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Practice Topics Exam 8 > Rheum 3 - Crystal Induced Arthropathies and Septic Arthritis > Flashcards

Rheum 3 - Crystal Induced Arthropathies and Septic Arthritis Flashcards

1
Q

Crystal induced arthropathies are what

A

Crystal deposits can occur in articular and periarticular tissues
Can be acute or chronic and affect multiple joints
Inflammation due to interaction between phagocytes and crystals
Important to differentiate crystal deposition from infection, trauma, tumor and degenerative arthritis

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2
Q

Types of crystal induced arthropathies

A

Gout
Pseudogout
Calcific periarthritis, sub acute arthritis, Milwaukee shoulder

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3
Q

Types of crystal induced arthropathies - Gout - crytsl

A

Monosodium urate

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4
Q

Types of crystal induced arthropathies - pseudogout crystal

A

Ca pyrophosphate

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5
Q

Types of crystal induced arthropathies - Calcific periarthritis, sub acute arthritis, Milwaukee shoulder

A

Basic Ca phosphate

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6
Q

Demographics of gout

A

90% of gout occurs in M between 30-50

Very uncommon in premenopausal F (estrogen enhances uric acid excretion)

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7
Q

Characteristics of gout

A

Severe acute inflammation - usually single joint
Metabolic disease related to abnormal uric acid metabolism/hyperuricemia
Leads to the deposition of monosodium urate crystals in joints or soft tissues

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8
Q

Joint involvement with gout

A

Severe pain, erythema, swelling and disability of a single LE joint

Acute attack - usually 1+ joints 20% of time (usually asymmetric) - polyarticular presentation commonly occurs in chronic gout and in gout due to secondary causes

Most common joint affected is 1st MTP (podagra)
Other common areas = ankle, knee, wrist

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9
Q

Differentials with gout

A

Acute monoarthritis - septic arthritis, thrombophlebitis, reactive arthritis, pseudogout
Chronic polyarticular arthritis - RA, chronic CPPD, seronegative spondyloarthopathies, erosive OA

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10
Q

Hyperuricemia - gout

A

Uric acid is primarily produced by the liver - 2/3 secreted by kidneys, 1/3 by intestines

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11
Q

Causes of hyperurecemia with gout

A

Overproduction of uric acid - due to enzyme deficiencies

Undersecretion of uric acid (90% of cases) - decreased renal excretion because kidneys not functioning well

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12
Q

Secondary causes of gout

A 
Medications - diuretics, cyclosporine, aspirin, niacin
Renal insufficiency
Hypothyroidism
Multiple myeloma
Lead poisoning
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13
Q

Risk factors for gout

A 
Alcohol use - beer, hard liquor, wine
High purine diet (sausages, cheese)
Trauma
Surgery
Immobility
Starvation (acid/base balance issue)
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14
Q

Stages of gout

A

Asymptomatic hyperuricemia - usually for years before an attack

Acute intermittent gout - acute attacks follows by asymptomatic periods of time

Chronic gouty arthritis - joint pain persists, tophi (uric acid deposits), gouty neuropathy of kidneys, uric acid stones in urinary tract

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15
Q

Podagra (gout)

A

Gout of big toe

Will be very sensitive to touch (one way to differentiate with RA)

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16
Q

Gout - olecranon bursitis

A

Generally don’t aspirate this - unless seems infected

This is thick fluid so requires a thick needle - can induce/spread infection

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17
Q

Chronic gouty arthritis

A

Left untx - gout usually progresses to chronic gout in 12 years (range from 5-40 though)

Tophi - uric acid deposits in soft tissue now rather than just joints

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18
Q

Chronic gouty arthritis - tophi

A

May cause deformity, pain, joint destruction and nerve compression
Occurs most commonly on external ear, hands, feet, olecranon, and prepatellar bursa

Tophi have a calcified feel to them

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19
Q

Lab values with gout

A

Normal uric acid levels - M is less than 6.5 and premenopausal F is less than 6
2/3 of uric acid excretion is via the kidneys - small amount by GI
Attacks associated with elevated ESR and leukocyte level

20
Q

Crystal exam findings - gout

A

Aspiration of fluid necessary for diagnosis
Crystal exam reveals monosodium urate crystals
- needle shaped
- negative birefringence on polarized microscopy

21
Q

x ray findings with gout

A

Normal during early stages

Rat btie lesions - punched out erosions, overhanging edges

22
Q

Tx of acute gout

A

NSAID - Indomethacin is NSAID of choice - should not be used in pts with hx of GI intolerance, renal insufficiency, or coumadin

