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MSK Exam 2 > MSK Infections > Flashcards

MSK Infections Flashcards

1
Q

Septic Arthritis (aka- infectious arthritis) etiology

A
  • Direct inoculation, contiguous spread from infected tissue, or bloodstream (most common)
  • Bacteremia likely to go to a joint with pre-existing arthritis
  • If you have more than one of the prior slide risk factors, your risk
    increases even more (ie-acute joint pain with prosthetic joint and skin
    infection)
  • > 50% cases by hematogenous spread
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2
Q

Predisposing factors for septic arthritis

A
  • Age >80 years old
  • DM
  • RA - other irritated joints (check if they are immunosuppressed, e.g. Humira)
  • Prosthetic joint
  • Recent joint surgery
  • Skin infection
  • IV drug abuse
  • Alcoholism
  • Prior intra-articular corticosteroid injection
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3
Q

Nongonococcal arthritis is _____ in 80-90% cases

A

monoarticular

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4
Q

Infectious monoarthritis typically involves:

A
  • knee (40-50%)
  • hip (13-20%)
  • shoulder (10-15%)
  • wrist (5-8%)
  • ankle (6-8%)
  • elbow (3-7%)
  • small joints of hand and foot (5%)
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5
Q

Pathogenic causes of septic arthritis

A
  • Gonorrhea caused
  • Lyme disease
  • TB
  • Fungal
  • Hepatitis
  • Other Viral
  • Other Bacterial
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6
Q

_____ is the most common source of acute bacterial arthritis in adults and children >2
years, and results in rapid joint destruction

A

Staph Aureus

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7
Q

Clinical Presentation of Septic Arthritis

A
  • Abrupt onset pain, warmth and swelling in joint - classic!
  • Fever, Pain and ROM impaired is classic Triad
  • Joint effusion, tender to palpation, marked restriction to passive and active ROM
  • Patients with one joint of pain should consider this
  • Presents with fever in 60-80%
    cases; usually mild
  • Can have chills, cough, GI sx, GU infection seen as cause
  • Bursitis (olecranon and prepatellar mostly) is typically the 1st sign of septic arthritis in
    patients with RA
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8
Q

Fever, Pain and ROM impaired is classic Triad for _____

A

Septic arthritis

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9
Q

Septic arthritis signs in patients with RA

A
  • Bursitis (olecranon and prepatellar mostly) is typically the 1st sign of septic arthritis in
    patients with RA.
    Slower less painful onset usually with RA and
    immunocompromised patients
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10
Q

Clinical Presentation - PE for Septic arthritis

A
  • Decide whether it is articular or periarticular
  • warmth
  • swelling
  • tenderness of involved joint
  • Considerable discomfort with any ROM
  • Similar Sx to gout
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11
Q

T/F Cellulitis and bursitis cause joint effusions

A

F

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12
Q

Septic olecranon bursitis distinguished from
elbow septic arthritis by _____

A

absence of joint pain on extension

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13
Q

Diagnostic Evaluation for septic arthritis

A
  • CBC (with WBC count and diff)
  • ESR
  • CRP (used to specifically show response to treatment)
  • Joint aspiration (WBC >50,000/mm3 is indicative)
  • Blood cultures
  • Other: Radiographs, MRI, US, Tc-99m scan, etc
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14
Q

Definitive dx of septic arthritis requires:

A
  • Gram stain: +Gram stain is Diagnostic
    for Septic arthritis
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15
Q

_______- most common cause of monoarthritis in native joint (60-70%)

A

S aureus

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16
Q

Importance of radiographs in Septic arthritis

A
  • Used mostly to prove no osteomyelitis, shows tissue swelling and can
    show gas formation from E-coli or anaerobic organisms.
  • Can show bone destruction or formation from infection, joint space
    narrowing or osteoporosis
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17
Q

Benefits of CT in septic arthritis

A
  • Shows joints that are harder to palpate- hip, shoulder, SI, sternoclavicular
  • Early bone erosions seen and soft tissue extension and effusions
  • Helps with arthrocentesis of above joints
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18
Q

MRI use in septic arthritis diagnosis

A
  • Soft tissue edema and abscesses
  • Help in detecting septic sacroiliitis
  • Early bone erosions
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19
Q

Scintigraphy use for septic arthritis

A
  • Uses labeled WBC’s, technetium colloid, or other to highlight areas
  • Many false positives, notes soft tissue infections
  • Cannot differentiate septic from aseptic joint inflammation
  • False +’s with recent surgery or fracture
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20
Q

Gallium study

A
  • Older test takes 1-3 days,
    which renders it low
    usefulness for septic arthritis. May use for
    osteomyelitis
  • Accumulates in areas where
    extravasation of serum
    proteins and leukocytes are
  • Distinguishes infection from
    mechanical damage
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21
Q

