The Red Hot Joint

James Bateman

Rheumatologist

One Real Case from UHNS which tells you all you need to know about

hot jointsYou are an FY1 in GP

• 31 year old presents to his with a 1 day history of painful clavicle/sternum.

• Temporary patient at the surgery

Differential Diagnosis at this stage?

What do you think?

• HPC

• PMHx

• Drug History

• Social History

• Systemic enquiry

• What are you going to do?

In A&E

• What are you going to do?

What are you sending the fluid for?

What will it tell you?

Gram positive cocci

Other Imaging…

Diagnosis: Septic arthritis

Whats missing?

Pathogenesis

FY1 in GP

• 70 year old lady,– Painful knee– AF on warfarin– DM type II– Hypertensive on BFZ and ACEi– Left knee is painful and swollen– Struggling to weight bear– What are you going to do?

In ED what are you going to do?

• History

• Investigations

• Treatments?

• Procedures?

• Imaging?

• In what order?

What Now?

• Do you need to do anything else?

What’s if you see this?

92 year old female with swollen knee

21 year old students with a swollen ankle and tenosynovitis

Case 1

• 82 year old lady• Admitted acute on chronic knee pain 3-4 days• Recent excision of shin BCC with skin graft

complicated by cellulitis• Ex Not unwell afebrile MEWS O• Warm, slightly tender knee effusion, tolerating

90 flexion• ? Wound infection started on antibiotics• CRP 187

Case 1• Radiological

abnormality?• Differential

diagnosis?• Further

investigations?• Management?

Example

• DB 45 year old man• PMH RA on

sulphasalazine• 4 day history painful

hot swollen red right big toe

• Differential?• Investigations?

Case 3

• 82 year old man• PMH LVF,AF, TIA, BPH• DH Aspirin, bumetanide, ramipril, digoxin,

statin• Referred with acute on chronic wrist pain

needing MST• WBC 13, CRP 155, Cr 143, XR OA

changes• Diagnosis and plan?

What single investigation is going to give you the answer?

• Joint Aspiration:– Need: green needle– Need: Sterile field– Syringe– Microbiologist– White topped bottle

What are other differentials for

monoarticular pain?

Monoarthritis - differential

• Monoarticular sero-ve spondyloarthritis eg psoriatic and reactive arthritis

• Monoarticular RA

Monoarthritis - differential

• Haemarthroses

(warfarin, bleeding disorders)

• Trauma – fracture, internal derangement, haemarthroses

Others to think about

• Osteonecrosis/AVN

(steroids/alcohol/SLE)

• Prosthetic joint -

loosening, # or infection

Others to think about

• Periarticular pathology

• Cellulitis

Septic arthritis

• 15-30 per 100,000 population

• Fatal in 11% of cases in UK

• Delayed or inadequate treatment leads to irreversible joint damage

How do you get septic arthritis?

Who gets septic arthritis ?

Who gets septic arthritis?• pre-existing joint disease

• prosthetic joints

• low SE status, IV drug abuse, alcoholism

• diabetes, steroids, immunosuppression

• Skin lesions e.g. ulcers, particularly in context RA often source of infection

• Which organisms cause septic arthritis?

Which organisms?

• common organisms Staphylococci or Streptococcus

• Elderly & immunocompromised gram -ve organisms

Which organisms?

• Anaerobes more common with penetrating trauma

• Pseudomonas - IV drug abusers

• young adults - significant incidence gonococcal arthritis

Who gets septic arthritis?

• poor prognostic features:

older

pre-existing joint disease & presence of syntheticmaterial within joint

What are the signs and

symptoms of septic

arthritis?

Symptoms & signs of septic arthritis

• Symptoms usually present for < 2/52

• Typically hot, swollen, red tender joint with reduced range of movement, difficulty weight bearing

• Night and rest pain • Large joints more

commonly affected than small

• majority of joint sepsis in hip or knee

• Systemic upset (MEWS)

Symptoms & signs of septic arthritis

• In pre-existing inflammatory joint disease symptoms in affected joint(s), out of proportion to disease activity in other joints.

• 10% of cases > one joint

• presence of fever not reliable indicator

• Features of gonococcal arthritis ?

Gonococcal arthritis• Women>men• Menses, pregnancy• 1-3% arthritis• 1day- weeks after sexual

encounter• Migratory (70%),

Tenosynovitis (70%), monoarthritis (32%), polyarthritis (10%)

• Fever, Dermatitis (pustules, vesicular, haemorrhagic bullae, mac.papular)

What investigations are useful

in septic arthritis?

Investigations

• Synovial fluid aspiration– gram stain/m,c,s– Absence of organism does

not exclude septic arthritis– polarised light microscopy

(crystals)

– NB suspected prosthetic joint sepsis should ALWAYS be referred to orthopaedics

Investigations• Blood cultures

• Significant proportion blood cultures + ve in absence of + ve synovial fluid cultures

• FBC ESR & CRP

• Absence of raised WBC, ESR or CRP does not exclude diagnosis of sepsis

Other investigations• CRP useful for monitoring response to

treatment

• Urate may be normal in acute gout

• U+E & LFT – prognosis and influence antibiotic regime

Other tests?

• Gonococcal - skin pustule - skin swab, urethral/cervical /rectal/throat swab, blood culture, joint aspirate

• genitourinary or respiratory tract infection then culture sputum and CXR & MSU

• If periarticular sepsis – appropriate swabs and cultures

• Radiology ?

Imaging

• Plain X rays no benefit in diagnosis but form baseline for any future joint damage. May show chondrocalcinosis (pyrophosphate arthritis).

