Rheumatological Emergencies

Question 1

Septic Arthritis/Septic Joint

Answer 1

-Medical emergency
-Likely present with pain, swelling, and/or functional loss
-50% are knees
-Risk factors: advanced age, immunosuppression including DM, Pre-existing joint disease, IV drug use, corticosteroid injections or recent joint surgery, skin or soft tissue infections, indwelling catheters
-Acquired 3 ways: hematogenous, direct contiguous, traumatic inoculation

Question 2

Imaging of Septic Arthritis/Septic Joint

Answer 2

-Obtain imaging of swollen/painful joints
-CT and MRI are most useful for soft tissue infection, osteomyelitis, periarticular extension of infection

Question 3

Septic Arthritis/Septic Joint Tx

Answer 3

-Abx (typically administer parenteral antibiotics for at least 14 days followed by oral therapy for an additional 14 days)
-Ortho consult
-Arthrocentesis (gram stain, crystals, culture)
-Endocarditis
-Washout
-ID consult possible
-MSU crystals indicate Gout, CPPD crystals indicate Pseudogout
->20,000 WBC on aspiration

Question 4

Organisms of infectious arthritis

Answer 4

-Staphylococcus aureus 40-50%
-Streptococcal species 20%
-Gram neg bacilli 15%
-Strep pneumoniae 2%
-Neisseria gonorrhea
-Can also be fungal
-Other species as well

Question 5

Abx for gram positive cocci

Answer 5

Vancomycin 15-20 mg/kg/dose q 8-12 hours
Renal function

Question 6

Gram Neg bacilli abx

Answer 6

-3rd generation cephalosporin
-Ceftriaxone, cefotaxime, ceftazidime
–PCN allergy: could use aztreonam or gentamicin

Question 7

Pseudomonas abx

Answer 7

Ceftazidime + Gentamicin

Question 8

Suitable choices of ABX with MRSA

Answer 8

-include clindamycin, trimethoprim-sulfamethoxazole, doxycycline (or minocycline), and linezolid (or tedizolid)

Question 9

Suitable choices of ABX with MSSA

Answer 9

-dicloxacillin (500 mg orally every 6 hours) or cephalexin (500 mg orally every 6 hours).
-Patients who are allergic to penicillins can be treated with clindamycin (600 mg orally every 8 hours).

Question 10

Giant Cell Arteritis (GCA) Origin

Answer 10

-Most common systemic vasculitis
-Also known as Horton’s disease, cranial arteritis, temporal arteritis
-Rheumatological disease of older adults (> 70 years old)
-Generally Scandinavian descent
-3:1 female to male ratio
-Polymyalgia rheumatica link
-Seek expert consultation

Question 11

GCA Symptoms

Answer 11

-New headaches, subacute or abrupt in 2/3 of GCA dx
-Fever, weight loss, fatigue
-Scalp tenderness, temporal headache, though may be frontal of generalized
-Transient, monocular vision loss
-½ have jaw claudication
-Symptoms improve within 24-48 hours. It is crucial to prevent vision loss as it is rarely reversible.

Question 12

GCA Workup

Answer 12

-ESR or CRP, LFTs, CBCs
-Head CT to rule out intracranial abnormality
-Temporal artery biopsy or color doppler US

Question 13

Tx of GCA with positive biopsy results

Answer 13

-High dose systemic glucocorticoids
-Initiate promptly, do not wait for confirmation of diagnosis
-May use glucocorticoid-sparing agents if high risk (Tocilizumab, Methotrexate)

Question 14

Tx of negative GCA biopsy

Answer 14

Begin glucocorticoids if high suspicion with negative workup

Question 15

Steroid Dosing

Answer 15

-Initial dose and subsequent taper not formally evaluated
-Recommendations:
-No vision loss: Prednisone 1 mg/kg, max dose 60 mg, single daily dose
-Threatened or established vision loss: Use pulses of methylprednisolone. Typically, 500 to 1000 mg IV daily x 3 days, followed by oral therapy 1 mg/kg/day (max 60 mg)

Question 16

Glucocorticoid sparing agents

Answer 16

-Tocilizumab, methotrexate
-Monitoring monthly via labs or visits; course dependent
-Low dose aspirin in the setting of atherosclerosis
-calcium, vitamin D, osteoporosis screening
-Consider PJP prophylaxis
-indications; Presence of significant premorbid condition, Significant glucocorticoid-related side effect, Relapse requiring prolonged steroid course

Question 17

GCA Prognosis

Answer 17

-Disease of variable duration
-One to two years, or chronic disease
-Majority eventually taper off of steroids
-GCA does not typically affect survival except for in aortic disease with dissection

Question 18

Vasculitis Workup

Answer 18

-CBC, liver function studies, basic metabolic panel
-ANCA
-ANA (lupus)
-CRP, ESR (inflammation)
-Anti-GBM antibodies
-C3 and C4 (lupus, mixed cryoglobulinemia)
-Hepatitis serologies
-Cryoglobulins
-HIV and tuberculosis screens
-UA
-Cxr, Chest CT
-Bronchoalveolar lavage
-biopsy

Question 19

Diffuse Alveolar Hemorrhage (DAH)

Answer 19

Bleeding into the alveolar spaces of the lungs characterizes the syndrome of diffuse alveolar hemorrhage (DAH) and is due to disruption of the alveolar-capillary basement membrane.

Question 20

what is Vasculitis

Answer 20

Inflammation of blood vessels leading to vessel and potential tissue damage

Question 21

Vasculitis classification

Answer 21

-Large vessel
-Medium vessel
-Small vessel (ANCA Associated, Non-ANCA associated)

Question 22

Granulomatosis with polyangiitis (GPA, formerly Wegener’s)

Answer 22

-Autoimmune disease
-Systemic necrotizing vasculitis affecting small and medium-sized vessels
-Characterized by granulomatous and necrotizing inflammatory lesions in the respiratory tract and often associated with pauci-immune glomerulonephritis.
–Medium sized vessels-kidneys
-Lung impacted

Question 23

GPA Dx

Answer 23

Must have 2 of 4 criteria:
1. Sinus involvement
2. Chest x-ray demonstrates nodules, a fixed pulmonary infiltrate or cavity
3. Urinary sediment with hematuria or red cell casts
4. Histological granulomas within an artery or in the perivascular area of an artery or arteriole

Question 24

GPA tx

Answer 24

Two-phased approach
Induction: 3-6 months
-Systemic corticosteroids and immunosuppressant (cyclophosphamide or rituximab)
-Maintenance: 12-24 months
Oral corticosteroids with azathioprine or methotrexate

Question 25

Additional Rheumatology emergencies

Answer 25

-Scleroderma renal crisis
-Catastrophic antiphospholipid antibody syndrome
-Capillary leak syndrome