Rheumatological Emergencies PDF

Preview

Summary

notes on rheumatology emergencies...

Description

Rheumatological Emergencies Teaching 8.10.19 Septic Arthritis Overview:  Most serious cause of monoarthritis  MEDICAL EMERGENCY  Mortality up to 10% - cause sepsis  Staph aureus most common Risk factors:  Extremes of age  Low socioeconomic status  Immunosuppression, any joint pathology especially RA  Joint prosthesis  Previous steroid injection  Cutaneous infection  IV drug use Symptoms:  Fever - fever absent in 50%  Red, hot, swollen joint acutely o Knee most common  Features of infection elsewhere  Acute, or subacute onset over 1-2 weeks  Looks ill  People with an inflamed joint hold it in flexion  Persistent pain, joint damage, functional impairment in 30% Investigations:  Bloods  Blood cultures  Joint aspiration in any suspected joint – frank pus, gram stain, WCC, C+S  X-rays of limited value acutely  FBC – elevated WCC, ESR, CRP (most sensitive)  MRI Management:  Medical resuscitation  IV antibiotics o Following joint aspiration o Modify with results of gram stain and culture o 2 weeks IV, then 4 weeks oral  Treat according to sepsis protocol if suspect sepsis  Analgesia  Daily aspiration/arthroscopic washout  Surgical removal of implant may be required  Refer to orthopaedic surgeons

Crystal Arthropathies – Gout

Risk factors:  Male gender – females do not tend to get gout, only really post-menopausal obese women get it  Family Hx  Alcohol excess  Dietary purines – bacon, turkey, liver, veal, oily fish, muscles, anchovies  Metabolic syndromes  Obesity  Increased BP  Renal impairment  Diuretics  Osteoarthritis – gout leads to osteoarthritis and recurrent gout can lead to osteoarthritis Symptoms:  Typical features of inflammation – rapid onset Men  >50 years  Visual loss in up to 1/5 of patients  Prompt treatment is essential Symptoms:  Abrupt onset new headache  Scalp pain/tenderness (diffuse or localised; difficult combing hair)  Jaw and tongue claudication  PMR symptoms – proximal myalgia  Visual symptoms (amaurosis fugax, blurring, diplopia)  Systemic symptoms of fever, weight loss, loss of appetite

Examination:  Fever  Abnormal superficial temporal artery  Reduced visual acuity  Pale, swollen Investigations:  FBC, ESR, CRP, CPK  Igs and serum electrophoresis  RLB profiles  Urinalysis  CXR  USS of temporal arteries – halo sign  Referral to ophthalmology if visual symptoms  Temporal artery biopsy – preferably within 1 week of starting steroids (may remain +ve for 2-6 weeks) Management:



 

Steroids – start on all patients with suspected GCA o 40-60mg until symptoms and lab abnormalities resolve o Reduce 10mg every 2 weeks until 20mg o Reduce 2.5mg every 2-4 weeks until 10mg o Reduce 1mg every 1-2 months provided no relapse Methotrexate Tocilizumab

Drug Reactions Methotrexate pneumonitis:  Patients may start becoming SOB  Counsel patients beforehand Infection in patients on biologics:  Adalimumab is a TNF inhibitor and is the most effective drug worldwide  rare association with cardiac failure  Increased risk of infection  May reactivate TB  Counsel patients to stop biologics

Bechet’s syndrome Epidemiology:  More common in the eastern Mediterranean (e.g. Turkey)  More common in men (complicated gender distribution which varies according to country. Overall, Bechet’s is considered to be more common and more severe in men)  Tends to affect young adults (e.g. 20 - 40 years old) Associated with HLA B51  Around 30% of patients have a positive family history Features:  Mouth/genital ulcers  Loss of vision  Sero-negative arthropathy  Skin lesions  Thrombophlebitis and DVT  Bowel problems  Associated with HLA B51  Pathergy  minor trauma such as a bump or bruise leads to the development of skin lesions or ulcers that may be resistant to healing.  Erythema nodosum  Arthritis  Neurological involvement (e.g. aseptic meningitis) Classically: 1) oral ulcers 2) genital ulcers

3) anterior uveitis

Diagnosis:  no definitive test  diagnosis based on clinical findings  positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with small pustule forming)  ANA  Anti-neutrophil cytoplasmic antibodies

Management:  No cure  Corticosteroids  Immunosuppressants – azathioprine, infliximab  Biological therapies  Skin creams, gels, ointments  Mouth rinses  Eyedrops

Spondyloarthrides Spondyloarthrides comprise a group of syndromes which are distinct from rheumatoid arthritis and are characterised by inflammation of the spine in many (but not all) cases. Other key features include asymmetrical oligoarthritis, enthesitis, psoriatic skin and mucous membrane lesions, and eye and bowel inflammation. Tests for anti-CCP and other autoantibodies are negative, but there is a strong association with the human leukocyte antigen HLA-B27.

