Monoarthritis

1. Monoarthritis 28th February 2012 Tehseen Ahmed

2. Aims and Objectives • Aim • To be able to manage the patient with an acute hot joint • Objectives • By the end of this session you should be able to: • Undertake a relevant history from a patient presenting with an acute hot joint. • Form a differential diagnosis for the patient. • Appropriately further investigate / refer the patient. • Institute initial treatment for your patient.

3. Diagnostic approach • Case scenarios • Diagnostic clues • Investigation • Treatment • Picture quiz

4. Monoarthritis • Inflammation of a single joint • Can be acute or chronic.

5. Acute monoarthritis – Diagnostic approach • History • review of symptoms • previous joint disease or trauma • concurrent illnesses • family history • medication use – e.g. diuretics, anticoagulants • other risk factors • travel, sexual history, diet, tick bites, occupational history, alcohol and intravenous drug use

6. Acute monoarthritis – Diagnostic approach • Examination • Focus on the involved and contralateral joint and surrounding area • General examination to look for other affected joints • Look for systemic manifestations of disease

7. Scenario 1 • A 35 year old man presents with a 1 day history of an intensely painful and swollen left knee. He is struggling to weight bear and cannot bend his knee much. • He is otherwise well except for hypertension.

8. Onset of pain • “ I went to bed fine doctor. When I woke up I could hardly bend my knee” • Any previous similar episodes • “Never in my knee doc. But I had something similar affecting my foot last year. It lasted about two weeks.” • “A&E treated me for a skin infection and gave me some painkillers.” • Medications • “I take a tablet for my blood pressure when I remember …… it don’t half make me pee a lot though doc.” • Any alcohol? • “No more than average like…… 6 pints a night say”

9. On examination

10. Diagnosis?

11. Gout • Most common cause of inflammatory arthritis in adults • Usually men >40 years and post-menopausal women • Initially acute monoarthritis • Associated with hyperuricaemia, renal impairment, diuretics, hypertension, hyperlipidaemia, excess alcohol, obesity • Family history in some

12. Gout • 50-70% of first attacks affect the big toe. • Other frequently affected joints include the midfoot, ankle, knee, wrist, and elbow. • Shoulders and hips rarely involved. • Can have low grade temperature. • Raised inflammatory markers (can be very high) with neutrophilia. • Majority of patients have further attacks. • Tophi can develop in chronic disease.

13. Scenario 2 • A 35 year old American tourist presents with a 2 day history of an intensely painful and swollen left knee. He is struggling to weight bear and cannot bend his knee much. • He reports feeling feverish.

14. Onset of pain “ It has swollen up over a few days and it feels hot” Any previous similar episodes “First time I have had anything like it” Medications “I don’t take anything” Any alcohol? “Very little” Associated symptoms “I felt feverish last night” “I noticed a couple of new spots on my body ………. ….like acne” Anything else? “I had a one-night stand last week …….. I didn’t use any protection” “Could it be related?”

17. Diagnosis?

18. Gonococcal arthritis • Gonococcal arthritis is caused by infection with the gram-negative diplococcus neisseria gonorhhoeae. • In the US, gonococcal arthritis is the most common form of septic arthritis. • This is in contrast to Western Europe, where gonococcal arthritis is uncommon. • Gonococcal arthritis is ultimately a consequence of disseminated gonococcal infection. • Haematogenous spread of the mucosal infection occurs in up to 3% of cases. • Time from initial infection to manifestations of disseminated infection ranges from 1 day to 3 months.

19. It manifests as either a bacteraemic infection (arthritis-dermatitis syndrome; 60% of cases) or as a localized septic arthritis (40%). • Arthritis-dermatitis syndrome includes the classic triad of dermatitis, tenosynovitis, and migratory polyarthritis. • Septic arthritis form • Joint symptoms begin within days to weeks of gonococcal infection. • Usually affects one joint. • Most commonly knees, wrists, ankles, elbows. • Synovial fluid cultures can be positive in up to 50% of cases • Cultures from likely sites of initial infection will increase the yield. • Blood culture / Cervix / Rectum / Urethra / Pharynx. • PCR testing of samples can also increase yield if cultures are negative. • Patients with gonococcal arthritis usually require initial IV abx. • Unlike in Staph. aureus septic arthritis, joint destruction is rare.

