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Clin Med- P > spondylarthropathy/septic arthritis > Flashcards

spondylarthropathy/septic arthritis Flashcards

1
Q

what are Spondyloarthropathies? what another name for it?

A

Group of conditions manifested by inflammatory arthritis of back
Also called seronegative arthritis

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2
Q

ANA and RF are negative or positive for spondyloarthropathies?

A

both negative

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3
Q

what are entheses? ethesitis?

A
  • The enthesis (plural entheses) is the connective tissue between tendon or ligament and bone. There are two types of entheses: Fibrous entheses and fibrocartilaginous entheses
  • inflammation of these tendon/ligament connection
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4
Q

4 kinds of spondyloarthropathies that we talked about?

A
  1. Ankylosing Spondylitis (AS – prototype)
  2. Reiter’s/reactive arthritis
  3. Psoriatic arthritis
  4. Arthritis of inflammatory bowel disease
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5
Q

7 clinical features shared (to varying degrees) by the spondyloarthropathies? (kinda weeds)

A
  1. Axial joint involvement (spinal and SI joint)
  2. Asymmetric peripheral arthritis
  3. Enthesitis (inflammation of tendon insertion
  4. Eye and bowel inflammation
  5. Preceding or ongoing infectious disorders
  6. HLA-B27 association
  7. Genital and skin lesions
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6
Q

what is included in the axial involvement?

A

Inflammatory back pain
Prolonged am stiffness in back >30 minutes
Better with exercise
Usually slow onset,

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7
Q

what is dactylitis?

A

inflammation of tendon along entire digit- looks like sausage digit

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8
Q

genital + skin lesions involve what?

A 
Superficial oral ulcers, transient, painless and unnoticed
Nonspecific urethritis (urethra inflamed)
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9
Q

what is Ankylosing Spondylitis (AS)?

A

Chronic, inflammatory disease of axial skeleton, progresses over decades
Involves spine, sacroiliac joints and pelvic joints

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10
Q

what happens eventually with AS?

A
  • Eventual fusion of spinal vertebrae - eventually lose all spinal mobility
  • Hip flexion contractures
  • hyperkyphosis
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11
Q

who get AS?

A

More in men

Starts in 20s and 30s

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12
Q

likely pathophys of AS?

A

Likely autoimmune - b/c immmune suppression makes it better

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13
Q

PE and onset of AS ?

A

Inflammatory back pain and symmetrical SI pain and stiffness (morning stiffness)
Insidious onset > 3 months duration

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14
Q

what are the limitations in for AS?

A

Limitation of spinal rotation and lumbar flexion ( can’t touch toes)

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15
Q

3 things to look for in Dx of AS?

A
  1. Look for evidence of inflammation with blood tests (ESR, CRP, seronegative - ANA and RF negative)
  2. Look for sacroiliitis (inflammation in SI joint)
  3. Look for inflammation in vertebrae
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16
Q

imaging AS: what bones are first involved? is this as sign of early disease? why/why not?

A

SI joints: not an early sign for the disease

Inflammation of lining of joint –> once you see bony changes, a lot of damage is already done,

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17
Q

3 types of imaging studies for SI?

A

X-ray - easy, cheap, show bony changes
MRI - most sensitive
Bone Scan

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18
Q

what is one characteristic sign of imaging of back for AS?

A

“bamboo spine” - vertebrae fuse at points around the disc

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19
Q

Diffuse idiopathic skeletal hyperostosis (DISH) (kinda weeds) - how does it compare to AS?

A

Usually fewer/less severe symptoms of spinal stiffness
Looks like AS on X ray
No S-I involvement
ESR and CRP are nl

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20
Q

non-pharm txt for AS? (2)

A

PT- make sure spine fuses (b/c it eventually will) - into the correct position
surgery stabilization- may need if they fracture b/c can’t heal on their own

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21
Q

AS: why should we not use toxic meds unless severe disease?

