WikEM - User contributions [en]

Giant cell arteritis

2016-11-01T04:58:55Z

Ajsantos: /* Background */

==Background==
*Systemic vasculitis most commonly involving medium-sized arteries in the carotid circulation affection 1% of the population<ref>Gonzalez-Gay, MA et al. Epidemiology of the vasculitides. Rheum Dis Clin North Am. 2001;27:729-749</ref>
*Giant cell arteritis, with possible involvement of large vessels like aorta leading to<ref>Morabito GC, Tartaglino B. Chapter 279. Emergencies in Systemic Rheumatic Diseases. In: JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. 's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hil</ref>:
**[[Temporal arteritis]]
**[[Aortic regurgitation]]
**Aortic arch syndrome
**[[Aortic dissection]]
*Elevated risk in Women and 50-70 yrs of age
*"Rule of 50s" can help remember useful points - "temporal arteritis affects patients at least 50 years of age, with a serum ESR > 50 mm/hr and is treated with 50mg of [[prednisone]] daily"
*Can cause painless, ischemic optic neuropathy with severe vision loss if left untreated
*Associated with [[polymyalgia rheumatica]] <ref> Lehrmann JF, Sercombe CT: Systemic Lupus Erythmatosus and the Vasculitides, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 116: p 1497-1510.</ref>
**50% of patients with Giant Cell Arteritis have concomitant Polymylalgia Rheumatica. 15% of patients with Polymyalgia Rheumatica develop Giant Cell Arteritis

==Clinical Features==
*[[Fever]]
*[[Headache]] in 85%
**Gradually worsens over days
**Worse at night
**Usually unilateral near temple
*Tender pulseless temporal artery
*Jaw claudication
**Weight Loss
*Myalgias (polymyalgia rheumatica)
*Visual loss in one eye in 50%
**Posterior ciliary artery
**May present as amaurosis fugax
**Second eye may be affected within weeks after first
===American College of Rheumatology Criteria<ref>Hunder GG. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990; 33(8):1122-8 </ref>===
*3 or more criteria 93% sensitive and 91% specific
**Age ≥ 50 years old
**New onset of headache
**Temporal artery tenderness or DECREASED temporal pulse (not related to carotid disease)
**ESR ≥ 50 mm/hr
**Artery biopsy with necrotizing arteritis or a granulomatous process with multinucleated giant cells

===Likelihood Ratio of Findings===
''Jaw claudication and a beaded temporal artery increase the likelihood of temporal arteritis the greatest''<ref>Smetana GW, et al. Does this patient have temporal arteritis? JAMA. 2002;287:92-101</ref>
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Finding'''
| align="center" style="background:#f0f0f0;"|'''(+) Likelihood Ratio of Temporal Ateritis'''
| align="center" style="background:#f0f0f0;"|'''Negative Likelihood Ratio'''
|-
| Jaw claudication||4.2 (2.8-6.2)||0.72 (0.65 - 0.81)
|-
| Diplopia||3.4 (1.3-8.6)||0.95 (0.91 - 0.99)
|-
| Temporal artery beading||4.6 (1.1 - 18.4)||0.93 (0.88-0.99)
|-
| Enlarged temporal artery||4.3 (2.1-8.9)||0.67 (0.5-0.89)
|-
| Painful temporal artery||2.6 (1.9-3.7)||0.82 (0.74-0.92)
|-
| Absent temporal artery pulse||2.7 (0.55 - 13.4)||0.71 (0.38 - 1.3)
|-
| Abnormal ESR||1.1 (1.0-1.2)||0.2 (0.08 - 0.51)
|}

==Differential Diagnosis==
{{Headache DDX}}

{{Acute vision loss noninflamed DDX}}

{{Primary Vasculitis DDX}}

==Evaluation==
*Temporal artery tenderness
*Afferent pupillary defect
*Pale and edematous optic disc
*ESR ~70-110
**84% sensitivity, 30% specificity<ref>Kermani TA, et al. Utility of erythrocyte sedimentation rate and C-reactive protein for the diagnosis of giant cell arteritis. Semin Arthritis Rheum. 2012; 41:866–871.</ref>
**>15% of patients can have a normal ESR
*CRP elevated
*4% of patients have normal CRP and ESR with biopsy confirmed diagnosis<ref>Jhun P, et al. Giant Cell Arteritis: Read the Fine Print! Ann Em Med. 2015; 65(5):615–617.</ref>

