Monoarticular arthritis
Septic Arthritis
Gonococcal Arthritis
Healthy, young sexually active adults
Women > men
Suppurative monoarthritis (may be preceded by polyarthralgias)
Knee, wrist, ankle
Arthritis-Dermatitis Syndrome
-Triad: dermatitis, tenosynovitis, migratory polyarthritis (hematogenous spread of bacteria and immune complexes)
-Skin lesions: scattered small painless erythematous macules or petechiae-->pustular -->necrotic lesions
-Transient painful extensor tenosynovitis (writs, hands, ankles)
-Asymmtric polyarthralgia of extremity joints
DiagnosisCx everything - jt, mucosal surfaces, lesions
TreatmentCTX 1gIV qd OR
Cefotax 1g q8
Empirically treat Chlamydia
Nongonococcal Arthritis
Fulminant presentation (abrupt, swelling, toxicity and fever) unless elderly
-Hematogenous
-Contiguous
-Direct traumatic implantation
-Postop
CausesBacterial
Mycobacterial
Spirochete (lyme, syphilis)
Fungal
VIral (HIV, Hep B, Rubella, etc)
Postinfectious
DiagnosisSynovial fluid aspiration
Cx - if only one test, use BCx bottles (may enhance yield)
Grm stain - 80% positive in gram-positive infxn; less sens in gram-negative
Cell count with dif - >50,000-150,000; PMN > 90%
TreatmentPCN-ase resistant synthetic PCN:
Nafcillin 1-2g
Cefazolin 1-2g
AND
3rd gen ceph
OR
Vanc*
- new evidence suggests significantly increased rate of MRSA septic arthritis
- cell counts are as low as 20,000 in MRSA Cx + synovial fluid
Crystal-Induced Monoarthritis
Gout
Monosodium urate crystals - needle shaped negative birefringence
Swelling, redness, warmth evolving rapidly over hours todays
First MTP (podagra) 60% > ankle > midfoot > knee
May have constitutional complaints
Precipitants: purine-rich food, EtOH, trauma, chemo, diueretic use, RI
DiagnosisSynovial fluid aspiration (above)
Note: serum uric acid levels unhelpful; ESR/CRP may be elevated
TreatmentNSAIDS eg Naproxen 500mg po bid x 3d and taper over 4-7d
Colchicine 0.6mg po qh x 3 or 1mg PO f/b 0.5mg q1h until relif, GI upset, or 8mg max
Can give 1-2mg IV over 30mins
- No further doses after initial load
- avoid NSAIDS, Colchicine in RF
Steroids
-Prednisone 40-60mg po qd x 3d f/b 7d taper
Pseudogout
Calcium pyrophosphate dihydrate (CPPD) - rhomboid shaped positive birefringence
chondrocalcinosis
acute attacks of mono or oligoarticular inlammatory arthritis
progressive joint deenerative changes similar to OA
Evolves over days
Age > 50
Knee, wrists, ankles, elbows
Systemic illness, surgery, trauma triggers
Assoc with hyperparathyroidism and hemochromatosis
Traumatic
Fracture
ligamentous
Overuse
Ischemic
Avascular necrosis
Decompression illness
Spontaneous osteonecrosis
pain in abscence of trauma
femoral head, medial conyle of knee
Hemorrhagic
Posttraumatic
-Joint aspiration if tense
-RICE
Hemophilia
Systemic anticoagulation
Neoplastic
Mets
Osteochondroma
Osteoid osteoma
Pigmented villonodular synovitis
Systemic Disease
Remote infxn, infectious endocarditis
Rheumatic fever
Seronegative (no RF) spondyloarthropathies (AS, IBS, psoriatic, reactive or Reiter's)
Rheumatoid arthritis, SLE
Sarcoidosis, amyloidosis
Periarticular
these conditions mimic joint involvement...
Cellulitis
Tendonitis
Bursitis
Peds
don't forget about...
Acute Transient Synovitis
-Children 3-10yo
-1-3 wks after viral illness
Self-limited
SCFE (portly pubescent)
Leff-Calve-Perthes (young school-age children)
Source
H-N