A

b/c AS doesnt increase morbidity or mortality

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22
Q

3 options for pharm txt of AS

A
  1. Non-steroidal anti-inflammatory to control pain and inflammation
  2. Steroid injections for single joint flares
  3. Severe disease: Biologic agents (TNF-α)
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23
Q

txt for acute uveitis (very common!) with AS?

A

topical corticosteroids and mydriatics are usually adequate.

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24
Q

what is reiter’s syndrome

A

reiter’s a reactive arthritis : Triad of eye inflammation (Uveitis or conjunctivitis), urethritis, and oligoarthritis after infection

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25
Q

what is “Reactive arthritis” that doesn’t qualify as “reiter’s”

A

Incomplete triad:

Oligoarthritis of lower extremities within 6 weeks of infection

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26
Q

reiter’s and reactive arthritis ; more men or women?

A

men

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27
Q

clinical presentation of reactive arthritis/reiter’s? (what prompts it, where is the arthritis and pain? )

A 
After STD (chlamydia) or gastroenteritis (Salmonella, Shigella, Campylobacter)
Oligoarthritis
Few, asymmetrical large joints
Back pain not common
Enthesopathy
Ulcers
28
Q

dx of reactive arthritis/reiters:

A

ESR and CRP increased

29
Q

pharm txt options for reactive arthritis/reiters? (4 options)

A

1 .NSAID:control pain, and do it well, don’t prevent progression

  1. Sulfasalazine: if NSAIDs don’t work
  2. Methotrexate:Only for severe disease
  3. steroid injections
30
Q

what is the “rule of thirds” for reiter’s?

A

1/3 self limited (< 6 months)
1/3 goes into remission and recurs intermittently
1/3 never subsides, waxing and waning

31
Q

psoriatic arthritis (PsA) occurs in ___% of those with psoriasis

A

10%

MUST have psoriasis for it to be called PsA

32
Q

other than psoriasis skin, what are two other physical presentations of PsA?

A 
Dactylitis (sausage digits) 
Nail changes (Pitting and ridging)
33
Q

join distribution for PsA?

A

Pretty much any joint or pattern- just have to have the skin rash
Often involves DIPs, spine and sacroiliac joints

34
Q

Dx lab tests for PsA

A

elevated ESR and CRP
Elevated uric acid (tested only when NOT an active flare
–B/c of skin turnover from rash
–Sometimes mistaken for gout

35
Q

non-pharm txt of PsA

A

PT

Surgery if needed once arthritis progressed

36
Q

pharm txt for PsA? (what to use and what to avoid? )

A

THINK about DMARDS- don’t just txt the symptoms.

no steroids- b/c will cause pustular psoriasis that can become systemic and kill you
- injection is ok just not oral

37
Q

what is “the most severe PsA”?

A

“arthritis mutilans” - joint is destroyed within months

38
Q

arthritis assoc. with inflamm bowel: what two types of inflamm. bowel? what is it like?

A

Ulcerative Colitis and Crohn’s

Nonerosive and non-deforming

39
Q

clinical presentation of “arthritis assoc. with inflamm. bowel

A

symptoms of inflammatory bowel and arthritis

  • Arthritis tends to be less active than bowel
  • Few peripheral joints and/or axial involvement
40
Q

txt of arthritis w/ inflamm bowel

A

Treat inflammatory bowel disease and usually arthritis gets better

41
Q

how do you know someone has spondyloarthropathy? (where is the pain? what are the “common features”)?

A
  • Inflammatory back pain/ few peripheral joints

- other common features: Enthesopathy- uveitis, skin ulcers, IBD

42
Q

which type of spondyloarthropathy?…If primarily back symptoms and losing motion in back

A

AS

43
Q

which type of spondyloarthropathy?..psoriasis

A

PsA

44
Q

which type of spondyloarthropathy?…History of inflammatory bowel

A

arthritis of inflamm bowel

45
Q

which type of spondyloarthropathy?…History of previous infection (GU or GI) and now triad or part of triad

A

reactive arthritis or Reiter’s syndrome

46
Q

two types of septic arthritis

A

gonoccocal and non-gonoccocal

47
Q

nongonoccocal arthritis: where does it come from ? is it dangerous?