Evidence based treatments for septic arthritis

A
  • Drainage: Early arthroscopic lavage, debridement, and drain insertion are replacing
    daily joint aspirations
  • Drain completed to decrease inflammatory cells, decreases joint damage
  • Open surgical drainage at times required
  • Antibiotics: After diagnostic aspiration, give IV abx immediately!
  • Mobilization
  • Immobilize after treatment initially
  • passive ROM to prevent adhesions and clear exudates
  • Passive is followed by active strengthening to prevent contractures
22
Q

Complications of septic arthritis

A
  • Osteomyelitis
  • Persistent/recurrent infections
  • Decreased joint mobility
  • Ankylosis
  • Persistent pain
  • Sepsis
  • Death
  • Contractures
23
Q

Gonococcal Arthritis

A

Also a common form of septic arthritis in the US…
Rarely associated with Joint destruction

23
Q

Gonococcal arthritis incidence

A
  • Most common overall in younger/sexually active individuals
  • Usually in healthy individuals
  • 2-3Xs more common in women, especially during menses and pregnancy
  • Rare after age 40
  • MSM common
  • pharyngitis and proctitis leads to dissemination
24
Q

Gonococcal Arthritis clinical presentations

A
  • 1 day-3 months migratory polyarthralgias
  • Typically asymmetric an usually upper extremities vs lower
  • Characteristic asymptomatic small necrotic pustules distributed over the extremities
  • DAYS TO WEEKS LATER, can locate into one or many joints, resulting in septic arthritis
25
Q

Gonococcal Arthritis diagnosis

A
  • Urethral, throat, cervical, and rectal
    cultures should be done in ALL
    patients
  • Blood leukocytes, synovial fluid WBC
    count and gram stain are not great
    detectors of Gonococcal arthritis
  • Radiographs usually normal
26
Q

Gonococcal arthritis treatment

A
  • Admit to the hospital
  • Test for other STIs (chlamydia, HIV, Syphilis, Mycoplasma Genitalium, HSV)
  • Confirm Diagnosis
  • Exclude endocarditis
  • Start Treatment
  • Ceftriaxone 1g IV/IM q24hrs plus single dosage of Azithromycin 1g PO
  • *** New Ceftriaxone 500mg IM (or 1 mg depending on size), Doxy 100mg BID
    x7days
  • Joint aspiration required if purulent fluid
27
Q

Hepatitis B Arthritis incidence

A
  • Self limited polyarthritis is common and usually prior to jaundice
  • 25% of patients with HBV develop joint symptoms
  • Most infections resolve, but less than 5% in healthy adults stay
    around (HBsAg, anti-HBc antibodies, HBeAg, anti-HBs)
28
Q

Pathogenesis of Hep B arthritis

A
  • Prodromal phase 1-6 months, symptoms fever,
    NV, anorexia, RUQ pain, malaise, etc; icterus follows
  • Viral replication continues and results are variable
  • Circulating immune complexes causing rash and polyarthralgias
29
Q

Hepatitis B Arthritis presentation

A
  • Rash and joint pain present at the same time
    usually
  • Urticarial rash and Maculopapular rash on
    lower extremities are typical
  • Resembles serum sickness
  • Joint symptoms can be symmetrical, migratory
    or additive- usually in the prodrome stage
  • Joint pain improves with the onset of jaundice
30
Q

Hepatitis B Arthritis Diagnosis

A
  • CMP shows elevated transaminase levels
  • Chronic Hepatitis panel: Hep B surface antigen positive/reactive (HbsAg +)
  • low complement levels in active arthritis
  • Increased circulating immune complexes
  • Joint fluid may show inflammatory changes, but not much else
31
Q

PREVENTION of Hep B Arthritis

A

Education on how it is transmitted (blood and sexual)

32
Q

Treatment for Hep B Arthritis

A
  • PREVENTION
  • Education on how it is transmitted (blood and sexual)
  • Vaccination has greatly decreased Hep B associated polyarthritis
  • Treatment is limited to symptomatic supportive care
  • Joint disease is self limited
33
Q

Hepatitis C Arthritis Incidence

A
  • Common cause of persistent viral infection
  • Arthritis noted in 2-20% of HCV patients
  • Chronic polyarthralgia in up to 20% of cases
  • Chronic polyarthritis in 3-5% cases
  • Frequently misdiagnosed as RA
  • Can have Hep C polyarthralgias and RA at the same time
34
Q

Hepatitis C Arthritis pathogenesis

A
  • Antibody response to viral products
  • This forms circulating immune complexes
  • Immune complexes deposit into tissues producing clinical
    manifestations (arthritis, glomerulonephritis, vasculitis, etc)
  • Mixed cryoglobulinemia
35
Q

Hep C arthritis clinical Presentations- extrahepatic

A
  • Lichen planus
  • necrolytic acral erythema
  • leukocytoclastic vasculitis
  • Sjogren’s
  • Arthritis noted in 2-20% of patients
  • SLE
  • RA
  • Polyarteritis nodosa
  • Antiphospholipid syndrome
36
Q

