Rheumatological Emergencies Flashcards
Septic Arthritis/Septic Joint
-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
Imaging of Septic Arthritis/Septic Joint
-Obtain imaging of swollen/painful joints
-CT and MRI are most useful for soft tissue infection, osteomyelitis, periarticular extension of infection
Septic Arthritis/Septic Joint Tx
-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
Organisms of infectious arthritis
-Staphylococcus aureus 40-50%
-Streptococcal species 20%
-Gram neg bacilli 15%
-Strep pneumoniae 2%
-Neisseria gonorrhea
-Can also be fungal
-Other species as well
Abx for gram positive cocci
Vancomycin 15-20 mg/kg/dose q 8-12 hours
Renal function
Gram Neg bacilli abx
-3rd generation cephalosporin
-Ceftriaxone, cefotaxime, ceftazidime
–PCN allergy: could use aztreonam or gentamicin
Pseudomonas abx
Ceftazidime + Gentamicin
Suitable choices of ABX with MRSA
-include clindamycin, trimethoprim-sulfamethoxazole, doxycycline (or minocycline), and linezolid (or tedizolid)
Suitable choices of ABX with MSSA
-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).
Giant Cell Arteritis (GCA) Origin
-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
GCA Symptoms
-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.
GCA Workup
-ESR or CRP, LFTs, CBCs
-Head CT to rule out intracranial abnormality
-Temporal artery biopsy or color doppler US
Tx of GCA with positive biopsy results
-High dose systemic glucocorticoids
-Initiate promptly, do not wait for confirmation of diagnosis
-May use glucocorticoid-sparing agents if high risk (Tocilizumab, Methotrexate)
Tx of negative GCA biopsy
Begin glucocorticoids if high suspicion with negative workup
Steroid Dosing
-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)
Glucocorticoid sparing agents
-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
GCA Prognosis
-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
Vasculitis Workup
-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
Diffuse Alveolar Hemorrhage (DAH)
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.
what is Vasculitis
Inflammation of blood vessels leading to vessel and potential tissue damage
Vasculitis classification
-Large vessel
-Medium vessel
-Small vessel (ANCA Associated, Non-ANCA associated)
Granulomatosis with polyangiitis (GPA, formerly Wegener’s)
-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
GPA Dx
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
GPA tx
Two-phased approach
Induction: 3-6 months
-Systemic corticosteroids and immunosuppressant (cyclophosphamide or rituximab)
-Maintenance: 12-24 months
Oral corticosteroids with azathioprine or methotrexate
Additional Rheumatology emergencies
-Scleroderma renal crisis
-Catastrophic antiphospholipid antibody syndrome
-Capillary leak syndrome
