year
• Rare before the age of 50 years
• Highest incidence aged 70-79 years
• x 7 more common in white people than in black people and it is particularly common in Scandinavian people, with annual incidence of approximately 30 / 100, 000 people in Norway
• 2-3 times more common in women than in men

Question 16

What are the complications of temporal arteritis?

Answer 16

Complications are largely prevented by treatment with adequate doses of corticosteroids, however may include:

• Vision loss - including amaurosis fugax and diplopia
• Large artery complications including aortic aneurysm, aortic dissection, large artery stenosis, and aortic regurgitation
• Cardiovascular disease - such as MI, heart failure, stroke and peripheral vascular arterial disease
• Others complications include:
• Peripheral neuropathy
• Depression
• Confusion and encephalopathy
• Deafness
• Complications of long term corticosteroid therapy - weight gain, bruising, osteoporosis and fractures and diabetes

Question 17

What is the prognosis of temporal arteritis?

Answer 17

• Relapses are common and can occur if corticosteroid treatment is reduced or withdrawn too quickly
• 30-50% of people have spontaneous exacerbations of disease, especially during the first 2 years (independent of the corticosteroid regime)

Question 18

When should a diagnosis of temporal arteritis be suspected?

Answer 18

• If the person is aged over 50 years or older with at least one of the following:
• New onset of localised headache that is usually unilateral, in the temporal area, but is occasionally diffuse or bilateral
• Temporal artery abnormality, such as tenderness, thickening, or nodularity (present in 45-75% of people)
• Occasionally the overlying skin is red, and pulsation may be reduced or absent

Question 19

What other symptoms in a patient would support a diagnosis of temporal arteritis?

Answer 19

• Systemic features
• Fever (usually low grade), fatigue, anorexia, weight loss and depression
• Features of polymyalgia rheumatica
• Bilateral upper arm stiffness, aching, and tenderness and pelvic girdle pain (present in around 40%)
• Scalp tenderness in about 50% of people especially over the temporal and occipital arteries
• Intermittent jaw claudication - occurs in nearly half of people with GCA, causing pain in the jaw muscles while eating
• Visual disturbances - permanent or complete loss of vision in one or both eyes occurs in up to 20% of people and is a common early symptom
• Typically it is described as a feeling of a shade covering one eye which can progress to total blindness - the eye is not painful
• Double visions, visual field defects, changes to colour vision may occur, on fundoscopy there may be pallor and oedema of the optic disc and cotton wool patches and less uncommonly small haemorrhages in the retina - untreated the second eye is likely to become affected within 1-2 weeks (although it can be affected within 24 hours)
• Neurological features - occur in about 30% of people and include
• Mono neuropathy or polyneuropathy of arms or legs
• Transient ischaemic attack or stroke in the distribution of the carotid or vertebrobasilar arteries
• Upper cranial nerve palsies
• Peripheral artheritis and distal swelling with pitting oedema - occurs in about 25% of people - swelling is most prominent in the dorsum of the hands and wrists, the ankles and the tops of the feet
• Respiratory tract symptoms - cough, sore throat and hoarseness (present in about 10% of people)

Question 20

What are the differential diagnoses for temporal arteritis?

Answer 20

• Herpes zoster
• Cluster headache or migraine
• Acute angle closure glaucoma
• Retinal transient ischaemic attacks and embolic visual deficits
• Temporomandibular joint pain, sinus disease and ear problems
• Cervical spondylosis or other upper cervical spine disease
• Ankylosing spondylitis
• Myeloma
• Serious intracranial pathology
• Connective tissue disease

Question 21

What is the initial management for someone with suspected temporal arteritis?

Answer 21

• Temporal arteritis is a medical emergency
• Urgently refer all people with suspected temporal arteritis (GCA) using a local GCA pathway for specialist evaluation (usually by a rheumatologist) on the same working day if possible and in all cases within 3 working days
• If there is visual loss (transient or permanent) - arrange an urgent (same day) assessment by an ophthalmologist
• Immediately treat people with suspected GCA with oral prednisolone
• People with visual symptoms - 60-100 mg as a one off dose (they should be seen by an ophthalmologist the same day)
• People WITHOUT visual symptoms - 40-60 mg daily (minimum 0.75 mg/kg)
• Document the persons symptoms, signs and level of function both before and after the onset of the condition to use as a baseline to compare response to treatment
• Assess the persons response after

Question 22

Which tests and investigations should be done for a person with suspected temporal arteritis to help establish a diagnosis?

Answer 22

• Liver function tests
• 1/3 have mild elevated LFTs
• Full blood count
• Normochromic normocytic anaemia and an elevated platelet count are common
• C-reactive protein
• CRP level is typically elevated and may be a more sensitive indicator of inflammation in some people with GCA
• ESR - often greater than 50 mm/hour

Question 23

What advice should be given to someone with suspected temporal arteritis (GCA)?

