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53 Cards in this Set
- Front
- Back
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Septic joint
Aspirate |
~100,000 WBC/mcL
>90% neutrophils |
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What should be excluded first in sudden onset joint pain? & why?
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Infected joint.
within first 24 hours of infection cartilage can be destroyed. |
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Monosodium Urate Crystals in Joint fluid.
Negative Birefringence= Vertical=Yellow; Horizontal=Blue |
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Monosodium Urate Crystals
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Needle Shaped
Strongly NEGATIVE Birefringence. (yellow=vertical; blue=horizontal) |
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Calcium pyrophosphate dehydrate
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Rod shaped & Rhomboid
Weak Positive Birefringence (yellow=horizontal; blue=vertical) Pseudogout |
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Calcium Hydroxyapatite
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Cytoplasmic inclusions (req electron microscopy)
Non-birefringent |
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Calcium oxalate
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Bipyramidal
Strongly Positive birefingent End-stage renal disease |
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Calcium Pyrophosphate Dehydrate crystal
Pseudogout |
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Calcium Oxalate
mostly End-stage Renal Disease. |
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Pseudogout
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Joint pain & Inflammation due to deposition of
Calcium Pyrophosphate Dehydrate crystals |
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Ddx of:
Non-traumatic Swollen Joint |
Crystal-induced arthritis (gout, pseudogout, ...)
Infectious arthritis Ostoarthrities Rheumatiod arthritis |
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Podagra
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Gout attack in MTP jt of first (great) toe.
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Appearance of acute gout
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Swelling & pain (usually 1 joint) with erythema & warmth.
Often spontaneous resolution 3-10 days. |
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Serum Uric Acid levels during acute gout attack
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Normal - Low
likely due to deposition |
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Radiologic appearance of gout.
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Cystic changed in joint surface with punched out lesions & soft-tissue calcifications
Non-specific: gout, Osteo-, Rheumatoid Arthritis. |
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3 most common joints affected by septic arthritis
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Knee
Hip Shoulder |
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Most common presentation of:
Fungal arthritis |
Chronic monoarticular arthritis
2-3 joint arthritis. |
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Most common presentation of:
Mycobacterially-infected arthritis |
(TB, leprae)
Chronic monoarticular arthritis 2-3 joint arthritis. |
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Most common causes of
Acute Polyarticular Arthritis |
(>3 joints)
Endocarditis Disseminated Gonococcal infection |
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Most common cause of septic joints in RA
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Staphylococcus aureus
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Most common population with septic arthritis.
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Rheumatoid arthritis is most common population with bacterial infection.
Chronic Inflammation + Steroids predisposes. |
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What septic arthritis organisms are associated with HIV positive patients?
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(common bugs are common) +
Pneumococcal Salmonella H. influenzae |
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What organisms causing septic arthritis are associated with IV drug use?
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Streptococcal
Staphylococcal Gram-Negative Pseudomonas |
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Septic joints are ___ in Range of Motion.
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Septic joints are very limited in ROM due to pain.
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Common findings of septic arthritis
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Very limited ROM
Joint effusion fever warmth ~100,000 WBC & >90% neutrophils |
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Osteoarthritis
- presentation |
"wear & tear arthritis"
Cartilage damage (+ bone surface, synovium, meniscus & ligaments) Gradual onset of dull, deep aching pain. ↑ with activity, ↓ with rest. |
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Osteoarthritis
- Physical exam |
Bony crepitus
small joint effusion periarticular muscle atrophy Advanced: joint deform & ↓ ROM |
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Osteoarthritis
- Radiologic signs |
Initially: normal - dec jt space
Advanced: Bone sclerosis, subchondral cysts, osteophytes |
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Age Group of average presentation in:
Osteoarthritis vs Rheumatoid Arthritis |
usually >65 = Osteoarthritis
Any (30-55) = Rheumatoid. |
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Diagnostic Criteria for Rheumatoid Arthritis
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1st 4 for >6wks. any 4 = RA
1. Morning Stiffness 2. Involvement of 3+ jts 3. Involvement of Hand jts 4. Symmetric arthritis 5. Presence of rheumatoid nodules 6. + Rheumatoid factor 7. Radiographic change: Erosions or Decalcifications. |
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Lab abnormalities associated with Rheumatoid Arthritis
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↑Erythrocyte sedimentation rate
↑C-reactive protein Anemia Throbocytosis ↓ Albumin - level correlates with severity. |
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Pathophysiology of Gout
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Metabolic d/o associated with hyperuricemia.