Steroids - intraarticular in cases of monoarthritis, oral in cases where NSAID can’t be used

Colchicine (Colcrys) - can be used chronically also

23
Q

Tx of chronic gout

A 
Uric acid lowering therapy - start them 6-8 wks after acute attacks 
Used when pts have multiple gout falres 
Allopurinol
Febuxostat (uloric)! 
Probenecid
24
Q

Pseudogout =

A

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease = inflammation in the connective tissue due to CPPD
May be asymptomatic or acute (psudogout)

25
Demographics of CPPD
Primarily disease of elderly - avg age is 72 More than 50% of pts over age of 85 have xray evidence of CPPD deposition More common in F
26
Pathophys of pseudogout
Can affect ligaments, tendons, articualr cartilage, and synovium High levels of Ca precipitate crystal formation
27
Pathophys of pseudogout - secondary causes
Hypothyroidism Gout Hymochromatosis
28
Pathophys of pseudogout - predisposing factors
Family hx | Joint trauma
29
Acute pseudogout
Similar to gout with erythema, swelling and pain of a single or several joints Cna be assoicated with fever, leukocytes, and inc ESR Attacks can be precipitated by illness, trauma, or surgery Knee most frequently invovled (50%) but can affect any joint
30
Chronic CPPD deposition
Slowly progressive joint pain ssuch as OA | Multiple joints may be affected
31
Diagnosis of CPPD
Based on hx, physical exam, radiograhic findings and crystal exam Ca, phosphorus, Mg, alkaline phosphatase, ferritin, iron, TIBC, and TSH levels
32
Crystal exam findings - CPPD
Typical synovial leukocyte count is 15000 - 30000 with neutrophil dominance Polarized microscopy shows crystals that have a pos birefringence, are smaller than urate crystals and may be rhomboid in shape Fluid should be sent for culture
33
X ray findings with CPPD
Chrondrocalcinosis - CPPD crystals deposited in joints - in the picture you can see white in between digits May be seen in asymptomatic indivduals Usually seen in cartilage (knee, wrist, GH, and symphsis pubis) and tendon insertion sites (achilles, quad)
34
Tx of psuedogout - acute cases
``` Joint aspiration may provide relief Corticosteroid injection only in cases where infection is NOT suspected NSAIDs Colchicine mght be helpful Oral corticosteroids ``` No therapy proven to eliminate CPPD crystal deposition or prevent acute attacks!
35
Tx with Gout vs. Psueo
Gout - you can prevent further attacks Pseudo - can't Good thing is, gout is usually more severe than pseudo
36
Septic arthritis is what
Bacterial infection of the joint space that may affect any type of joint
37
demographics for septic arthritis
CAN BE ANYONE!
38
Etiology - septic arthritis
Most cases hematogenously disseminated | May occur due to direct invasion (trauma)
39
Presentation - septic arth
Classic = Effusion, warmth, erythema of a single joint with or without fever (Pts on high prednisone have dec fever response, so if they have a fever definitely need to suspect infection) Polyarticular onset occurs rarely - leads to worse prognosis
40
Pathogens - septic arth
Staph Strep Neisseria
41
Septic arth - presentation - Gonococcal arthritis
Typically seen in young, sexually active F Affects knees, ankles, wrists, elbows Could be 1-3+ joints)
42
Septic arth - presentatin - staphylococcal
Usually monoarticular Knee, hip, shld, elbow, wrist, or ankle 90% have fever Pt with RA are prone to this
43
Septic arth - presentation - prosthetic joints
Fewer than 2% develop it Greatest risk in those with RA, distanc infection, corticosteroid use, revision arthroplasty Immediately after surgery - high fevers and purulent effusion Late prosthetic infection (more than 1 yr post op) - usually less symptomatic
44
Septic arth - presentation - IC drug use
Shoulder, sternoclavicular and sacroiliac infections
45
Septic arthritis - diagnosis
Joint aspiration is KEY!!! Send for cell count and culture - WBC count determiens how inflammatory the fluid is - the higher the WBC count means higher liklihood for infection (over 30,000) Labs - CRP and ESR (inflammatory), CBC (elevated WBC might mean infection) X rays usually not helpful
46
Septic arthritis - treatment
IV antibiotics should be given as quickly as possible after aspiration of joint Cultures take 24-48 hrs so initial tx should include S aureus coverage IV antibiotics for 2-3 wks depending on bacteria Prosthetic joint infection requires removal of components, prolonged antibiotic treatment and revised reconstruction

Practice Topics Exam 8 (12 decks)

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