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Week 11- Musculoskeletal > Septic arthritis and reactive arthritis > Flashcards

Septic arthritis and reactive arthritis Flashcards

1
Q

What are the causes of acute mono arthritis?

A 
•Infection 
•Crystal induced: 
 - gout 
 - calcium pyrophosphate 
•Reactive: 
 - haemarthrosis 
 - systemic rheumatic condition 
 - trauma
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2
Q

What is the clinical presentation of acute mono arthritis?

A
  • Cardinal features of inflammation: rubber, calories, dollar and tumour
  • May have fever
  • May have leukocytosis and raised CRP
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3
Q

What is acute mono arthritis until proven otherwise?

A

Septic

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4
Q

What are the risk factors for septic arthritis?

A
  • Previous arthritis
  • Trauma
  • Diabetes mellitus
  • Immunosuppression
  • Bacteremia
  • Sickle cell anaemia (increased risk of strep and staph)
  • Prosthetic joint
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5
Q

What is the pathogenesis of septic arthritis?

A

•Bacteria enters the joint and deposit in synovial lining
- haematogenous spread
- local invasion/inoculation
•Rapid entry into the synovial fluid (no basement membrane and close relationship to blood vessels)

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6
Q

What is the most common joint involved in septic arthritis?

A

Knee

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7
Q

What is polyarticular septic arthritis

A
  • Septic arthritis involving multiple joints

* On average 4 involved: knee, elbow, hip and shoulder predominate

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8
Q

What is there a high prevalence of in polyarticular septic arthritis?

A

Rheumatoid arthritis

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9
Q

What are the most common causative organisms in polyarticualr septic arthritis?

A

Staph and strep

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10
Q

Why should you use a large bore needle when you suspect infection in a joint?

A

Pus may be very viscous so difficult to aspirate

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11
Q

What is the management of septic arthritis?

A
  • Joint aspiration: daily or more frequently as needed
  • Antibiotic therapy based on gram culture stain and clinical factors
  • Surgical intervention- only if pt not responding after 48hrs of appropriate therapy
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12
Q

What is the most common empirical antibiotic therapy for septic arthritis?

A

Iv flujloxacillin and gentamicin

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13
Q

What are the non modifiable risk factors of gout?

A
  • Age
  • MAle
  • Race
  • genetic
  • impaired renal function
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14
Q

What are the modifiable risk factors of gout?

A
  • Obesity
  • Alcohol consumption
  • High purine diet
  • HFCS (high fructose corn syrup)
  • Certain medication
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15
Q

Which medications can predispose to gout?

A
  • Aspirin: bimodal effect, large doses increase UA excretion, small doses reduce UA excretion
  • diuretics
  • cyclosporin
  • Pyrazinamide and ethambutol
  • Nicotinic acid
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16
Q

When can a diagnosis of gout be made in the absence of synovial fluid aspiration?

A
  • Typical presentation of podagra
  • History of gout flares or hyperuricaemia
  • Raised sUA between attacks
17
Q

What are the differential diagnoses in the context of gout?

A
  • Septic arthritis

* CPPD (pseudo gout)

18
Q

What are the goals of treatment of gout?

A
  • Acute attacks: reduce pain and reduce inflammation: NSAIDs, Coxibs, corticosteroids
  • Long term: prevent further acute attacks, prevent joint damage, eliminate tophi
19
Q

What is seen in the synovial fluid in someone with gout?

A

Tophi

20
Q

What are the lifestyle modifications for people with gout?

A 
•Diet: 
 - reduce purine intake 
 - reduce fructose containing drinks 
 - include skimmed milk, low fat yoghurt, vegetable protein and cherries every day 
•Weight loss
 - aim 1kg/month and avoid crash diets 
 - avoid high protein diets 
•moderate exercise 
•reduce alcohol
21
Q

Who with gout should you treat?

A
  • Those with recurring attacks (more than 2 in 12 months)
  • Tophi
  • Chronic gouty arthritis
  • Renal impairment
  • history of urolithiasis
  • Diuretic therapy use
  • Primary gout starting at a young age
  • Very high serum rate>500micromol/l
22
Q

What are the rate lowering therapies?

A
  • Allopurinol

* Febuxostat

23
Q

What is reactive arthritis?

A
  • Seronegative spondyloarthropathies
  • Seronegative for Rheumatoid factor
  • It develops soon after an infection occurring elsewhere in the body
  • No viable organisms can be recovered from the joint
24
Q

What does reactive arthritis have a strong association with?

A

HLA-B27

25
Q

What is SARA?

A

A subgroup of reactive arthritis related to sexually acquired infection, often chlamydia trachomatis

26
Q

What are the enteric infections causing reactive arthritis?

A
  • Salmonella
  • Shigella
  • Yersinia
  • Campylobacter
  • Clostridium
27
Q

What are the GU infections causing reactive arthritis?

A
  • Chlamydia trachomatis
  • Neisseria gonorrhoea
  • Mycoplasma genitalium
  • Ureplasma urealyticum
28
Q

Describe the typical presentation of reA

A
  • Acute onset, usually 2-6 weeks post infection
  • Warm, swollen, Tender joints, usually lower limb
  • Systemically unwell- elevated inflammatory markers and malaise
  • Triad of arthritis, conjunctivitis and urethritis
29
Q

What is the prognosis of ReA?

A
  • 70% resolve within 3-12 months

* 50% recur

30
Q

What is the pathogenesis of reactive arthritis?

A
  • May involve cross reactivity between bacterial antigen and joint tissues leading to Th2 cell mediated response
  • Persistence of antigenic material due to failed clearance possibly due to polymorphisms of toll like receptor
31
Q

What are the investigations for reactive arthritis?

A
  • Joint aspiration to exclude sepsis
  • Swabs- urethral/cervical
  • Screen for other related infections
  • Inflammatory markers ESR and CRP
  • Chlamydia serology
  • HLA-B27 for prognostic not diagnostic reasons
32
Q

What is the management of mild reactive arthritis?

A
  • NSAID

* Simple analgesia

33
Q

What is the management of moderate reactive arthritis?

A
  • NAID
  • Joint aspiration
  • Corticosteroid injection
34
Q

What is the management of severe or prolonged reactive arthritis?

A
  • Refer to rheumatology

* Consdieration of DMARD

35
Q

Why should joint effusions be aspirated in the context of reactive arthritis?

A

To exclude sepsis

36
Q

What is the effect on the joints in reactive arthritis

A
  • Lower limb asymmetric oligoarthritis
  • Dactylitis
  • Enthesopathy
  • inflammatory back pain
37
Q

What extra-articular conditions are seen in ReA?

A
  • Conjunctiivitis, iritis, keratitis, episcleritis
  • Keratoderma blemmorhagica, nail dystrophy
  • Urethritis, prostatitis, cystitis, cervicitis
  • Circinate balanitis
  • Stomatitis, diarrhoea

Week 11- Musculoskeletal (11 decks)

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