ORTHOPAEDIC BLUNDER

• WARD 5F• EDENDALE

HOSPITAL

HISTORY

• 24/02- N.M- 24 YEAR OLD BLACK MALE

• ORTHOPAEDIC WARD-CONSULT-ON SKIN TRACTION X2/52…..??ARTHRITIS

• C/O- PAINFUL SWOLLEN JOINTS X2/12• -UNABLE TO WALK• - LOSS OF FUNCTION>> L HAND

• ON ENQUIRY- EARLY MORNING STIFFNESS-FIRST EPISODE- LOW , NO LOA, NIGHTSWEATS- NO HX TB/ TB CONTACTS

- NO HX OF CONJUNCTIVITIS; VISUAL PROBLEMS

-NO PENILE D/C, INCONTINENCE

• PAST MEDICAL HX/ SURGICAL HX-NAD

• SOCIAL HX- NO ROH, SMOKING, TOXIC SUBSTANCES

ON EXAMINATION

• IN BED, UNABLE TO WALK; PALLOR+;ORAL CANDIDIASIS; SHOTTY CERVICAL L/N; NO JAUNDICE; NOT EMACIATED; NO SKIN LESIONS.

• CHEST= CLEAR; NORMAL CHEST EXP• C.V.S= NAD• ABDOMEN= SNT; NO SPLENOMEGALY; NOI

PENILE D/C

• CNS= GCS- 15/15; PEARL; NO CONJUNCTIVITIS

• SENSORY SYSTEM= DECREASED VIBRATION SENSE; JOINT POSITION SENSE LOWER LIMBS

• MOTOR SYSTEM- NO FASICULATIONS; NO MUSCLE WASTING; TONE= NORMALPOWER- L.L= 3/5; U.L= 4/5; DECREASED REFLEXES- L.L NO CLONUS OR BABINSKI.

• MUSCULOSKELETAL SYSTEM- SWOLLEN TENDER JOINTS- DIP, PIP,

WRIST,ELBOW, ANKLE- SYMMETRICAL, NO EFFUSIONS-DECREASED POWER ACTIVE +

PASSIVE .- NO DEFORMITIES

ASSESSMENT

• R.V.D----ORAL CANDIDIASIS---L/N’S

• POLYARTHRITIS—SYMMETRICAL• PERIPHERAL NEUROPATHY

INVESTIGATIONS

• X-RAY– L HAND; KNEE;CXR• FBC- HB= 10; MCV=101; WBC=5;

PLT=259;TLC=1100• U+E= NAD• LFT- TP=88; ALB= 14• LDH= 680; CK= 140• ESR=105MM/HR]

• COLLAGEN VASCULAR SCREEN = NEGATIVE

• RHEMATOID FACTOR = NEGATIVE• HIV=ELISA POSITIVE• VIT B12<<100• FOLATE=4.8• U/S ABDOMEN = NAD

FINAL DIAGNOSIS

• HIV +• VITAMIN B12 DEF-----SUBACUTE

DEGENERATION OF SPINAL CORD• SERONEGATIVE SYMMETRICAL

POLYARTHRITIS?? HIV RELATED

TREATMENT

• FOLATE; VIT B12; DIFLUCAN• NSAID- INDOCID 25MG TDS• PRENISOLONE 40MG DAILY• INH; VIT B6• O.T• ******IMPROVEMENT ----after 2/52

function of hand back; able to walk

DISCUSSION

• APPROACH TO ARTHRITIS• MANAGEMENT OF ARTHRITIS• HIV + ARTHRITIS• HIV + MACROCYTIC ANAEMIA

MUSCULOSKELETAL COMPLAINT

• 1. ARTICULAR ?• 2.ACUTE / CHRONIC• 3. INFLAMMATION• 4.HOW MANY JOINTS• 5. SYMMETRICAL ??

ARTICULAR-complaint >>6/52

• ACUTE• Acute arthritis• Infectious arthritis• Gout• Pseudogout• Reiters syndrome• Initial presentation

• CHRONIC• Is there inflammation

no yes

HOW MANY JOINTS??

• <3• INDOLENT INFXN• PSORIATIC• REITERS• PAUCIARTICULAR

J.A

• > 3• CHRONIC

INFLAMMATION• ASYMMETRICAL--PSORIATIC--REITERSSYMMETRICAL--R.A

• ESTABLISH DIAGNOSIS OF R.A

• DOCUMENT BASELINE DX ACTIVITY + DAMAGE

• ESTIMATE PROGNOSIS

INITIATE THERAPY

• EDUCATE• START DMARD WITHIN 3/12• CONSIDER NSAID• CONSIDER LOCAL/ SYSTEMIC

STEROIDS• OT

PERIODICALLY ASSESS DX ACTIVITY

• ADEQUATE RESPONSE WITH DECREASING DX ACTIVITY

• INADEQUATE RESPONSE—ONGOING ACTIVE DX AFTER 3/12 RX

• CHANGE / ADD DMARD

• MULTIPLE DMARD FAILURE/ STRUCTURAL JT DAMAGE =SURGERY

MUSCULOSKELETAL MANIFESTATIONS OF HIV

• MYOPATHIES- PYOMYOSITIS- POLYMYOSITIS- RX S/E

INFLAMMATORY ARTHROPATHIES# ARTHRALGIA- 45% OF PTS- ?? CYTOKINES/ TRANSIENT BONE

ISCHAEMIA

• -ANY STAGE OF HIV • 50 TO 70% OF ACUTE HIV• ACUTE ONSET , SEVERE PAIN• 4 OR FEWER JOINTS• << 24 HRS; SELF-LIMITING• LATE STAGES OF HIV- 10% OF AIDS• RX= NSAID

ACUTE SYMMETRICAL POLYARTHRITIS

• RESEMBLES POLYARTHRITIS• SMALL JTS OF HAND ACUTE ONSET;

R.F= NEGATIVE• X- RAY MIMICS R.A• GOLD THERAPY

HYPERTROPHIC OSTEOARTHROPATHY

• SYSTEMIC D/O AFFECTING BONES, JTS, SOFT TISSUES WITH PCP

• SEVERE PAIN LOWER EXTREMITIES; DIGITAL CLUBBING; ARTHRALGIAS; NON PITTING OEDEMA; PERIARTICULAR SOFT TISSUE INVOLVEMENT OF ANKLE, KNEE, ELBOW

• REITERS SYNDROME• PSORIATIC ARTHRITIS• AVASCULAR NECROSIS

HIV ASSOCIATED ARTHRITIS

• 1ST DESCRIBED 1988• 2 THEORIES-RXN TO IMMUNE

COMPLEXES WITHIN SYNOVIUM; DIRECT HIV INFXN OF SYNOVIUM–HIV + ASSAY SYNOVIAL FLUID

• >> MALES• ACUTE ONSET; SEVERE PAIN,

DISABILITY >>KNEES + ANKLES

• X RAY= OSTEOPAENIA, NO ERROSIONS

• HLA B27, R.F = NEGATIVE• SYNOVIAL BIOPSY= CHRONIC

MONONUCLEAR INFILTRATES• RX = NSAID

HIV + MACROCYTIC ANAEMIA

• MALABSORPTION• ACHLORYDIA

THE END• RHEMATIC DX AND

AIDS- JOSEPH GOLBUS 1994

• GUIDELINES MX R.A-2002 UPDATE-AMERICAN COLLEGE

• HARRISONS-15TH

• MUSCULOSKELETAL MANIFESTSTIONS OF HIV- AIDS READER 2003