Clinical Approach to Acute Arthritis: A Diagnostic Guide by Dr. Afsar Sayeeda

1. Clinical Approach to Acute Arthritis DR.AFSAR SAYEEDA MRCP(UK) CONSULTANT INTERNIST & RHEUMATOLOGIST HEAD CTU DIVISION,DEPT OF MEDICINE KING KHALID UNIVERSITY HOSPITAL

2. Normal Joint..

3. ARTHRALGIA / ARTHRITIS • INTRAARTICULAR / PERIARTICULAR /NONARTICULAR • MONOARTHRITIS/ POLYARTHRITIS • INFLAMMATORY / NONINFLAMMATORY

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

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

6. Acute Monoarthritis - Etiology • THE MOST CRITICAL DIAGNOSIS TO CONSIDER: INFECTION ! • SEPTIC(gonococcal/nongonococcal) • CRYSTAL INDUCED(gout, pseudogout) • TRAUMATIC (fracture, internal derangement) • Other (hemarthrosis, osteonecrosis, presentation of polyarticular disorders)

7. 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

8. 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

9. 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.

10. 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.” • Any alcohol? • “No more than average like…… 6 pints a night say”

11. On examination

12. Diagnosis?

13. Acute Gouty Arthritis

14. Gout • Most common cause of inflammatory arthritis in adults • Usually men >40 years and post-menopausal women • Initially acute monoarthritis • Risk Factors -Primary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis. • Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure. • Family history in some

15. Caused by monosodium urate crystals. • 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.

16. Gout • Can have low grade temperature.(mimics infection) • Raised inflammatory markers (can be very high) with neutrophilia. • The cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis. • Majority of patients have further attacks. • Tophi can develop in chronic disease.

17. Urate Crystals • Needle-shaped • Strongly negative birefringent

18. Scenario 2 • A 35 year old American tourist presents with a 2 day history of an intensely painful and swollen left knee. He is unable to bear weight and has marked difficulty in bending his knee. • He reports feeling feverish.

19. 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?”

22. Diagnosis?

23. 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. • 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.

24. It manifests as either a bacteraemic infection (arthritis-dermatitis syndrome.tenosynovitis; 60% of cases) or as a localized septic arthritis (40%). • 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. • Unlike in Staph. aureus septic arthritis, joint destruction is rare.

25. 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.

26. On examination

27. Diagnosis?

28. Septic arthritis • More common in those with inflammatory arthropathies, joint prostheses, impaired immunity.(DM,Cancer) • Any age affected but more commonly young and elderly. • Systemic symptoms usually present but not in immunocompromised. • Fever has poor sensitivity and specificity for septic arthritis. • Synovial fluid culture positive in 90%. • Knee joint - commonest .(others-Hip, shoulder) • Most develop from hematogenous spread. • Monoarticular-80% Polyarticular- 20%.

29. SEPTIC ARTHRITIS • Bacterial Gonococcal Non-gonococcal -Gram positive aerobes (80%) (Staphylococcus aureus(60%) , non­group-A beta-hemolytic streptococci, gram-negative bacteria(18%), & Streptococcus pneumoniae) • Viral– HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus • Fungal

30. 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.

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

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

33. Pseudogout • More elderly age group. • Mean age early 70’s. • Acute monoarticular presentation. • Occpolyarticular- . • Often affects the knee, wrist, or shoulder. • Triggers include: • Intercurrent illness • Trauma • Surgery CPPD disease may be asymptomatic (deposition of CPP in cartilage).

34. CPPD Crystals • Rod or rhomboid-shaped • Weakly positive birefringent

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

36. Diagnostic clues

37. 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

38. Insidious onset of pain & swelling over days-weeks • Low grade/atypical infection, OA, malignancy, granulomatous disease. • Previous similar attacks?,drugs-diuretics – crystals or inflammatory arthritis. • DM, Cellulitis, Prosthetic joints, RA, IV drug abuse,a recent infection • Septic arthritis • Steroid exposure • Septic arthritis • Avascular necrosis • Coagulopathy, Use of anticoagulants • Haemarthrosis

39. Other causes of monoarthritis

40. Seronegative spondyloarthropathies

41. Monoarthritic presentation of polyarthritis

42. Investigations JOINT ASPIRATE !!! • Gram stain • C & S • Total leucocyte count • Polarising microscopy (Crystal analysis)

43. 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

44. 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

45. 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.

46. Polyarthritis • Definite inflammation (swelling, tenderness, warmth of > 5 joints • A patient with 2-4 joints is said to have pauci- or oligoarticular arthritis

47. Inflammatory Vs. Noninflammatory

48. Approach to Inflammatory Arthritis • Main Diagnostic Groupings – 3 • RA, SPA, SLE • Crystalline arthritis • Infectious arthritis

49. Temporal Patterns in Polyarthritis • Migratory: Rheumatic fever • Additive : RA, SLE, psoriasis • Intermittent: Gout, reactive arthritis

50. Patterns of Joint Involvement • Symmetric: viral, RA, SLE, psoriasis. • Asymmetric, : reactive arthritis, psoriasis, enteropathic arthritis. • DIP joints: Psoriatic.