Hepatitis C Arthritis diagnostic evaluation

A
  • X-rays
  • RA - causes objective arthritis (not just arthralgias) and can be erosive
  • Hep C associated arthritis is non-erosive
  • Chronic Hepatitis panel: Hepatitis B Core Antibody Total, Hepatitis B Surface Antigen, Hepatitis B Surface Antibody, Hepatitis C Antibody (+)
37
Q

Evidence Based Treatment Options in
addition to treatment directed
against Hepatitis C Virus:

A
  • NSAIDS and hydroxychloroquine may
    be helpful
  • TNF-a inhibitors are relatively safe to
    use in RA like disorders
  • AVOID glucocorticoids
  • Antiviral Treatment mixed with
    biologics is the most effective
    treatment potentially***
38
Q

HIV Arthritis pathogenesis

A
  • Issues from the disease and from the medications used
  • Painful articular syndrome- lasts <24 hours
  • HIV associated arthritis- self limited and lasts <6 weeks
  • Reactive Arthritis- (primary for spondyloarthritis seen in HIV patients)
  • HLA-B27 antigen is usually positive in 70%
  • Septic Arthritis - Similar bacteria to non HIV patients with some opportunistic infections
  • Psoriatic arthritis - most affected are feet and ankles
  • Diffuse Infiltrative Lymphocytosis Syndrome - resembles Sjogren’s… Parotid enlargement
  • New onset SLE and RA (Rare)
  • Vasculitis- Polyarteritis nodosa commonly
    reported and all vessel sizes are seen
  • Immune reconstitution inflammatory
    syndromes- (IRIS)
39
Q

HIV Arthritis clinic presentation

A
  • Most common sign is arthralgias and arthritis
  • HIV painful articular syndrome- oligoarticular/asymmetric pattern that resolves in 24 hours
  • Joint exam is WNL
  • HIV associated arthritis
  • Severe psoriatic and reactive arthritis happen in HIV patients
  • Muscle weakness-
  • Inflammatory myositis
  • Diffuse infiltrative lymphocytosis syndrome with
    parotid gland enlargement (resembles Sjogren’s)
  • Various vasculitis forms
40
Q

Diagnostic Evaluation of HIV arthritis

A
  • labs: HIV +/-, CD4 count, etc.
  • Include all other labs discussed prior initially!
41
Q

Treatment of HIV Arthritis

A
  • Some of the spondyloarthropathies respond to NSAIDs though many are
    unresponsive
  • Antiretroviral therapies
  • Immunosuppressives meds
  • Antiviral intro has decreased articular syndromes
  • Methotrexate or Sulfasalazine can be used if refractory to NSAIDs
42
Q

Lyme Disease Arthritis clinical history

A
  • Rely on history and location/trips
  • Only 25% have known tick bite
  • Lyme disease involving the knee is less acute,
    does not show positive cultures, and may be
    preceded by known tick exposure and
    characteristic rash (Erythema Migrans).
  • NE USA, parts of Asia and Europe as well
43
Q

Clinical Presentation of lyme disease arthritis

A
  • Early localized (within a month after bite)
  • Erythema Migrans, viral syndrome
  • Early disseminated (weeks to months after bite)
  • Cardiac and neurological involvement
  • Bell’s Palsy and pericarditis are most common
  • Late Disease (months to years after bite)
  • Arthritis (60% of untreated patients) and neurologic Sx
  • Arthritis: knee most commonly affected, 2nd most frequent manifestation
  • Encephalopathy, neuropathies
44
Q

Diagnostic Evaluation of lyme disease arthritis

A
  • Can cause false(+) with history of syphilis
  • Can do separate IgM and IgG Borrelia antibodies and usually positive if early disseminated phase
  • 2 tiered test recommended for serological testing to support Dx
  • If ELISA or IFA negative- testing can be stopped
  • If (+)ELISA or IFA, do Western blot
45
Q

Lyme Disease Arthritis distinguishing features

A
  • Erythema Migrans rash
  • Timeline as discussed prior
  • History of travel
46
Q

Can be misdiagnosed as fibromyalgia

A

Lyme Disease Arthritis

47
Q

Lyme Disease Arthritis management

A
  • Prevention is key**
  • Erythema Migrans- Doxycycline 10 days
  • Late disease - Longer duration
  • Typical treatment of diagnosed Lyme Disease:
  • Doxycycline 100mg BID X 21 daysOR
  • Amoxicillin 500 mg TID X 21 days
  • others require IV treatment
  • Anti-inflammatory therapy or arthroscopic synovectomy
  • Avoid reinfection
48
Q

Osteomyelitis antibiotics

A

– Likely staph
* Vancomycin
– Consider pseudomonas coverage?

49
Q

Diagnosis of osteomyelitis

A

X-rays and Labs- CBC, CRP, ESR
* Cultures
– Blood cultures
– Bone cultures
– Need susceptibility

MSK Exam 2 (5 decks)

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