Answer 23

• Advise the person:
• Seek urgent (same day) medical attention if they develop any visual disturbances (such as vision loss, double vision, or visual field defects)
• That the dose of prednisolone is normally reduced very slowly over several months - treatment is often required for 1-2 years but people may require low doses of corticosteroids for several years
• Relapses are common whilst the dose is being reduced
• Frequent follow up visits are required to monitor for relapses and adverse effects of corticosteroids

Question 24

How should diagnosis of temporal arteritis be made in secondary care?

Answer 24

• All people with suspected temporal arteritis should have at least one of the following confirmatory diagnostic tests:
• Temporal and axillary artery USS or
• Temporal artery biopsy

Question 25

What is the ongoing management of a person with confirmed temporal arteritis?

Answer 25

• Shared care is recommended
• Reduce the dose of prednisolone to zero over 12-18 months providing there are no signs and symptoms or laboratory markers of inflammation
• Relapses occur when corticosteroids are reduced too rapidly particularly in the first 12 months
• Ensure the person is provided with a blue steroid care - discuss the potential adverse effects of corticosteroids
• Consider the need for a proton pump inhibitor for gastro-protection in people at high risk of gastrointestinal bleeding or dyspepsia
• Specialists may consider methotrexate or tocilizumab in combination with a glucocorticoid taper in people at high risk of glucocorticoid toxicity

Question 26

What is a suggested reducing dose of prednisolone for a person being treated for temporal arteritis?

Answer 26

• Continue high dose prednisolone 40-60 mg daily until the person has been in remission for 4-8 weeks then
• Reduce the dose by 10 mg every 2 weeks to 20 mg daily, then
• Reduce the dose by 2.5 mg every 2-4 weeks to 10 mg daily, then
• Reduce the dose by 1 mg every 1-2 months, provided there is no relapse

Question 27

What monitoring is advised for a person being treated for temporal arteritis?

Answer 27

• At least every 2–8 weeks for the first 6 months following diagnosis.
• Evaluate people for hypertension and hyperglycaemia within the first 2 weeks of starting prednisolone.
• Every 12 weeks during the second 6 months.
• Every 12–24 weeks during the second year.
• Additional appointments may be required in cases of relapse or as prednisolone is tapered.

At all review appointments:

• Take a full history.
• Conduct a targeted physical examination.
• Monitor full blood count, erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP).
• Ask about the adverse effects of corticosteroids, such as weight gain, dyspepsia, muscle weakness, skin thinning, and easy bruising
• Consider monitoring urea and electrolytes if there is a clinical indication.
• Assess and manage osteoporotic fracture risk

Question 28

When should relapse of temporal arteritis be suspected?

Answer 28

• Ischaemic complications
• Unexplained fever (more than 38c for more than 1 week with no obvious cause)
• Symptoms of poly myalgia rheumatica, particularly if there is a rise in ESR or CRP

Question 29

How should a relapse of temporal arteritis be managed?

Answer 29

• New onset of visual disturbance:
• Refer for urgent (same day) assessment by an opthalmologist
• Increase the daily dose of prednisolone to 60 mg
• If the person develops jaw or tongue claudication:
• Consider high dose oral prednisolone (40-60 mg)
• Seek specialist advice
• If the person develops headaches without jaw claudication or develops only features of polymyalgia rheumatica (shoulder or pelvic girdle pain, morning stiffness):
• Increase prednisolone to the previous higher dose
• Seek specialist advice

Question 30

What does spinal cord compression refer to?

Answer 30

• Oncological emergency and affects up to 5% of cancer patients
• Extra-dural compression accounts for the majority of cases, usually due to vertebral body metastases
• More common with lung, breast and prostate cancer

Question 31

What are the presenting features of MSCC?

Answer 31

• Back pain - earliest and most common symptom - may be worse on lying down and coughing
• Lower limb weakness
• Sensory changes - sensory loss and numbness
• Neurological signs depend on the level of the lesion
• Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level
• Lesions below L1 usually cause lower motor neuron signs in the legs and peri-anal numbness
• Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion

Question 32

What is the management of MSCC?

Answer 32

• High dose IM dexamethasone 16 mg as soon as possible after assessment - monitor blood glucose
• PPI
• Insert catheter
• Urgent MRI spine
• Surgery or targeted radiotherapy

Question 33

Which factors influence the plan for definitive treatment for MSCC?

Answer 33

• Patients should not be denied either surgery or radiotherapy on the basis of age alone
• Use recognised prognostic factors such as the revised Tokuhashi scoring system and ASA grading
• Only consider major surgical treatment for patients expected to survive longer than 3 months