acute hot swollen joint - rcp london

Acute hot swollen joint

Dr Edward Roddy

Senior Lecturer in Rheumatology and Consultant Rheumatologist

Acute monoarthritis: differential diagnosis

• Septic arthritis

• Crystal arthritis (gout, pseudogout)

• Haemarthrosis

• Reactive arthritis

• Monoarticular presentation of inflammatory arthritis

• Traumatic synovitis

Septic arthritis

• The most serious cause of monoarthritis

• A medical emergency

• Mortality 10%

• Persistent pain, joint damage, functional impairment 30%

Weston Ann Rheum Dis 1999

Septic arthritis: risk factors

• Extremes of age

• Low socioeconomic status

• Immunosuppression

• alcoholism, diabetes mellitus

• Any joint pathology (esp RA)

• Joint prosthesis

• Previous ia steroid injection

• Cutaneous ulcers

• iv drug abuse Mathews Ann Rheum Dis 2007Mathews Lancet 2010

Septic arthritis: clinical features

• Sub-acute onset over 1-2 weeks

• Painful, swollen, red, tender joint(s)

• 85% present as monoarthritis

• Knee most common

• Fever absent in 50%

• Features of infection elsewhere?

Mathews Ann Rheum Dis 2007Mathews Lancet 2010

Septic arthritis: which joint?

0

5

10

15

20

25

30

35

%

Weston Ann Rheum Dis 1999

Septic arthritis: diagnosis

• Refer prosthetic joints to orthopaedics

• Aspirate the (native) joint

• frank pus, Gram stain, WCC, culture & sensitivity

• as soon as possible

• prior to starting antibiotics

• Blood cultures

• Markers of infection may be absent

• X-rays of limited value acutely

Coakley Rheumatology 2006Mathews Ann Rheum Dis 2007

Markers of infection

0

10

20

30

40

50

60

70

80

90

100

Fever Elevated WCC ESR>20mm/hr CRP>20mg/l SF WCC >50000/mm3

%

Weston Ann Rheum Dis 1999Coutlakis J Clin Rheumatol 2002

Septic arthritis: organisms

Staph aureus

MRSA

Staph epidermidis

Strep spp

Gram negative spp

Gupta Rheumatology 2001

Septic arthritis: management

• Medical resuscitation

• iv antibiotics

• following joint aspiration

• according to local guidelines

• modify with results of Gram stain & cultures

• typically 2 weeks iv, then 4 weeks oral

• Analgesia!!

• Daily aspiration/arthroscopic washout

• Surgical removal of implant Coakley Rheumatology 2006Mathews Ann Rheum Dis 2007

Acute gout

[Na] + [Urate] Male gender

Family history

Alcohol excess

Dietary purines

Metabolic syndrome

Obesity

BP

Renal impairment

Diuretics

Osteoarthritis

Acute arthritisTophi

Chronic gouty arthritis

Acute gout: clinical features

• Typical features of crystal inflammation

• Rapid onset (<24 hours)

• Severe pain, heat, swelling, (erythema)

• Exquisite tenderness

• Skin desquamation

• May be systemic upset

• 1st attack 1st MTPJ in 50-70%

• 1st MTPJ = gout likely

Zhang Ann Rheum Dis 2006Roddy J Foot Ankle Res 2011

“The patient goes to bed and sleeps quietly till about two in the morning, when he is awakened by a pain

which usually seizes the great toe…The pain resembles that of a dislocated bone…and this is

immediately succeeded by a chillness, shivering and a slight fever. The pain grows gradually more violent

every hour, and comes to a height towards evening…becomes so exquisitely painful as not to

endure the weight of the clothes nor shaking of the room from a person’s walking briskly therein”

Thomas Sydenham (1624-89)

Acute gout - other sites

Roddy J Foot Ankle Res 2011

Acute gout: diagnosis

• Crystal identification is the gold standard

• Not necessary when classical podagra

• Consider when:• presentation atypical

• affects joints other than 1st MTPJ

Zhang Ann Rheum Dis 2006

Acute gout: lab tests

• Serum uric acid:

• Acute phase reactant: normal during attack in 25-49%

• Hyperuricaemia does not equal gout

• But useful for monitoring therapy

• WCC/ESR/CRP may well be elevated


Acute gout: management

• Aim: rapid relief of pain and inflammation

• Main options:

