Musculoskeletal - Joint - Infectious Flashcards
1
Q
Lyme DIsease
A
- Lyme disease is a multisystem infection with primary manifestations involving the skin, joints, and nervous system. It is due to infection with the spirochete Borrelia burgdorferi.
AKA - Lyme arthritis, Lyme borreliosis, Bannwarth’s syndrome, Acrodermatitis chronica atrophicans
2
Q
Lyme DIsease - History
A
- Incidence of Lyme disease has been increasing over time and is likely due to increases in the deer herd and expansion in the range.
- CDC reported 16,461 cases in 1996, although 80-90% of these cases were from 8 states (CT, RI, NY, PA, NJ, DE, Maryland, WI), lyme disease has been reported in almost every state
- In 202, th enumber of new cases reported to the CDC was 23,763. CT has incidence of 0.47/1000, the highest in the US
- Epidemiologic data suggests that actual incidence of Lyme disease may be as much as 10 times higher than that indicated by the CDC data
3
Q
Lyme DIsease - Presentation - Early
A
- Itchy or painful rash with an influenza-like ilness; erythema migrans (90%) within 7-14 days of tick bite
- Fever, joint and muscle pain, headache, neck stiffness, malaise, neurologic deficit (peripheral or cranial nerves), shortness of breath and dizziness (heart block), substernal chest pain (myopericarditis)
- Secondary skin lesions (single or multiple erythema migrans) 3-10 weeks after tick bite, also:
- lymphadenopathy (regional or disseminated)
- conjunctivitis (red eye)
- meningismus (stiff neck)
- cranial neuropathies (facial nerve palsy, often bilateral)
- motor and sensory neuropathies
- myocarditis and heart block (irregular heart rate)
- pericarditis (pleural rub) and endocarditis (murmurs)
4
Q
Lyme DIsease - presentation - Late
A
- Sclerodema0like skin lesions, central nervous system involvement (neuroborreliosis), such as confusion, amnesia, and sleep disturbance
- Swelling and loss of single, large joint function, joint deformity (knees commonly affected), skin changes, and loss of higher mental functions
5
Q
Lyme DIsease - Diagnostic Testing
A
- White blood cell (WBC) count and erythrocyte sedimentation rate (ESR): both are nonspecific
- Serologic testing with Lyme ELSA, specificity is improved with western blot testing
- Immunofuorescence Antibody testing of the leading edge of the erythema migrans (biopsy)
- ECG only if indicated
- Lumbar puncture if indicated
6
Q
Lyme DIsease - Treatment
A
- Removal of any ticks that might remain on patient
- Blood samples for serologic testing
- Firstline:
- Doxycycline (over 8 years of age); Amoxicillin (under 8 years of age)
- Second choice:
- Cefuroxime (oral treatment)
7
Q
Lyme DIsease - Management with complications
A
- Neurologic complications
- IV ceftriaxone, cefotaxime or penicillin
8
Q
Bacterial (Nongonococcal) Arthritis
A
Arthritis occuring secondary to a bacterial infection; classified into the following types:
- Nongonococcal bacterial arthritis
- Spirochetal arthritis (Lyme disease)
- Myobacterial arthritis
- The seeding of bacteria into a joint can lead to an infected joint, typically monoarticular. Urgent diagnosis and treatment necessary to prevent permanent damage to the joint.
AKA - Suppurative arthritis, Nongonococcal arthritis, infectious arthritis, pyogenic arthritis, septic arthritis
9
Q
Bacterial (Nongonococcal) Arthritis - History
A
- 20,000 cases of suppurative arthritis (7.8 cases per 100,000 person-years)
- Suppurative arthritis is becoming increasingly common among people who are immunocompromised and elderly people who have a variety of comorbid diagnoses
- Nongonococcal septic arthritis is most common in small children and the elderly; note: Gonococcal septic arthritis is most common in young, healthy adults.
- Common organisms involved in the nongonococcal infections include:
- staph aureus - 61%
- beta-hemolytic Streph. - 15%
- gram negative bacteria - 17%
- strep. pneumoniae - 3%
- Rare causes of nongonococcal arthritis involve such organisms as Fusobacterium, Treponema, and Mycobacterium
- Most commonly effected joints are:
- Knee 55%
- Hip 11%
- Ankle - 8%
- Shoulder - 8%
- wrist 7%
- elbow 6%
- Routes of infection
- hematogenous spread
- direct inoculation by puncture
- contiguous spread from underlying epiphyseal osteomyelitis
- Risk Factors
- very young age or old age
- pre-existing arthritis
- prosthetic joint
- trauma
- Diabetes mellitus
- Skin or other infections
- joint surgery
- immunosuppression
- chronic debilitating disease
- IV drug use
10
Q
Bacterial (Nongonococcal) Arthritis - Presentation
A
- Acute onset of pain and swelling in a joint
- often in the setting of other serious illness
- fevers (40-90%) and rigors (20-60%) can be present in approximately half of the cases
- Any monoarthritis should be considered septic until proven otherwise
- Note that signs and symptoms can be minimal and can be complicated by other forms of arthritis
11
Q
Bacterial (Nongonococcal) Arthritis - Diagnostic Testing
A
- Arthrocentesis and aspiration with culture of the aspirant
- Gram stain
- WBC count
- ESR and CRP
- Synovial biopsy when appropriate
- Radiographs useful for baseline; demonstrable changes can take several days to 2 weeks
12
Q
Bacterial (Nongonococcal) Arthritis - treatment
A
- Appropriate antibiotic based on patient age, clinical situation, and gram stain finding
- Adequately drain the joint
- Culture synovial fluid
- Analgesics as needed
13
Q
Bacterial (Nongonococcal) Arthritis- Management with Complications
A
- Follow up to guard against recurrence
- In general 60-65% of cases recover completely
- Residuals can involve reduced range of motion, ankylosis, pain on movement, chronic infection
- Physical therapy:
- immobilization
- passive range of motion
- active range of motion with gradual weight-bearing
- Cartilage and bone destruction will occur if untreated or if treatment has been delayed
- Epiphyseal damage can occur in children
14
Q
Bacterial (Nongonococcal) Arthritis - Prevention
A
- Lifestyle modification and awareness of risk factors
- Avoidance of intervenous drug use
- good glycemic control
15
Q
Gonococcal Arthritis
A
- Seeding of a gonococcal infection into a joint