20. Scenario 3 • An 80 year old woman with type 2 diabetes and rheumatoid arthritis presents with a two week history of increasing pain and swelling in her right wrist. • Her rheumatoid is well controlled on medication but her wrist has been a problem and has been injected with steroids recently. • She is feeling feverish and unwell.

21. On examination

22. Diagnosis?

23. Septic arthritis • More common in those with inflammatory arthropathies, joint prostheses, impaired immunity. • Any age affected but more commonly young and elderly. • Systemic symptoms usually present but beware in immunocompromised. • Fever has poor sensitivity and specificity for septic arthritis. • Synovial fluid culture positive in 90%. • More than one joint can be involved in up to 20% of cases.

24. Scenario 4 • 85 year old woman • RA, OA of the knees, Leg ulcers, Hypertension, PPM • Awaiting Right TKR • 2 week history of marked swelling in her left knee • Started suddenly following some physiotherapy • Not systemically unwell.

25. On examination Large, warm effusion left knee. Any further info?

28. Haemarthrosis • Not always associated with a history of trauma. • Usually significant swelling. • Traumatic causes include cruciate ligament rupture and intra-articular fracture. • Other causes include pigmented villonodular synovitis and bleeding diatheses.

29. In approximately 1/3 of cases of monoarthritis no definitive diagnosis will be identified even after appropriate investigation.

30. Diagnostic clues

31. Sudden onset of pain over seconds to minutes • Trauma • Onset of pain, swelling, tenderness maximal within 12 hours • Crystal arthropathy • Onset of pain over several hours or 1-2 days • Crystal arthropathy • Septic arthritis • Monoarthritic presentation of other inflammatory arthropathy

32. Insidious onset of pain & swelling over days-weeks • Low grade/atypical infection, OA, malignancy, granulomatous disease • DM, Cellulitis, Prosthetic joints, RA, IV drug abuse • Septic arthritis • Steroid exposure • Septic arthritis • Avascular necrosis • Coagulopathy, Use of anticoagulants • Haemarthrosis

34. Other causes of monoarthritis

35. Seronegative spondyloarthropathies

36. Monoarthritic presentation of polyarthritis

37. Pseudogout • More elderly age group. • Mean age early 70’s. • Acute monoarticular presentation. • In CPPD can also get oligoarticular and occasionally polyarticular disease (can mimic RA). • Often affects the knee, wrist, or shoulder. • Triggers include: • Intercurrent illness • Trauma • Surgery

38. Investigations • JOINT ASPIRATE !!! • Gram stain • M, C & S • Crystal analysis

39. Investigations • Blood cultures • Bloods – ESR/CRP, FBC, U+E’s, Clotting • X-ray – affected and contralateral joint • Consider:serum urate, CXR, sputum sample, urine culture, skin swabs

40. Treatment – depends on the cause! • Aspirate joint • Analgesia – NSAIDs, Colchicine • Rest / Ice / Elevation • Antibiotics if indicated – 2 weeks IV, 4 weeks oral follow-on • Intra-muscular/Intra-articular/Oral steroids if indicated

41. Learning points • In acute inflammatory monoarthritis, symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy. • Serum uric acid levels do not confirm or exclude gout. • Demonstration of urate crystals in synovial fluid or tophus aspirates is diagnostic of gout. • Beware that gout and sepsis can co-exist. • Repeated culture of synovial fluid, blood and other sources of sepsis may be needed if initial samples are negative but clinical suspicion remains high. • In a young patient with a monoarthritis but no history of trauma, refer to rheumatology NOT orthopaedics.

42. References • Lingling M, Cranney A, Holroyd-Leduc JM. Acute monoarthritis: What is the cause of my patient’s swollen joint? CMAJ. 2009 January 6; 180(1): 59–65 • Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis?JAMA 2007 Apr 4;297(13):1478-88