approach to the hot swollen - rcp london
TRANSCRIPT
Approach to the hot swollen
joint
History
Examination
Investigations
When to get help
Septic Arthritis
Gout
CPPD/Pseudogout
History/Examination
Site
Monoarthritis vs oligo-(<4) or polyarthritis
Onset
“Went to bed normal” –crystal arthritis
Preceeding illnesses
Last 6 weeks – diarrhea; urogenital infection; intravesicular BCG
Trauma
History/Examination
Fevers/rigors/SEPSIS
Restricted range of movement
Eyes: conjunctivitis, uveitis
Mouth: oral ulceration
Skin: keratoderma
blenorrhagica, psoriasis,
erythema nodosum
Genital: ulceration, urethritis,
discharge
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British Society of Rheumatology
“Patients with a short history of a hot,
swollen and tender joint (or joints) with
restriction of movement should be
regarded as having septic arthritis until
proven otherwise”
Coakley G., et al., BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology
(2006) , 45(8) pp 1039-1041
Investigations
Neutrophilia Septic arthritis
↑ESR/CRP Non-specific: inflammatory arthritis
Immunology: ANA
Rheumatoid Factor
Anti-CCP
Lupus
RA/Sjorgrens/MCTD/SLE
Rheumatoid Arthritis ?palindromic
RA
Clotting Prior to aspiration. Presence of
haemarthosis
Synovial Fluid Interpretation
White cell count: EDTA bottle
<2000 white cells/mm3 – non-inflammatory
>2000 wcc/mm3 – inflammatory
Higher values eg >50,000 wcc/mm3 – joint sepsis
Polymorphs just suggests inflammatory process
Lymphocytosis – TB?
Gram stain, allow ≥48 hours culture
Some organisms don’t show up on gram stain or culture
Fluid crystals
Can I aspirate?
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RELATIVE C.I.
Anticoagulation –
aspirate if infection
suspected
Plts – aspirate
Haemophilias – factor
support
ABSOLUTE C.I.
Septic Arthritis
Most serious differential
Between 8-27% of presentations of acutely swollen joints1,2
11% mortality3
Hot, swollen, tender joints
Very often decreased range of movement
May not be a fever
Polyarticular septic arthritis
Up to 22% of all septic arthritis thought to be polyarticular4
20% afebrile4
Only 63% leucocytosis4
Other studies of pneumococcal septic arthritis
Up to 36% patients polyarticular disease5
Endocarditis, HIV
RA, Diabetes, EtOH excess
Septic Arthritis
Coakley G. et al. BSR & BHPR, BOA, RCGP and BSAC
guidelines for management of the hot swollen joint in
adults. Rheumatology (2006); 45:1039-1041
Aetiology
Haematogenous or direct
Often damaged joints eg RA, SLE
Differential: reactive?
Reactive arthritis vs septic joint? Suspect sepsis if WCC
>50,000mm3 (higher count, higher suspicion)6
Septic arthritis
Common agents:
Gonococcal – especially in young, sexually active
Staphylococcus aureus
Prosthetic joints
Immunocompromised
Rheumatoid arthritis
Strepotococcus viridans, S pneumoniae and Group B
streptococci
Pseudomonas in IVDU
MRSA residential care/hospitalized/skin ulcers
Imaging
Limited use from plain films
chondrocalcinosis
MRI
Osteomyelitis
Hips require radiologically guided aspiration
USS
Orthopaedics with image intensfier
Sepsis Six
THREE IN
①Antibiotics
②Oxygen – high flow
③Fluid: Hartmanns
30-60ml/kg
THREE OUT
①Lactate
②Catheter – hourly
urine output
③Blood Cultures
Aspirate the joint before antibiotic (but
don’t delay antibiotic therapy)
Antibiotic choices
2 weeks IV, 4 weeks oral
Flucloxacillin
Rifampicin
Useful for killing organisms that are protected within a
biofilm
Not used alone
Consider MRSA or pseudomonas risk factors
Involve microbiology: ITU, IVDU
Surgical options
Arthroscopic drainage
Arthroscopic lavage
Prosthetic joint infection
Removal of joint followed by 6 weeks antibiotic therapy
Realm of T&O only
Prosthetic joints must only be aspirated in a sterile
environment (i.e. orthopaedic theatre)
Gout: epidemiology
Epidemiology
M:F = 9:1