==Management==
*[[Methylprednisolone]] 1000mg IV QD x3d
*Needs temporal artery biopsy

==Disposition==
*Admission

==See Also==
*[[Headache]]

==References==
<references/>

[[Category:Ophthalmology]]
[[Category:Neurology]]
[[Category:Rheumatology]]

Gout and pseudogout

2016-11-01T04:14:43Z

Ajsantos: /* Evaluation */

==Pathophysiology==
*Primarily an illness of middle-aged males and elderly adults
*Gout in females occurs only after menopause
*Gout is most common form of inflammatory joint disease in men >40yr
*Presence of crystals does not exclude septic arthritis

===Precipitants===
*Trauma
*Surgery
*Medication ([[allopurinol]], thiazide/loop diuretics, ASA)
*Alcohol consumption
*Meat/Seafood consumption
*Dehydration
*Lower body temperature

==Clinical Features==
*Joint pain may develop over period of hours
*Primarily involves first MTP, knee, ankle

==Differential Diagnosis==
{{Differential Diagnosis Monoarthritis}}

==Evaluation==
*Synovial fluid aspiration
**Gout: yellow monosodium urate negative Negatively birefringent
**Pseudogout: calcium pyrophosphate positive birefringence crystals

*Serum uric acid levels are not helpful (30% of patients with gout attack have normal levels)
**Uric acid during attacks will be low due to the precipiation of gout crystals
** High uric acid is <6.8
*ESR may be elevated
*'''no bacteria on [[Gram Stain]]'''
*XR of joint space may have radiolucent calcium pyrophosphate formation as opposed to in [[gout]]
{{Arthrocentesis diagnostic chart}}

==Management==
''Patients usually only require [[opioid]] and [[NSAID]] treatment in the ED with continued [[NSAID]] treatment as an oupatient. However any combination of the following treatments are acceptable<ref>Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61</ref>''

===[[NSAIDs]]===
*Do not give to patients with renal insufficiency (use [[opioids]] instead)
*Substantial pain relief should occur within 2hr
*Options:
**[[Indomethacin]] 50mg po TID x3-5d, OR
**[[Naproxen]] 500mg po BID x3-7d, OR
**[[Ibuprofen]] 800mg PO TID x 3-5d

===Other options===
====[[Colchicine]]====
*Can be used as alternative agent to NSAIDs in patient with normal renal/hepatic function
*1.2mg PO (load), followed by 0.6mg one hour later x 1 <ref>Terkeltaub RA et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060.</ref>
*May use to maximum of x3 doses, with more aggressive regimens totaling max dose up to 6mg<ref>GlobalRPH. http://www.globalrph.com/gout.htm*colchicine</ref>
*Wait at least x3 days before starting another round of colchicine therapy
*Renal impairment not absolute contraindication for acute flare but may consider dose reduction.
*Dose adjustments for CYP3A4 inhibitors (HARRT, Calcium Channel Blockers, fluconazole, erythromycin, clarithromycin)
*Colchicine should not be administered intravenously

Initial: 0.6-1.2mg, followed by 0.6 every 1-2 hours; some clinicians recommend a maximum of 3 doses; more aggressive approaches have recommended a maximum dose of up to 6mg. Wait at least 3 days before initiating another course of therapy

====[[Steroids]]====
*[[Prednisone]] 30 to 50mg initially, and gradually tapered over 10 days, results in clinical resolution without rebound pain or complications<ref>Groff GD et al. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum. 1990;19(6):329</ref><ref>Janssens H. et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008;371(9627):1854.</ref>

====Glucocorticoid injection====
*Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a [[Septic Arthritis|septic joint]] can coexist with gout and a steroid injection would then worsen the patient's clinical status.