Summary table:

Common features:  Associated with HLA-B27  Rheumatoid factor negative - hence 'seronegative'

   

Peripheral arthritis, usually asymmetrical Sacroiliitis Enthesopathy: e.g. Achilles tendonitis, plantar fasciitis Extra-articular manifestations: uveitis, pulmonary fibrosis (upper zone), amyloidosis, aortic regurgitation

Spondyloarthropathies:  Ankylosing spondylitis  Psoriatic arthritis  Reiter's syndrome (including reactive arthritis)  Enteropathic arthritis (associated with IBD)

Reactive Arthritis Overview:  HLA-B27 associated seronegative spondyloarthropathy  Reiter's syndrome  classic triad of urethritis, conjunctivitis and arthritis following a dysenteric o ‘can’t see, pee, or climb a tree’  Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint  Post-STI form much more common in men 10:1  Post-dysenteric form equal sex incidence Features:  Typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months  Arthritis is typically an asymmetrical oligoarthritis of lower limbs  Dactylitis (inflammation of a digit i.e. finger/toe)  Symptoms of urethritis  Eye: conjunctivitis (seen in 10-30%), anterior uveitis  Skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles) Causes:  STI – Urethritis  Salmonella

Organisms:

Post-dysenteric form Shigella flexneri Salmonella typhimurium Salmonella enteritidis Yersinia enterocolitica Campylobacter

Post-STI form Chlamydia trachomatis

Management:  Symptomatic: analgesia, NSAIDS, intra-articular steroids  Sulfasalazine and methotrexate are sometimes used for persistent disease  Symptoms rarely last more than 12 months

Ankylosing Spondylitis Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old. Features:  Typically a young man who presents with lower back pain and stiffness of insidious onset  Stiffness is usually worse in the morning and improves with exercise  The patient may experience pain at night which improves on getting up Clinical examination:  Reduced lateral flexion  Reduced forward flexion - Schober's test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible  Reduced chest expansion Other features - the 'A's:  Apical fibrosis  Anterior uveitis  Aortic regurgitation  Achilles tendonitis  AV node block  Amyloidosis  and cauda equina syndrome  peripheral arthritis (25%, more common if female) Investigations:  Plain X-ray of sacro-iliac joints  Later changes in radiographs: o sacroiliitis: subchondral erosions, sclerosis o squaring of lumbar vertebrae o 'bamboo spine' (late & uncommon) o syndesmophytes: due to ossification of outer fibres of annulus fibrosus o chest x-ray: apical fibrosis  Spirometry – may show restrictive defect due to combination of PF, kyphosis, and ankylosis of the costovertebral joints

Management:  Encourage regular exercise such as swimming  NSAIDs are the first-line treatment  Physiotherapy  Disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement  2010 EULAR guidelines suggest: 'Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments'  Research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease Enteric arthropathy   

Associations: Inflammatory bowel disease, GI bypass, coeliac and Whipple’s disease Arthropathy often improves with the treatment of bowel symptoms (beware NSAIDS) Use DMARDS for resistant cases.

Psoriatic arthritis  

  

Occurs in 10–40% with psoriasis and can present before skin changes. Patterns are: o Symmetrical polyarthritis (like RA) o DIP joints o Asymmetrical oligoarthritis o Spinal (similar to AS) o Psoriatic arthritis mutilans (rare, ~3%, severe deformity) Radiology: Erosive changes, with ‘pencil-in-cup’ deformity in severe cases. Associations: nail changes in 80%, synovitis (dactylitis), acneiform rashes and palmo-plantar pustulosis. Management: NSAIDS, sulfasalazine, methotrexate and ciclosporin. Anti-TNF agents are also effective.

Rheumatology Serology...