Monoarticular Arthritis Clinical Flashcards
1
Q
Most common causes of acute monoarticular arthritis (three)
A
crystals, trauma, infection
2
Q
infections in monoarticular arthritis
A
gonococcal, nongonoccal, lyme diseae, mycobacterial/viral/fungal
3
Q
inflammatory causes of monoarticular arthritis
A
RA, seronegative spondyloarthropathies, SLE, sarcoidosis, reactive arthritis
4
Q
hot or swollen joints usually means
A
infection
5
Q
constitutional symptoms (fever, weight loss, malaises) usually means
A
infection
6
Q
weakness in monoarticular arthritis usually means
A
compartment syndrome or acute myelopathy
7
Q
burning pain, numbness, paresthesia suggests _____ (3 things) in monoarticular arthritis
A
myelopathy, radiculopathy, neuropathy
8
Q
risk factors for septic arthritis
A
prosthetic hip or knee joint, skin infection, joint surgery, rheumatoid arthritis, age >80, DM
9
Q
symptoms of worse with immobility usually means
A
inflammatory arthritis (esp if lasting more than one hour –> RA or polymyalgia rheumatica)
10
Q
symptoms aggravated by motion and weight bearing and relieve by rest usually means
A
OA
11
Q
antecedent trauma can point towards this kind of diagnosis
A
fracture, meniscal tear, hemathrosis
12
Q
systemic complaints: chills, malaise, fever are more seen in
A
infectious (high grade fever more than low grade fever because low grade can be seen in crystals)
13
Q
GI or GU complaints, recent sexual exposure suggest
A
infectious portals or entry or seronegative spondyloarthropathy (reactive arthritis, psoriasis, IBD)
14
Q
recent travel to endemic regions suggests
A
infection (Lyme disease, mycobacerial and parasitic)
15
Q
synovitis symptoms are
A
soft tissue swelling, warmth over a joint, joint effusion
16
Q
reduced active range of motion with preserved passive range of motion suggests
A
soft tissue disorders - bursitis, tendinitis, or muscle injury
17
Q
both active and passive ROM decreased suggests
A
soft tissue contracture, synovitis, structural abnormality
18
Q
fever is seen in these types of rheumatic illnesses
A
infectious, posinfections, reactive, RA, Still’s, systemic rheumatic illness (SLE/vasculitis), crystal induced, cancer, sarcoidosis
19
Q
sudden onset of pain in seconds/minutes
A
fracture, internal derangment, trauma, loose body
20
Q
onset of pain over several hours or days
A
infection, crystals, inflammatory
21
Q
insidious onset of pain over days to weeks
A
indolent infection, OA, infiltrative, tumor
22
Q
previous acute attacks in any joint with spontaneous resolution
A
crystal depo disease, other inflammatory arthritic
23
Q
IVDA or immunosuppression
A
septic arthritis
24
Q
previous prolonged corticosteroid therapy
A
infection, AVN
25
coaguloapthy or anticoag use
hemarthrosis
26
urethritis, conjunctivitis, diarrhea, rash
reactive arthritsi
27
psoriatic patches or nail changes (pitting)
psoriatic arthritis
28
diuretic use, tophi, renal stones, alcoholic binges
gout
29
eye inflammation, low back pain
ankylosing spondylitis
30
young adulthood, migratory polyarthralgias, inflammation of the tendon sheaths of hands and feet, dermatitis
gonoccocal arthritis
31
hilar adenopathy, erythema nodosum
sarcoidosis
32
most common test in monoarticular arthritis
synovial fluid analysis - arthrocentesis; ATTEMPTED IN ALL PATIENTS WHO HAVE AN EFFUSION OR SIGNS SUGGESTING INFLAMMATION WITHIN THE JOINT
33
septic arthritis synovial fluid looks like:
>100,000 WBC with greater than 75% PMN, also should get a culture on preservative-free choclate agar plates, reduction in glucose and elevation in LDH are also consistent with bacterial infection
34
noninflammatory fluids look like:
fewer than 2000 WBC, less than 75% PMN
35
crystalline arthritis fluid looks like:
MSU in gout, intracellular crystal within in the PMN; calcium pyrophosphate crystals in pseudogout
36
bloody synovial fluid with no trauma you should order these tests
PT, PTT, platelet count, bleeding time
37
ESR and CRP indicated this kind of arthritis
inflammatory
38
ANA is sensitive for
SLE
39
RF is used for
RA but limited diagnostic value (esp in monoarthritis)
40
Anti-CCP used for
RA, more specific than RF
41
indications for synovial biopsy
refractory monoarthritis, suspicions of atypical infectious agent, intraarticular tumors; performed using arthroscope or Parker pearson technique
42
Bacterial arthritis risk factors
age >80*, DM, malignancy, immunosuprressive drugs, RA*, joint replacement/hardware*, high risk sexual behavior
*indicate increase likelihood of poor outcome
43
Bacterial arthritis onset, pain level, presents as, other sx
acute onset, severe pain, inability to weight bear, fever/chills/malaise
44
Bacterial arthritis PE
erythematous, swollen, warm, TTP, pain with AROM/PROM, splinter hemorrhages/ Janeway's lesions/Osler's nodes on hands and feet --> endocarditis may be present if these are present; other sources of infection: GU, respiratory, skin, GI
45
Bacterial arthritis imaging findings and what type of imaging used
effusion, soft tissue swelling, underlying arthritis (associated with poor outcome); MRI/CT/bone scan reserved for osteomyletits suspicion
46
Bacterial arthritis lab data
Joint fluid: culture, Gram stain, cell count, crystal eval; cell count exceed 50,000 (less with immunocompromised) with >75% PMN
47
MC pathogens in Bacterial arthritis and do you need a positive Gram to confirm?