===All patients===
*Hold [[diuretics]]
*Consider starting [[losartan]] to replace diuretic (has modest uricosuric effect)
*Alcohol and dietary counseling
*Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
*Follow up with Primary Doctor or Rheumatology if having continued flares

==See Also==
*[[Joint Pain]]
*[[Monoarticular Arthritis]]
*[[Knee Diagnoses]]

==References==
<references/>
[[Category:Orthopedics]]
[[Category:Rheumatology]]

Gout and pseudogout

2016-11-01T04:12:05Z

Ajsantos: /* Evaluation */

==Pathophysiology==
*Primarily an illness of middle-aged males and elderly adults
*Gout in females occurs only after menopause
*Gout is most common form of inflammatory joint disease in men >40yr
*Presence of crystals does not exclude septic arthritis

===Precipitants===
*Trauma
*Surgery
*Medication ([[allopurinol]], thiazide/loop diuretics, ASA)
*Alcohol consumption
*Meat/Seafood consumption
*Dehydration
*Lower body temperature

==Clinical Features==
*Joint pain may develop over period of hours
*Primarily involves first MTP, knee, ankle

==Differential Diagnosis==
{{Differential Diagnosis Monoarthritis}}

==Evaluation==
*Synovial fluid aspiration
**Gout: yellow monosodium urate negative Negatively birefringent
**Pseudogout: calcium pyrophosphate positive birefringence crystals

*Serum uric acid levels are not helpful (30% of patients with gout attack have normal levels)
*ESR may be elevated
*'''no bacteria on [[Gram Stain]]'''
*XR of joint space may have radiolucent calcium pyrophosphate formation as opposed to in [[gout]]
{{Arthrocentesis diagnostic chart}}

==Management==
''Patients usually only require [[opioid]] and [[NSAID]] treatment in the ED with continued [[NSAID]] treatment as an oupatient. However any combination of the following treatments are acceptable<ref>Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61</ref>''

===[[NSAIDs]]===
*Do not give to patients with renal insufficiency (use [[opioids]] instead)
*Substantial pain relief should occur within 2hr
*Options:
**[[Indomethacin]] 50mg po TID x3-5d, OR
**[[Naproxen]] 500mg po BID x3-7d, OR
**[[Ibuprofen]] 800mg PO TID x 3-5d

===Other options===
====[[Colchicine]]====
*Can be used as alternative agent to NSAIDs in patient with normal renal/hepatic function
*1.2mg PO (load), followed by 0.6mg one hour later x 1 <ref>Terkeltaub RA et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060.</ref>
*May use to maximum of x3 doses, with more aggressive regimens totaling max dose up to 6mg<ref>GlobalRPH. http://www.globalrph.com/gout.htm*colchicine</ref>
*Wait at least x3 days before starting another round of colchicine therapy
*Renal impairment not absolute contraindication for acute flare but may consider dose reduction.
*Dose adjustments for CYP3A4 inhibitors (HARRT, Calcium Channel Blockers, fluconazole, erythromycin, clarithromycin)
*Colchicine should not be administered intravenously

Initial: 0.6-1.2mg, followed by 0.6 every 1-2 hours; some clinicians recommend a maximum of 3 doses; more aggressive approaches have recommended a maximum dose of up to 6mg. Wait at least 3 days before initiating another course of therapy

====[[Steroids]]====
*[[Prednisone]] 30 to 50mg initially, and gradually tapered over 10 days, results in clinical resolution without rebound pain or complications<ref>Groff GD et al. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum. 1990;19(6):329</ref><ref>Janssens H. et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008;371(9627):1854.</ref>

====Glucocorticoid injection====
*Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a [[Septic Arthritis|septic joint]] can coexist with gout and a steroid injection would then worsen the patient's clinical status.