• MRI sensitive for osteomyelitis and spinal involvement

Imaging

• Ultrasound useful in guiding needle aspiration eg hip

• White cell scanning helpful in diagnosing prosthetic sepsis

• What are the radiological features of infected prosthesis?

Prosthetic infection

Spinal infection

• Discitis – with destruction end plates

• Management?

• MEWS score?

• Shock?

• Multi-organ failure?

• RESUSCITATION

Antibiotic treatment of septic arthritis

• Local and national guidelines

• Liaise with micro. guided by gram stain

• Conventionally given iv for 2 weeks or until signs improve, then orally for around 4 weeks

Joint drainage & surgical options

• medical aspiration, surgical aspiration via arthroscopy or open arthrotomy

• Suspected hip sepsis – early orthopaedic referral – may need urgent open debridement

Recommendations specific to 1o care & emergency department

• commonest hot joint to present in 1o care is 1st MTP gout

• diagnosed on clinical grounds without needle aspiration or referral to hospital. (Make referral if inadequate recovery)

• Some GPs aspirate & inject joints for inflammatory arthritis or osteoarthritis. If withdraw pus/unexpected cloudy fluid should send sample with patient to local emergency department

Recommendations specific to 1o care & emergency department

• GPs & doctors in EAU should refer patients with suspected septic arthritis to specialist with expertise to aspirate joint.

• May be orthopaedic surgeon or rheumatologist

• Admit if sepsis is suspected or confirmed.

Summary

• with a short history of a hot, swollen, tender joint (or joints) plus restriction of movement; septic arthritis until proven otherwise

• If clinical suspicion high investigate & treat as septic arthritis even in absence of fever – always joint aspiration and blood cultures

GOUT

• Definition and metabolism?

Gout

• An inflammatory arthritis caused by hyperuricaemia

• Uric acid is formed from the breakdown of purines (DNA)

• Excreted in the urine• Characterised by the deposition of

urate crystals in the joints and soft tissues

Gout Epidemiology

• Prevalence 1-2%

• Most common cause of inflammatory arthritis in men 3-5:1 and post-menopausal women

• Usually presents between 40-60 years

• Risk factors?

• Associations?

Risk factors for Gout • Genetics

• Gender, age, OA

• Diet – red meat, seafood

• Alcohol

• Drugs – diuretics, low dose aspirin, cyclosporin, anti-TB drugs

Risk factors for Gout

• Renal disease

• Metabolic syndrome – hypertension, obesity, dyslipidaemia and insulin resistance

• Diagnosis of gout ?

Polarized microscopy - negatively birefringent needle shaped crystals

Clinical - usually self-limiting monoarthritis

• Usually resolves 7-10 days

Diagnostic criteria for gout – ACR criteria

• > 1 attack of acute arthritis• Maximum inflammation within 1 day• Attack of monoarthritis• Redness over joints• Painful or swollen 1st MTP• Unilateral attack 1st MTP• Unilateral attack tarsal joint• Tophus• Hyperuricaemia• Asymmetric swelling within joint on x-ray• Subcortical cysts without erosions on x-ray• Joint fluid culture –ve for organisms• 6 or more criteria

Chronic gout

• Up to 10 years to develop

• Less painful• Older age• Tophi – hands, feet,

elbows, ears• Erosions• Poly/oligoarticular

Erosive gout

• Pyrophosphate arthritis features ?

Clinical

• Acute monoarthritis in elderly esp in hospital

• Chronic polyarthritis with hypertrophic OA changes

Chondrocalcinosis

• Polarized microscopy features?

• Metabolic Causes?

• Triggers?

Pyrophosphate Crystals

Metabolic Causes of pyrophosphate arthritis

• Haemochromatosis

• Hyperparathyroidism

• Hypophosphatasia

• Hypomagnasaemia

Triggers of pyrophosphate arthritis

• Management of gout?

Management of acute gout

• Analgesic

• NSAIDs

• ? increased risk of GI side-effects - co-prescription of gastro-protective agents

• Colchicine in doses of 500 µg bd–qds

Management of acute gout

• Ct allopurinol if on it

• Steroids

• Alternative anti-hypertensive to diuretics

Non-Pharmacological

• Weight reduction

• skimmed milk and/or low fat yoghurt, soy beans and vegetable sources of protein, cherries encouraged

• Restrict red meat, offal, shellfish and yeast extracts.

• Reduce alcohol

Management of recurrent, intercritical and chronic gout

• uric acid lowering drug therapy:

• second attack, or further attacks occur within 1 yr

• with tophi

• with renal insufficiency

• with uric acid stones

Management of recurrent, intercritical and chronic gout

• uric acid lowering drug therapy:

• Commencement delayed until 1–2 weeks after inflammation has settled

• allopurinol starting in a dose of 50–100 mg/day and increasing by 50–100 mg increments every few weeks, adjusted if necessary for renal function, until the therapeutic target (SUA <300 µmol/l) is reached (maximum dose 900 mg)

• NB renal impairment, elderly, azathioprine

• Febuxostat – new non-purine xanthine oxidase inhibitor

Management of recurrent, intercritical and chronic gout

• Uricosuric agents: second-line drugs, under-excretors of uric acid and resistant/intolerant of allopurinol eg sulphinpyrazone in patients with normal renal function or benzbromarone in patients with mild/moderate renal insufficiency.

• Colchicine should be co-prescribed following initiation of treatment with allopurinol or uricosuric drugs, and continued for up to 6 months

• In patients who cannot tolerate colchicine, an NSAID or Coxib can be substituted provided that there are no contraindications, but the duration of NSAID or Coxib cover should be limited to 6 weeks

Other drugs and diseases

• consider losartan and fibrate if hypertensive and hyperlipidaemia (uricosuric)

• Screen for and treat metabolic syndrome

THANK-YOU