staphylococci, streptococci, gram neg bacilli, mycobacteria, neisseria gonorrhea; absence of organisms on Gram's stain does no rule out bacterial arthrtitis (gonococcal)
48
if bacterial arthritis involves prosthetic joint you should
call an orthopedic consult
49
when do you start antibiotics for Bacterial arthritis and how?
preferred: diagnosis made before starting antibiotics BUT dont delay treatment if synovial fluid is hard to obtain --> admit to hospital for empiric broad coverage IV antibiotic therapy for gram-positive organisms
50
MRSA is considered in Bacterial arthritis when
there is a high risk patient or present in the community
51
orthopedics should be consulted immediate for this in Bacterial arthritis
open drainage of the join, but if not indicated then can use closed drainage of daily needle aspiration until all fluid gone
52
how long should parenteral antibiotics be continued after drainage completed in Bacterial arthritis
minimum of 2 weeks
53
how do you treat viral arthritis
self limited monoarthritis
54
lyme disease is caused by ____ in this region of the US
borrelia burgdorferi carried by deer tick Ixodes scapularis in the Northeast and central northern US
55
Lyme disease presents with these lesions
target lesions or erythema chronicum migrans (ECM), or monoarthritis of the knee (late presentation)
56
Lyme disease PE and imaging
erythematous swollen joint with pain on PROM and AROM
imaging: effusion but in chronic can show osteoporosis, loss of cartilage, periarticular erosions
57
Lyme disease synovial fluid
WBC 500 to 50,000; Lyme disease PCR because B. burgdorferi is rarely cultured
58
Lyme disease treatment
doxycycline twice a day but if contraindicated then amoxicillin three times a day for 28 days
59
patient that engage in high risk sexual behavior are at risk for this arthritis
gonococcal arthritis (N. gonorrhea is MC bacterial arthritis in sexually active young people from 18 to 24)
60
Gonococcal arthritis PE
Initial infection 1 day to 3 months prior, arthritis in UE (wrist/extensors), myalgia, arthralgias, fever, malaise, dermatitis
61
Gonococcal arthritis imaging
soft tissue swelling, effusion
62
Gonococcal arthritis labs
mostly based on Hx and PE because N. gonorrhea is difficult to culture
63
Gonococcal arthritis treatment
admitted to hosptial, IV ceftriaxone (if allergic in fluoroquinolone) then oral cefixime (if allergic in fluoroquinolone)
64
Gonococcal arthritis caused by chlamydia is treated with
azithrymycin
65
CPPD can be initial presentation of these underlying metabolic diseases
hyperparathyroidism, hemochromatosis, sarcoidosis, acromegaly
66
BCP crystals are associated with
long term hemodialysis
67
gout uric acid levels, male vs female, age of presentation, associated conditions, precipitating factors
Uric acid: >7mg/dl in men or 6 in women
Male to female: 7 to 1
Increases with increasing age
Conditions: lead intoxication, hematopoietic malignancy, renal impairment; DM, HTN, obesity, hypothyroid, hyperlipidemia
Precipitating: dietary indiscretions, diuretics, dehydration, discontinue hypouricemic therapy, trauma
68
gout presents as ___ pain of a ____ joint (most commonly the _____ joint)
acute onset of severe pain of a single joint (MTP but also seen in foot, ankle, knee, fingers, elbows, wrists)
69
gout PE of joint (acute and chronic)
erythematous and swollen, warm, painful, tophaceous deposits (longstanding), uric acid deposits on ear/elbow/achilles tendon and fingers/brusa/other joints
70
gout imaging
plain films: effusion for aspiration in acute, periarticular erosions in recurrent
71
gout synovial fluid
synovial fluid: uric acid crystals, needle-shaped that are strongly negatively birefringent as bright yellow needle shaped crystals; WBC 200 to 50,000 (can be higher), purulent, Gram stain and culture to rule out infection
72
acute treatment of gout (1st, 2nd, and 3rd line)
start at very first sign of attack for best results, NSAIDs are first line (max dose for 2 to 3 days), prednisone/colchicine for contraindicated NSAID (renal disease, heart failure, GI bleeds); prednisone is 2nd line; colchicine is third line at first sign of attack (GI side effects and contraindicated in renal insuff)
73
long term chronic gout treatment (for what kind of patients, goals of treatment, when to start tx)
long term prophylaxis for pt with recurrent gout attacks, uric acid kidney sotones, tophaceous gout
want to lower urate less than 6 gm
can't start until sx free of (NSAID prophylaxis can be given to prevent acute attack from starting urate lowering drug)
74
long term chronic gout treatment drug types and side effects