A

Results from persistent bacteremia in synovial fluid plus joint w/ history of damage (e.g. arthritic, prosthetic joints)
Urgent: destruction of joint very quickly

48
Q

viral septic arthritis: how does it compare to bacterial?

A

less aggressive, self-limited, and without major sequelae

49
Q

clinical presentation for NG septic arthritis, what causes pain? what joint is most commonly involved?

A

Sudden acute pain, swelling and heat over joint

  • pain w/ ROM
  • knee most common
50
Q

PE for NG septic arthitis

A

Fever - systemically sick, acute
Soft tissue swelling or joint effusion warmth & erythema
If prosthetic joint then may be loosened
Painful and decreased ROM

51
Q

labs: NG septic arthritis

A

increased WBCs
ESR/CRP increased - ESR may normal but CRP will be VERY high
Blood cultures positive in 50%

52
Q

what does joint fluid analysis show for NG septic arthitis?

A

WBCs > 50,000 (specific for synovial fluid) with >90% neutrophils

53
Q

xray of NG septic arthritis

A

Are negative early, then demineralization

Erosions and degenerative change in 2 weeks

54
Q

3 part txt of NG septic arthritis

A
  1. Antibiotics (4-8wks: IV then PO, broad –> narrow)
  2. Drain joint of infected fluid, either with needle or surgically
  3. Rest acutely, then move, to maintain mobility of the joint
55
Q

2 types of drainage for NG septic arthritis

A

Arthrocentesis: Aspirating joint (draw all fluid off) daily if clinically improving. Continue until dry
Arthrotomy: Surgically opening the joint to drain

56
Q

whens is arthrotomy used over arthrocentesis? (for NG septic arthritis)

A

Do this over arthrocentesis if hip or not getting better with arthrocentesis

57
Q

NG septic arthritis: rest and splint joint until clinically better, then do what?

A

ASAP active range of motion exercise to preserve joint ROM and function

58
Q

3 potential complications of NG septic arthritis

A
  1. 10% die from sepsis
  2. Osteoarthritis and bony ankylosis
  3. Osteomyelitis
59
Q

what is gonococcal septic arthritis ?

A

Joint can be normal- just need GC infection - not as much as an emergency as non-gonoccocal

60
Q

epidemiology of Gon. Septic arthritis

A
  • If acute monoarticular arthritis < 35 yo it is GC until proven wrong
  • Women
61
Q

-Most common acute bacterial arthritis

A

gonococcal septic arthritis

62
Q

how does someone get Gon. arthritis?

A

GC spread hematogenously (through blood) to joint

not super destructive though

63
Q

clinical presentation of Gon. arthritis? (two phases)

A
  1. Multiple joint pains without frank arthritis
  2. Then one of two things…
    Tenosynovitis or Purulent monoarthritis(Knee most common)
64
Q

PE of Gon. arthritis

A
  1. +/- fever
  2. One swollen joint or tenosynovitis
  3. Rash (lesions on arms/legs, palms and soles)
65
Q

what does CBC and synovial fluid show for Gon. arthritis?

A

CBC: Mildly elevated serum WBCs

Synovial fluid: looks infected, WBCs> 50,000

66
Q

Dx: gold standard for Gon. arthritis? what an alternative Dx method?

A

culture it! hard to culture, but gonorrhea is a reportable disease, so culture everything
(NAAT is a good alternative to culture)

67
Q

txt for gon. arthritis? (4)

A
  1. most likely admit
  2. (make sure not endocarditis) - echo to check
  3. Ceftriaxone for 48 hours, then oral cephalosporins for 7-10 days
  4. Don’t forget it’s an STD and to check/treat for Chlamydia

Clin Med- P (124 decks)

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