Rheum - Monoarticular Arthritis

Question 0

Why is acute monoarthritis a medical emergency?

Answer 0

Could be infectious arthritis, which could lead to joint destruction and severe morbidity

Question 1

Patient with suspected gout. Next step? Best initial treatment?

Answer 1

Aspirations of joints to send food for cell count, culture, Crystal analysis.

If infection needs drainage. If crystal induced arthritis treat with colchicine, NSAIDs, or corticosteroids

Question 2

Differential for monoarthritis?

Answer 2

1. Infection (bacterial, fungal, lime disease, TB)
2. Crystal induced arthritis (gout and pseudogout)
3. Systemic disease (rheumatoid arthritis or lupus)
4. Noninflammatory (trauma, osteoarthritis)

Question 3

Gout most commonly involves? Pseudogout?

Answer 3

First MTP joint, ankle, midfoot, or knee

Knee, wrist, first MTP joint

Question 4

Findings in gonococcal arthritis?

Answer 4

1. Migratory arthralgias and tenosynovitis on wrist and hands
2. Pustular skin lesions
3. Purulence

Question 5

Location of gonococcal versus nongonococcal septic arthritis?

Answer 5

Wrists and hands versus large weight-bearing joints (knee and hip)

Question 6

True arthritis versus bursitis?

Answer 6

Swelling, redness, painful limitations during active and passive motion

Versus

Full range of passive motion

Question 7

Noninflammatory joint effusions: WBC count? Percentage of PMNs?

Answer 7

1000 to 2000. Less than 50% PMNs

Question 8

Description of Gout versus pseudogout crystals?

Answer 8

Intracellular (within PMN), yellow, needle shaped, negatively birefringent crystals

Vs

Blue, Short & rhomboid, weakly positive birefringent crystals

Question 9

Typical culture findings in gonococcal arthritis?

Answer 9

Negative joint fluid cultures but positive blood/skin lesion cultures

Question 10

Normal joint aspirate volume? Viscosity? Color? Clarity? Leukocytes? PMNs? Culture? Glucose?

Answer 10

<25, Negative, equal to blood

Question 11

Changes to joint aspirate findings in noninflammatory causes?

aspirate volume? Viscosity? Color? Clarity? Leukocytes? PMNs? Culture? Glucose?

Answer 11

Volume >1 mL
Straw to yellow color
50-10,000 leukocytes

Question 12

Changes to joint aspirate findings in inflammatory causes?

aspirate volume? Viscosity? Color? Clarity? Leukocytes? PMNs? Culture? Glucose?

Answer 12

Volume >1 mL
Low viscosity
Yellow color
Translucent clarity
2000 – 75,000 leukocytes
Greater than 50 PMNs
About 50 mg/dL less glucose

Question 13

Changes to joint aspirate findings in septic causes?

aspirate volume? Viscosity? Color? Clarity? Leukocytes? PMNs? Culture? Glucose?

Answer 13

>1 mL
Variable viscosity
Variable color
Opaque clarity
>100,000 leukocytes
Greater than 85% PMNs
Positive cultures
50 mg/dL lower glucose

Question 14

X-ray finding that suggests monoarthritis etiology?

Answer 14

Chondrocalcinosis (linear calcium deposition in joint cartilage) suggests pseudogout

Question 15

Treatment for gonococcal arthritis?

Answer 15

Ceftriaxone

Question 16

Typical cause of nongonococcal septic arthritis? Treatment?

Answer 16

Staph aureus. Nafcillin or vancomycin

Question 17

Stages of gout?

Answer 17

1. Asymptomatic hyperuricemia
2. Acute gouty arthritis (severe monoarticular pain, often at night in typical joints)
3. Intercritical gout (Period between attacks that last 1 to 2 years?
4. Chronic tophaceous gout (after 10+ years of acute intermittent gout, critical periods no longer asymptomatic and joints have chronic swelling)

Question 18

Treatment for each stage of gout?

Answer 18

1. No specific treatment
2. Indomethacin or oral colchicine every hour (steroid injection if patient has renal insufficiency)
3. Prevention – avoid meat and alcohol, switch off thiazides, probenecid, allopurinol
   Stage four. Same treatment as acute attack with the addition of allopurinol to resolve tophi

Question 19

The most common cause of monoarthritis in patient younger than 40? Most useful diagnostic test?

Answer 19

Gonococcal. Urethral, cervical or pharyngeal culture.

Question 20

Patient with joint aspirate that reveals numerous leukocytes and PMNs but no organisms on gram stain. Few negatively birefringent crystals. Treatment?

Answer 20

Not enough information to rule out infection. Treat with IV antibiotics

Question 21

Causes for gouty attacks?

Answer 21

##Overproduction 
#Increased cell turnover (cancer, chemo, hemolysis, psoriasis)
# enzyme deficiency (Lesch-Nyhan, glycogen storage disease)

##underexcretion
#renal insufficiency
#Acidosis 
#thiazides
#ASA

Question 22

Uric acid levels in gout pts?

Answer 22

#elevated at some point in 95% of patients 
#a single level during an attack is elected in 75% of patients

Question 23

Which is better - NSAIDs vs steroids vs colchicine in acute attack?

When steroids?

Answer 23

NSAIDs better then steroids then colchicine

#No response to NSAIDs
#renal insufficiency

Question 24

Side effects of colchicine?

Answer 24

Diarrhea and bone marrow suppression (neutropenia)

Question 25

Drug for gout pt with HTN?

HTN Drug to stop?

Answer 25

Losartan lowers uric acid (stop thiazides)

Question 26

Gout medications contraindicated with renal insufficiency?

Safe to give?

Answer 26

#NSAIDS
 #probenecid
#sulfinpyrazone

Allopurinol

Question 27

Drugs for chronic management of gout?

Answer 27

#Colchicine
#allopurinol or febuxostat
#pegloticase (dissolves Uric acid)
#probenecid or sulfinpyrazone (increase renal uric acid secretion)

Question 28

Risk factors for pseudogout?

Answer 28

#Hemochromatosis 
#Hyperparathyroidism
#Diabetes
#Wilson disease
#hypothyroidism

Question 29

Treatment of pseudogout? For ppx?

Answer 29

NSAIDs or steroids

Colchicine got ppx

Question 30

Patient with suspected osteomyelitis – best initial test? Most accurate test? If normal x-ray, next step in management? (If contraindicated, get?

Answer 30

X-ray; biopsy

MRI; bone scan

Question 31

Patient with osteomyelitis – role of ESR?

Answer 31

Follow response to therapy

Question 32

Only oral therapy for osteomyelitis?

Answer 32

Ciprofloxacin

Question 33

For quinolones contraindicated in?

Answer 33

Pregnancy and children (interfere with bone growth)