===All patients===
*Hold [[diuretics]]
*Consider starting [[losartan]] to replace diuretic (has modest uricosuric effect)
*Alcohol and dietary counseling
*Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
*Follow up with Primary Doctor or Rheumatology if having continued flares

==See Also==
*[[Joint Pain]]
*[[Monoarticular Arthritis]]
*[[Knee Diagnoses]]

==References==
<references/>
[[Category:Orthopedics]]
[[Category:Rheumatology]]

Gout and pseudogout

2016-11-01T04:11:19Z

Ajsantos: /* Pathophysiology */

==Pathophysiology==
*Primarily an illness of middle-aged males and elderly adults
*Gout in females occurs only after menopause
*Gout is most common form of inflammatory joint disease in men >40yr
*Presence of crystals does not exclude septic arthritis

===Precipitants===
*Trauma
*Surgery
*Medication ([[allopurinol]], thiazide/loop diuretics, ASA)
*Alcohol consumption
*Meat/Seafood consumption
*Dehydration
*Lower body temperature

==Clinical Features==
*Joint pain may develop over period of hours
*Primarily involves first MTP, knee, ankle

==Differential Diagnosis==
{{Differential Diagnosis Monoarthritis}}

==Evaluation==
*Synovial fluid aspiration
**Gout: monosodium urate negative Negatively birefringent
**Pseudogout: calcium pyrophosphate positive birefringence crystals

*Serum uric acid levels are not helpful (30% of patients with gout attack have normal levels)
*ESR may be elevated
*'''no bacteria on [[Gram Stain]]'''
*XR of joint space may have radiolucent calcium pyrophosphate formation as opposed to in [[gout]]
{{Arthrocentesis diagnostic chart}}

==Management==
''Patients usually only require [[opioid]] and [[NSAID]] treatment in the ED with continued [[NSAID]] treatment as an oupatient. However any combination of the following treatments are acceptable<ref>Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61</ref>''

===[[NSAIDs]]===
*Do not give to patients with renal insufficiency (use [[opioids]] instead)
*Substantial pain relief should occur within 2hr
*Options:
**[[Indomethacin]] 50mg po TID x3-5d, OR
**[[Naproxen]] 500mg po BID x3-7d, OR
**[[Ibuprofen]] 800mg PO TID x 3-5d

===Other options===
====[[Colchicine]]====
*Can be used as alternative agent to NSAIDs in patient with normal renal/hepatic function
*1.2mg PO (load), followed by 0.6mg one hour later x 1 <ref>Terkeltaub RA et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060.</ref>
*May use to maximum of x3 doses, with more aggressive regimens totaling max dose up to 6mg<ref>GlobalRPH. http://www.globalrph.com/gout.htm*colchicine</ref>
*Wait at least x3 days before starting another round of colchicine therapy
*Renal impairment not absolute contraindication for acute flare but may consider dose reduction.
*Dose adjustments for CYP3A4 inhibitors (HARRT, Calcium Channel Blockers, fluconazole, erythromycin, clarithromycin)
*Colchicine should not be administered intravenously

Initial: 0.6-1.2mg, followed by 0.6 every 1-2 hours; some clinicians recommend a maximum of 3 doses; more aggressive approaches have recommended a maximum dose of up to 6mg. Wait at least 3 days before initiating another course of therapy

====[[Steroids]]====
*[[Prednisone]] 30 to 50mg initially, and gradually tapered over 10 days, results in clinical resolution without rebound pain or complications<ref>Groff GD et al. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum. 1990;19(6):329</ref><ref>Janssens H. et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008;371(9627):1854.</ref>

====Glucocorticoid injection====
*Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a [[Septic Arthritis|septic joint]] can coexist with gout and a steroid injection would then worsen the patient's clinical status.