Purines Uric Acid (NaUrate) MonoSodiumUrate crystal deposition. Phage infiltration & inclusion Lysozyme Release + Lactate production = ↓pH & ↑MSU deposit. |
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Treatment of Acute Gout
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↓granulocyte infiltration.
- Low-dose Colchicine - Indomethacin NSAIDs = ↓ pain & inflammation Intra-articular joint steroid injection Ice Packs |
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C/I in gout
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Aspirin
Competes with UA for organic acid secretion mechanism in proximal tubule of kidney. |
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Causes of acute gouty arthritis
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- Ethanol intake (excess)
- Purine rich diet (liver, red meats, beer, salty fish & scallops ... - Kidney Disease |
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Cause of chronic gout
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1. Genetic defect ↑purine synth rate.
2. Renal deficiency 3. Lesch-Nyhan syndrome 4. ↑synthesis of uric acid with chemotherapy |
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Treatment strategies for Chronic gout
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Uricosuric drugs (probenecid / sulfinpyrazone)
Inhibition of UA synthesis (allopurinol) |
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What patient characteristics make Allopurinol the preferred treatment for Chronic Gout?
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Patients with:
- excess Uric acid excretion - previous history uric acid stones - Renal insufficiency |
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What patient characteristics make Probenecid the preferred treatment for Chronic gout?
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Uricosuric agent
First line for gout with normal urinary uric acid excretion |
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What patient characteristics make Sulfinpyrazone the preferred treatment for Chronic gout?
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Uricosuric agent
First line for gout with normal urinary uric acid excretion |
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Mechanism of action:
Colchicine |
Binds to tubulin → Depolymerization
Disrupt microtubule formation: - mobility (migratory ability) of granulocytes - block cell division - inhibit synthesis & release of leukotrienes |
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Therapeutic Uses:
Colchicine |
acute Gout anti-inflammatory.
<12 hrs Prophylaxis of recurrent attacks, esp in first frew weeks of allopurinol titration. |
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Adverse Effects:
Colchicine |
GI: Nausea, Vomiting, Abdominal Pain, Diarrhea.
Chronic administration: myopathy, agranulocytosis, aplastic anemia, alopecia |
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Mechanism of Action:
Allopurinol |
Purine analog, Competitively inhibits Xanthine Oxidase in biosynthesis of Uric Acid
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Therapeutic Uses:
Allopurinol |
Hyperuricemia
- primary gout - secondary to: * malignancies, esp post chemotherapeutic treatment * renal disease |
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Adverse Effects:
Allopurinol |
Generally well tolerated.
- Hypersensitivity = Skin rashes (not time dependent) - Acute gout attacks during first several wks of therapy -> treat with colchicine & NSAID concurrently - GI side effects: Nausea, diarrhea - Drug interaction (via metabolism): 6-mercaptopurine & Azathioprine (immunosuppressant) |
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Mechanism of Action: Uricosuric Agents
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Probenecid & Sulfinpyrazone
Weak organic acids inhibit urate-anion exchanger (proximal tubular resorption of uric acid) = promote renal clearance of uric acid |
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Adverse Effects:
Propbenecid |
Blocks tubular secretion of penicillin, Naproxen, Ketoprofen, indomethacin.
= increse drug levels. |
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Adverse Effects:
Sulfinpyrazone |
Gastric Distress
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Treatment of:
Septic Joint |
Surgical I&D (incision & drainage)
+ Antibiotics corresponding to culture |
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Treatment of:
Degenerative Joint Disease |
- Mobility exercises
- maintain ROM - Weight loss - NSAIDs - Intra-articular corticosteroid injection no sooner than 4-6 months (avoid cartilage destruction) - Joint replacement in severe disease that affect functioning |
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Treatment of:
Rheumatoid Arthritis |
1. Education: Disease progression, Treatment options, Lifestyle implications
2. Exercise: maintain joint mobility & muscle strength (PT & OT) - reasess for devices needed 3. Meds: NSAIDS, Glucocorticoids, DMARDs (sulfasalazine, methotrexate), anticytokines (infliximab, etanercept), topical analgesic |
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Treatment of:
Gonnococcal Arthritis |
Surgical I&D
Cephalosporin for total 7-10 days. - IV (ceftriaxone 1g q24hrs) for 48 hrs inpt - with improvement --> PO cephalosporin to completion |