uricosurics (probenecid and sulfinpyrazone --> younger patients who underexcrete uric acid, SE: urolithaisis, acute gout flare) and xanthine oxidase inhibitors (allopurinol --> can be used in renal insuff, SE - hypersensitivity reaction)
75
CPPD presentation
similar to gout, disability of single joint, erythematous and swollen, TTP
76
MC joints in CPPD
ankles, knees, wrists, shoulders, MCP
77
CPPD imaging findings
Chondrocalcinosis - linear calcification or cartilage (esp in fibrocartilage) in the menisci, pubis, hips, discs, wrist
78
CPPD synovial fluid
rhomboid shaped calcium pyrophosphate dihydrate crystals weakly positively birefringent, culture and Gram to exclude infection
79
CPPD treatment
high dose NSAID, colchicine is not as effective, prednisone will relieve attack
80
BCP is also called and presents like
calcific periarthritis, tendoitis or bursitis
| presents like gout with deposits of BCP rupturing into soft tissue --> acute pain, swelling, erythema, warmth
81
BCP is MC in this joint
shoulder (Milwaukee shoulder syndrome is chronic)
82
BCP imaging
calcific deposits in supraspinatus tendon or subdeltoid bursa, degenerative changes of GH and AC joints
83
Joint fluid of BCP
serosanguinous or milky white fluid with mononuclear cell, WBC <1000, BCP crystals on electron microscopy
84
BCP treatment
NSAID or colchicine, joint aspiration, intraarticular steroid injection; surgery if pain is unremitting
85
Meniscal tears caused by
sudden deceleration, change in direction, or landing from jumping
86
Meniscal/ligament tears can present this inflammatory timeline and patient complaint
inflammatory response over several hours (if quick then can be hemarthrosis --> ACL TEAR)
pt feels knee giving out, locking/catching, unable to fully extend w/o pain
87
Meniscal/ligament tears PE (provocative test)
feel a clunk on full extension
McMurray's test positive - extends knee from flexed position while externally rotating the foot and palpating the knee medially (feels clunk); lateral meniscus - foot internally rotated during extension.
anterior drawer sign positive if ACL damage
posterior drawer sign positive if PCL damage
88
Meniscal/ligament tears imaging needed
plain radiography first for arthritis and loose bodies and then MRI/arthroscopy for meniscal tear
89
Meniscal/ligament tears treatment
refer to ortho surgeon (peripheral area can heal without intervention bc blood supply but in the inner will need arthroscopy)
90
occult fracture presents in these populations
young adult athletes, osteoporosis, osteomalacia, fibrous dysplasia
91
stress fractures present with trauma - true or false
false because repetitive muscular forces or physiologic forces in people with mineralization abnormalities
92
patietns that get stress fractures
track and field, dancers, military recruits, menstrual disturbances, eating disorders, metabolic conditions
93
stress fracture PE
hot, swollen, painful joint
94
stress fracture imaging and joint fluid
radiographs will usually be negative but MRI/bone scans can diagnose and joint fluid will be negative for crystals/organisms
95
what is the first step in treating stress fracture
find the underlying cause (DEXA, 25-OH vit D levels, CBC, chemistry, liver)
96
treatment of stress fracture
referral to ortho surgeon
97
what should patients with JIA do every 3 months
ophthalmologist for asymptomatic uveitis --> blindness
98
most common inflamma arthropathy with monoarthritis
reactive arthritis
99
reactive arthritis occurs after
diarrheal illness or GU infection
100
bacteria associated with reactive arthritis
Enteric: salmonella, higella, clostridium, vibrio, hyersinia. GU: chlamydia
101
typical patient with reactive arthritis
20 to 40 yoa, male or female, HLAB27 positive
102
MC joint in ReA
knee (also see UE, sacroiliacs, spine)
103
other symptoms of ReA
fatigue, morning stiffness, fevers, malaise
104
ReA PE
MC knee or other weight bearing, warm/tender/swollen with effusion, dactylitis (sausage fingers), ENTHESITIS, keratoderma blenorrhagicum, circinate balantitis, conjunctivitis
105
ReA imaging (acute and chronic)
soft tissue swelling/effusion, asymmetric sacroiliitis, later can present with reactive bone proliferation/fluffy periosteal reaction/erosions
106
ReA labs
ESR and CRP elevation, anemia, leukocytosis, inflammatory synovial (WBC 2000 to 50,000) with crystal and culture neg, RF and ANA neg
107
ReA treatment
resolution of sx in 3 to 6 months; chlamydia - azithromycin; therapeutic drainage; NSAIDs are mainstay daily; prednisone for more debilitating, HLA B27 and keratoderma blenorrhagicum refer to rheumatologist, ophthalmologist referral