• NSAIDs

• Colchicine

• Corticosteroids

Acute gout: NSAIDs

• No evidence for any particular NSAID

• Any fast-acting NSAID at full dose

• eg naproxen, diclofenac

• Indomethacin best avoided

• Gastrointestinal concerns:

• PPI as indicated

• etoricoxib 120mg daily

Schumacher BMJ 2002Sutaria Rheumatology 2006Zhang Ann Rheum Dis 2006

Janssens Lancet 2008Khanna Semin Arthritis Rheum 2014

Acute gout: colchicine

• Traditional dosing regime

• 1mg initially then 500mcg every 2-3 hours

• until pain abates or diarrhoea/vomiting occurs

• BNF since November 2008:

• 500mcg two to four times daily

• until symptoms relievedAhern Aust NZ J Med 1987

Morris BMJ 2003Sutaria Rheumatology 2006Zhang Ann Rheum Dis 2006

Terkeltaub Arthritis Rheum 2010Khanna Semin Arthritis Rheum 2014

Acute gout: other options

• Joint aspiration/injection

• Oral/intramuscular steroids

• eg prednisolone 20mg daily

• when NSAIDs/colchicine inappropriate AND

• joint injection not possible (site of attack, expertise, multiple joints)

• Local application of ice-packs

Schlesinger J Rheumatol 2002Sutaria Rheumatology 2006Zhang Ann Rheum Dis 2006

Janssens Lancet 2008Khanna Semin Arthritis Rheum 2014

What to do with allopurinol?

• Not normally started during attack

• But not stopped if attack occurs

• attack = “successful treatment” not a “side-effect”

Don’t reinforce the myths

• Gout is:

• Not funny

• Not self-inflicted

• Not a rich man’s disease

• Commonly nothing to do with diet or alcohol

Acute pseudogout

Calcium pyrophosphate crystal deposition

• Common age-related phenomenon

• Very rare under 50 years

• Most common cause of cartilage calcification

• Acute pseudogout

Acute pseudogout: clinical features

• Acute attack of synovitis at a single joint

• Typical features of crystal inflammation

• Rapid onset (<24 hours)

• Severe pain, heat, swelling, (erythema)

• Exquisite tenderness

• Systemic upset common

• Knee most common site

• Most likely cause of acute arthritis of knee, wrist or shoulder >65 years


Acute pseudogout: diagnosis

• Crystal identification is the gold standard

• Radiographic chondrocalcinosis• Common at the knee, wrist, symphysis pubis

• Does not confirm acute pseudogout

• Can be caused by other crystals too

• Insensitive may miss small deposits

• Diagnosis should be crystal-proven

Acute pseudogout: management

• Aims for rapid relief of joint pain/swelling

• Joint aspiration/injection is treatment of choice

• NSAID – caution in elderly, consider PPI

• Low-dose colchicine 500mcg bd-qds

• im/oral steroid if:

• joint difficult to inject eg mid-foot

• oligo/polyarticular attacks

• Topical ice therapy


Sepsis or crystals?

• History: speed of onset

• Crystals: rapid (<24 hours)

• Septic arthritis: sub-acute 1-2 weeks

• Gout very likely if 1st MTPJ

• Knee over 65 years suggests CPPD; less certain

• Can’t rely on fever/WCC/ESR/CRP

• Serum uric acid often normal in acute gout

• Joint aspiration is the investigation of choice

When not to aspirate?

• Prosthetic joints

• Overlying skin infection

• Difficult joints – hip, mid-foot

• Anticoagulation

• Rapid onset of severe pain and tenderness at 1st MTPJ: aspiration probably not needed

Image courtesy of Prof M Doherty

Key messages

Joint aspiration is the single investigation of choice

Acute gout:

• NSAID or low-dose colchicine first-line

• don’t stop allopurinol

Fever, WCC, ESR, CRP, uric acid are poor discriminators

Septic arthritis:

• aspirate ASAP but before antibiotics

• high-dose iv antibiotics

Acute pseudogout:

• acute arthritis of knee, wrist, shoulder in over 65s

• CC not reliable: aspiration needed

• Low-dose colchicine/steroids first-line

acute hot swollen joint - rcp london

Documents