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Yr 4 - ACC > MSK: Gout & Septic Arthritis > Flashcards

MSK: Gout & Septic Arthritis Flashcards

1
Q

What is gout?

A

Gout is a type of crystal arthropathy associated with chronically high blood uric acid levels.

It is the most common form of inflammatory arthritis.

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2
Q

Pathophysiology of gout?

A

1) Chronically high uric acid (hyperuricaemia) levels due to purine breakdown.

2) Accumulation of monosodium urate (MSU) crystals in the joint

3) Inflammatory response

4) Repeated episodes of acute gout can lead to chronic gouty arthritis, characterised by tophi formation, joint damage, and chronic pain

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3
Q

How does gout typically present?

A

SINGLE acute, hot, swollen and painful joint.

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4
Q

What is the critical differential diagnosis for gout?

A

Septic arthritis

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5
Q

What are gouty tophi?

A

Subcutaneous uric acid deposits typically seen on the hands, elbows and ears.

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6
Q

What joint does the FIRST gout attack typically affect?

A

Metatarsal-phalangeal joint (MTP of the great toe)

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7
Q

What joints does gout typically affect?

A

1st attack: MTP of big toe

If chronic: peripheral joints including ankles, knees and fingers etc

N.B. It is uncommon for gout to affect more central joints such as hips.

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8
Q

How can the diagnosis of gout be confirmed?

A

Aspirate synovial fluid and view under polarising light microscopy.

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9
Q

Risk factors for gout?

A
  • Male (aged between 30-50)
  • FH
  • Obesity
  • High purine diet (e.g. meat, seafood)
  • Alcohol
  • Diuretics
  • CVS disease
  • Kidney disease
  • African American origin
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10
Q

What are purines broken down into?

A

Uric acid

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11
Q

How can renal disease contribute to gout?

A

Impaired renal excretion of uric acid can contribute to hyperuricaemia.

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12
Q

What medications can contribute to gout?

A

1) thiazide diuretics
2) aspirin at low dosease
3) certain anti-tuberculosis medications

Can all increase uric acid levels and precipitate gout.

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13
Q

What are the 3 most commonly affected joints by gout?

A

1) The base of the big toe – the metatarsophalangeal joint (MTP joint)

2) The base of the thumb – the carpometacarpal joint (CMC joint)

3) Wrist

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14
Q

Clinical features of gout?

A

Gout develops RAPIDLY:
- reaching max intensity within 24 hours
- resolves within 5-15 days
- 70% of first presentations involve the first MTP

Features of joint:
- intense pain: ‘stabbing’, prevent from sleeping
- erythema: red and warm to touch
- joint swelling & tenderness

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15
Q

What systemic symptoms may be present in gout?

A

1) Tophi (deposit of MSU crystals) e.g. joint, cartilage, feet, knees, wrists, ears, fingers, kidneys and sclerae.

2) Eye movement - MSU crystals deposited in cornea (very rare)

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16
Q

How is a diagnosis of gout made?

A

Diagnosing gout for the first time can be achieved primarily using clinical features and patient history.

Other investigations:

1) Synovial fluid aspiration

2) Serum uric acid levels (measure -6 weeks following the first presentation of suspected gout)

3) Screen for kidney & CVS disease

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17
Q

What does aspirated joint fluid show in gout?

A

Monosodium urate crystals: needle-shaped and negatively birefringent of polarised light.

There should be no bacterial growth.

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18
Q

Fine needle aspiration of the affected joint can be used to differentiate between gout and pseudogout.

Describe crystals seen in gout vs pseudogout:
a) birefringence
b) shape
c) crystal type

A

a)
gout –> negatively birefringent
pseudogout –> positively birefringent

b)
gout –> needle shaped
pseudogout –> rhomboidal

c)
gout –> monosodium urate
pseudogout –> calcium pyrophosphate

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19
Q

What is the gold standard investigation for the diagnosis of gout?

A

Fine-needle aspiration of the affected joint

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20
Q

Does the absence of hyperuricaemia exclude gout?

A

No

Hyperuricaemia is NOT diagnostic of gout however, increased levels do correlate with increased risk of developing gout.

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21
Q

What does an xray of a joint affected by gout show?

A

1) maintained joint space (no loss of joint space)

2) lytic lesions in the bone

3) punched out erosions

4) erosions can have sclerotic borders with overhanding edges

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22
Q

What can an US show in gout?

A

tophi present in chronic gout can be observed via ultrasound appearing hyperechoic (white appearance).

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23
Q

Medical management of ACUTE gout flares (1st, 2nd & 3rd line)?

A

1st line –> NSAIDs (co-prescribed with PPI)

2nd line –> Colchicine

3rd line –> Oral steroids

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24
Q

Who is colchicine used in in an acute gout attack?

A

Patients who are inappropriate for NSAIDs e.g. renal impairment or significant heart disease

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25
Q

What are 2 common side effects of colchicine?

A

Abdo symptoms & diarrhoea

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26
Q

Dangers of colchicine?

A

More severe side effect symptoms may indicate toxicity.

Colchicine is very dangerous in overdose and can cause multiple organ failure.

27
Q

1st & 2nd line for prophylaxis for gout?

A

1st –> Allopurinol
2nd –> Febuxostat

28
Q

What is the mechanism of allopurinol & febuxostate?

A

xanthine oxidase inhibitors, which lower the uric acid level

29
Q

Who is offered urate-lowering therapy (e.g. allopurinol)?

A

Offered to ALL patients after their FIRST attack of gout.

30
Q

Lifestyle modifications in gout?

A

1) reduce alcohol intake and avoid during an acute attack

2) lose weight if obese

3) avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products

31
Q

When is gout prophylaxis started after an attack?

