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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
Q

Demographics of CPPD

A

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
Q

Pathophys of pseudogout

A

Can affect ligaments, tendons, articualr cartilage, and synovium
High levels of Ca precipitate crystal formation

27
Q

Pathophys of pseudogout - secondary causes

A

Hypothyroidism
Gout
Hymochromatosis

28
Q

Pathophys of pseudogout - predisposing factors

A

Family hx

Joint trauma

29
Q

Acute pseudogout

A

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
Q

Chronic CPPD deposition

A

Slowly progressive joint pain ssuch as OA

Multiple joints may be affected

31
Q

Diagnosis of CPPD

A

Based on hx, physical exam, radiograhic findings and crystal exam

Ca, phosphorus, Mg, alkaline phosphatase, ferritin, iron, TIBC, and TSH levels

32
Q

Crystal exam findings - CPPD

A

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
Q

X ray findings with CPPD

A

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
Q

Tx of psuedogout - acute cases

A 
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
Q

Tx with Gout vs. Psueo

A

Gout - you can prevent further attacks
Pseudo - can’t

Good thing is, gout is usually more severe than pseudo

36
Q

Septic arthritis is what

A

Bacterial infection of the joint space that may affect any type of joint

37
Q

demographics for septic arthritis

A

CAN BE ANYONE!

38
Q

Etiology - septic arthritis

A

Most cases hematogenously disseminated

May occur due to direct invasion (trauma)

39
Q

Presentation - septic arth

A

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
Q

Pathogens - septic arth

A

Staph
Strep
Neisseria

41
Q

Septic arth - presentation - Gonococcal arthritis

A

Typically seen in young, sexually active F
Affects knees, ankles, wrists, elbows
Could be 1-3+ joints)

42
Q

Septic arth - presentatin - staphylococcal

A

Usually monoarticular
Knee, hip, shld, elbow, wrist, or ankle
90% have fever
Pt with RA are prone to this

43
Q

Septic arth - presentation - prosthetic joints

A

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
Q

Septic arth - presentation - IC drug use

A

Shoulder, sternoclavicular and sacroiliac infections

45
Q

Septic arthritis - diagnosis

A

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
Q

Septic arthritis - treatment

A

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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