Prevalence increases in women after menopause
Risk factors
Increased urate production
Psoriasis, malignancy, obesity
Increased purine intake
Meat, alcohol
Renal risk factors
Genetics
Metabolic syndrome
Renal impairment
Drugs that reduce renal function
Relationships between hyperuricaemia and insulin resistance, cardiovascular disease and hypertension7
Drugs
Low dose aspirin
Calcineurin inhibitors
Diuretics
Urate nephropathy
Chronic uric acid nephropathy
Chronic interstitial nephritis
Uric acid nephrolithiasis
Acute uric acid nephropathy
Urate crystals precipitate out and obstruct tubules
Often with malignancy or tumour lysis
Manage by lowering serum urate levels
General principles of acute
flare
Treat secondary inflammatory process (synovitis)
More effective if started sooner
Don’t attempt to lower urate in acute flare
Don’t stop already commenced urate lowering therapy
Hydrate
Stop precipitating medication if possible
Low dose salicylate
Thiazide or loop diuretics
Management of acute flare:
oral NSAIDs
Poor quality RCTs – but anecdotally very useful
Commonly used
Safety
GI
Renal failure and CKD
Cardiovascular events with COX-2 inhibitors
Naproxen 500mg BD
Management of acute flare:
oral COLCHICINE
500 micrograms TDS
Reduce dose if CrCl <45ml/min
Diarrhoea, peripheral neuopathy
Caution with statins, clarithromcyin, drugs that inhibit
Cytochrome P450 3A4
Caution in severe hepatic or renal impairment
Use UNTIL FLARE SUBSIDES
Management of acute flare:
intrarticular steroids
Commonly used where comorbidites preclude use of NSAIDs/colchicine
One (or two) affected joint(s)
Exclude infection
Not to be used in systemic infection
Little direct evidence in gout
Anecdotally very effective, quick
Management of acute flare:
Oral glucocorticoids
Cannot tolerate NSAIDs/colchicine
Multiple joint flare
Caution:
Heart failure
Poorly controlled hypertension
Diabetes
Prednisolone 30 – 50mg daily
Taper over 7-10 days after resolution flare
Prone to recurrence on withdrawal
Management of acute gout
in end stage renal disease
Commonly glucocorticoids used
Any residual kidney function or peritoneal dialysis:
AVOID NSAIDs
Colchicine is not removed by haemodialysis –
colchicine toxicity
Avoid colchicine if GFR <10ml/min/1.73m2
Gout prophylaxis
Not to be commenced acutely
Can trigger an acute gout flare on commencement
Allopurinol
Usually 300mg/d
100mg/d renal failure
Titrate dose to maintain plasma urate concentration <350micromol/L
Check FBC, UEs
Febuxostat
Others: lesinurad, probenecid, benzbromarone, sulfinpyrazone
CPPD (Pseudogout)
Typically modelled on the treatment of acute gout
Intraarticular steroid injection
NSAIDs
Oral colchicine
Oral glucocorticoids (with a steroid taper)
Prophylaxis
Involve rheumatology – low dose colchicine/NSAIDs
Summary
Septic arthritis: significant mortality
Remember polyarticular septic arthritis
Warfarin/DOACs not a contraindication to needle aspiration
Gout: acute management
NSAIDs
Colchicine
Oral/intra-articular prednisolone
CPPD/pseudogout
References
1. Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluid tests. What should be ordered? JAMA. 1990;264(8):1009.
2. Jeng GW et al. Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis. Am J Emerg Med. 1997;15(7):626
3. Coakley G. et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology (2006); 45:1039-1041
4. Dubost JJ et al. Polyarticular septic arthritis. Medicine (1993):72:296-310
5. Ross JJ. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis (2003);36:319-27
6. Mathews CJ, Coakley G, Septic arthritis: current diagnostic and therapeutic algorithm. Curr OpinRheumatol. 2008;20(4):457.
7. Anker AU et al. Uric acid and survival in chronic heart failure: validation and application in metabolic, functional, and hemodynamic staging. Circulation. 2003;107(15):1991.