A

1) Prophylaxis is not started until weeks after the first acute attack has resolved.

2) Once allopurinol or febuxostat is initiated, it is continued during an acute attack.

32
Q

What is septic arthritis?

A

An infection in a joint (medical emergency).

Can be caused by direct inoculation of the joint or by haematogenous spread of bacteria from another site.

33
Q

Where can infection in septic arthritis occur?

A

1) native joint (original joint)

2) prosthetic joint replacement

34
Q

What measures are taken to try prevent septic arthritis in a prosthetic joint replacement?

A

perioperative prophylactic antibiotics

35
Q

When is septic arthritis in a prosthetic joint replacement more likely to occur?

A

It is more likely to occur in revision surgery than in the initial joint replacement.

36
Q

Presentation of septic arthritis?

A

Rapid onset of:

1) hot, red, swollen & painful joint

2) stiffness & reduced range of movement

3) systemic symptoms e.g. fever (40-60%) , lethargy, sepsis

Usually only a single joint will be affected (80%) BUT this may not be the case if the infection is disseminated, such as in gonococcal infection.

37
Q

What is the most common causative organism in septic arthritis?

A

Staph. aureus

38
Q

Give 5 bacteria that cuse septic arthritis

A

1) Staph. aureus

2) Neisseria gonorrhoea (gonococcus): in sexually active individuals

3) Group A strep (most commonly Strep. pyogenes)

4) Haemophilus influenza

5) E. coli

39
Q

Who is gonococcal septic arthritis most common in?

A

Sexually active individuals.

In a young patient presenting with a single acutely swollen joint, consider gonococcal septic arthritis until proven otherwise.

40
Q

What would a gram stain reveal in gonococcal septic arthritis?

A

a gram-negative diplococcus.

41
Q

In a patient presenting with pain & tenderness in joint as well as urinary/genital/eye symptoms, what should you consider?

A

reactive arthritis

42
Q

What are some risk factors for septic arthritis?

A

1) Rheumatoid arthritis & SLE (joints vulnerable as immunity compromised)

2) Prosthetic joints

3) Invasive joint procedures e.g. steroid injectinos, arthroscopy

4) IV drug use

5) Diabetes mellitus

6) Immunosuppression

7) Chronic skin infections

43
Q

When septic arthritis is caused by haematogenous spread it may be a result of:

a) Bacterial migration from a distant site

b) Disseminated infection

Give examples for both

A

a) abscesses & wounds, septicaemia

b) gonorrhoea

44
Q

When septic arthritis is caused by direct inoculation it may be a result of:

a) iatrogenic procedures

b) traumatic injuries

Give some examples for both

A

a)
- Joint injections (e.g. steroid injections)
- Joint arthrocentesis
- Athroscopy

b)
- Infected wounds around the joint
- Penetrating injuries from foreign objects

45
Q

Diagnosis of septic arthritis can be complicated in elderly patients, who commonly have atypical presentations.

How may the elderly present?

A

1) Elderly patients tend to present as afebrile and systemically well.

2) WCC may be normal in 50%.

3) More likely to present with non-specific symptoms such as worsening cognitive impairment, confusion and more frequent falls.

46
Q

What is the most common joint affected by septic arthitis?

A

Knee

47
Q

Give 5 most commonly affected joints by septic arthritis

A

1) knee
2) hips
3) wrist
4) shoulders
5) ankle

48
Q

Infections of axial joints such as the sternoclavicular or sacroiliac joints are rare, but present more frequently in patients with a history of what?

A

IV drug use

49
Q

What are the 4 key differentials of a single warm swollen joint?

A

1) gout

2) pseudogout

3) reactive arthritis

4) haemarthrosis

50
Q

What is reactive arthritis usually triggered by?

A

Urethritis or gastroenteritis

51
Q

what is haemoarthrosis?

A

bleeding into the joint, usually after trauma

52
Q

Investigations in septic arthritis?

A

1) Joint arthrocentesis for synovial fluid analysis, grain staining & culture PRIOR to beginning empirical antibiotic therapy.

2) synovial fluid WCC: often raised in cases of septic arthritis

3) Other useful tests include:
- Blood cultures
- CRP
- ESR

53
Q

Synovial fluid appearance in septic arthritis?

A

often yellow/green and turbid on aspiration (compared to uninfected fluid which is clear and usually colourless).

54
Q

What criteria is used for the diagnosis of septic arthritis?

A

Kocher criteria

55
Q

What is the Kosher criteria?

A

1) fever >38.5 degrees

2) non-weight bearing

3) raised ESR

4) raised WCC

56
Q

Is joint aspiration performed before or after starting antibiotics in septic arthritis?

A

Before:

The sample is sent for gram staining, crystal microscopy, culture and antibiotic sensitivities.

The gram stain result is usually available quickly and may give a clue about the organism. Culture and antibiotic sensitivities take longer.

Empirical IV antibiotics should be given until the sensitivities are known

57
Q

Management steps in septic arthritis?

A

1) rule out systemic bacteraemia: would warrant sepsis 6

2) admit for IV antibiotics and joint drainage

58
Q

How long are Abx given for in septic arthritis?

A

4-6 weeks (IV then oral)

59
Q

What is typical 1st line Abx given in septic arthritis (or until sensitivities are known)?

A

Flucloxacillin

Other options:
- Clindamycin (penicillin allergy)
- Vancomycin (if MRSA is suspected)

60
Q

Which Abx is typically used for the treatment of Neisseria gonorrhoea in septic arthritis?

A

Ceftriaxone

61
Q

3 most common complications if septic arthritis?

A

1) joint damage

2) osteomyelitis

3) sepsis

62
Q

if osteomyelitis is suspected, what investigation should be done?

A

MRI

63
Q
A

Yr 4 - ACC (73 decks)

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