===All patients===
*Hold [[diuretics]]
*Consider starting [[losartan]] to replace diuretic (has modest uricosuric effect)
*Alcohol and dietary counseling
*Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
*Follow up with Primary Doctor or Rheumatology if having continued flares

==See Also==
*[[Joint Pain]]
*[[Monoarticular Arthritis]]
*[[Knee Diagnoses]]

==References==
<references/>
[[Category:Orthopedics]]
[[Category:Rheumatology]]

Gout and pseudogout

2016-11-01T04:08:11Z

Ajsantos: /* Pathophysiology */

==Pathophysiology==
*Primarily an illness of middle-aged males and elderly adults
•Gout in females occurs only after menopause
*Gout is most common form of inflammatory joint disease in men >40yr
*Presence of crystals does not exclude septic arthritis

===Precipitants===
*Trauma
*Surgery
*Medication ([[allopurinol]], thiazide/loop diuretics, ASA)
*Alcohol consumption
*Meat/Seafood consumption
*Dehydration
*Lower body temperature

==Clinical Features==
*Joint pain may develop over period of hours
*Primarily involves first MTP, knee, ankle

==Differential Diagnosis==
{{Differential Diagnosis Monoarthritis}}

==Evaluation==
*Synovial fluid aspiration
**Gout: monosodium urate negative Negatively birefringent
**Pseudogout: calcium pyrophosphate positive birefringence crystals

*Serum uric acid levels are not helpful (30% of patients with gout attack have normal levels)
*ESR may be elevated
*'''no bacteria on [[Gram Stain]]'''
*XR of joint space may have radiolucent calcium pyrophosphate formation as opposed to in [[gout]]
{{Arthrocentesis diagnostic chart}}

==Management==
''Patients usually only require [[opioid]] and [[NSAID]] treatment in the ED with continued [[NSAID]] treatment as an oupatient. However any combination of the following treatments are acceptable<ref>Khanna D. et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res. Oct 2012;64(10):1447-61</ref>''

===[[NSAIDs]]===
*Do not give to patients with renal insufficiency (use [[opioids]] instead)
*Substantial pain relief should occur within 2hr
*Options:
**[[Indomethacin]] 50mg po TID x3-5d, OR
**[[Naproxen]] 500mg po BID x3-7d, OR
**[[Ibuprofen]] 800mg PO TID x 3-5d

===Other options===
====[[Colchicine]]====
*Can be used as alternative agent to NSAIDs in patient with normal renal/hepatic function
*1.2mg PO (load), followed by 0.6mg one hour later x 1 <ref>Terkeltaub RA et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060.</ref>
*May use to maximum of x3 doses, with more aggressive regimens totaling max dose up to 6mg<ref>GlobalRPH. http://www.globalrph.com/gout.htm*colchicine</ref>
*Wait at least x3 days before starting another round of colchicine therapy
*Renal impairment not absolute contraindication for acute flare but may consider dose reduction.
*Dose adjustments for CYP3A4 inhibitors (HARRT, Calcium Channel Blockers, fluconazole, erythromycin, clarithromycin)
*Colchicine should not be administered intravenously

Initial: 0.6-1.2mg, followed by 0.6 every 1-2 hours; some clinicians recommend a maximum of 3 doses; more aggressive approaches have recommended a maximum dose of up to 6mg. Wait at least 3 days before initiating another course of therapy

====[[Steroids]]====
*[[Prednisone]] 30 to 50mg initially, and gradually tapered over 10 days, results in clinical resolution without rebound pain or complications<ref>Groff GD et al. Systemic steroid therapy for acute gout: a clinical trial and review of the literature. Semin Arthritis Rheum. 1990;19(6):329</ref><ref>Janssens H. et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet. 2008;371(9627):1854.</ref>

====Glucocorticoid injection====
*Even if gout has been diagnosed in the past, be cautious with glucocorticoid joint injection if the current clinical picture is uncertain since a [[Septic Arthritis|septic joint]] can coexist with gout and a steroid injection would then worsen the patient's clinical status.

===All patients===
*Hold [[diuretics]]
*Consider starting [[losartan]] to replace diuretic (has modest uricosuric effect)
*Alcohol and dietary counseling
*Continue uric acid-lowering agents if already on prophylactic regimen (do not start)
*Follow up with Primary Doctor or Rheumatology if having continued flares

==See Also==
*[[Joint Pain]]
*[[Monoarticular Arthritis]]
*[[Knee Diagnoses]]

==References==
<references/>
[[Category:Orthopedics]]
[[Category:Rheumatology]]