Rheum - Monoarticular Arthritis Flashcards Preview

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Flashcards in Rheum - Monoarticular Arthritis Deck (34):
0

Patient with suspected gout. Next step? Best initial treatment?

Aspirations of joints to send food for cell count, culture, Crystal analysis.

If infection needs drainage. If crystal induced arthritis treat with colchicine, NSAIDs, or corticosteroids

1

Why is acute monoarthritis a medical emergency?

Could be infectious arthritis, which could lead to joint destruction and severe morbidity

2

Differential for monoarthritis?

1. Infection (bacterial, fungal, lime disease, TB)
2. Crystal induced arthritis (gout and pseudogout)
3. Systemic disease (rheumatoid arthritis or lupus)
4. Noninflammatory (trauma, osteoarthritis)

3

Gout most commonly involves? Pseudogout?

First MTP joint, ankle, midfoot, or knee

Knee, wrist, first MTP joint

4

Findings in gonococcal arthritis?

1. Migratory arthralgias and tenosynovitis on wrist and hands
2. Pustular skin lesions
3. Purulence

5

Location of gonococcal versus nongonococcal septic arthritis?

Wrists and hands versus large weight-bearing joints (knee and hip)

6

True arthritis versus bursitis?

Swelling, redness, painful limitations during active and passive motion

Versus

Full range of passive motion

7

Noninflammatory joint effusions: WBC count? Percentage of PMNs?

1000 to 2000. Less than 50% PMNs

8

Description of Gout versus pseudogout crystals?

Intracellular (within PMN), yellow, needle shaped, negatively birefringent crystals

Vs

Blue, Short & rhomboid, weakly positive birefringent crystals

9

Typical culture findings in gonococcal arthritis?

Negative joint fluid cultures but positive blood/skin lesion cultures

10

Normal joint aspirate volume? Viscosity? Color? Clarity? Leukocytes? PMNs? Culture? Glucose?

<25, Negative, equal to blood

11

Changes to joint aspirate findings in noninflammatory causes?

aspirate volume? Viscosity? Color? Clarity? Leukocytes? PMNs? Culture? Glucose?

Volume >1 mL
Straw to yellow color
50-10,000 leukocytes

12

Changes to joint aspirate findings in inflammatory causes?

aspirate volume? Viscosity? Color? Clarity? Leukocytes? PMNs? Culture? Glucose?

Volume >1 mL
Low viscosity
Yellow color
Translucent clarity
2000 – 75,000 leukocytes
Greater than 50 PMNs
About 50 mg/dL less glucose

13

Changes to joint aspirate findings in septic causes?

aspirate volume? Viscosity? Color? Clarity? Leukocytes? PMNs? Culture? Glucose?

>1 mL
Variable viscosity
Variable color
Opaque clarity
>100,000 leukocytes
Greater than 85% PMNs
Positive cultures
50 mg/dL lower glucose

14

X-ray finding that suggests monoarthritis etiology?

Chondrocalcinosis (linear calcium deposition in joint cartilage) suggests pseudogout

15

Treatment for gonococcal arthritis?

Ceftriaxone

16

Typical cause of nongonococcal septic arthritis? Treatment?

Staph aureus. Nafcillin or vancomycin

17

Stages of gout?

1. Asymptomatic hyperuricemia
2. Acute gouty arthritis (severe monoarticular pain, often at night in typical joints)
3. Intercritical gout (Period between attacks that last 1 to 2 years?
4. Chronic tophaceous gout (after 10+ years of acute intermittent gout, critical periods no longer asymptomatic and joints have chronic swelling)

18

Treatment for each stage of gout?

1. No specific treatment
2. Indomethacin or oral colchicine every hour (steroid injection if patient has renal insufficiency)
3. Prevention – avoid meat and alcohol, switch off thiazides, probenecid, allopurinol
Stage four. Same treatment as acute attack with the addition of allopurinol to resolve tophi

19

The most common cause of monoarthritis in patient younger than 40? Most useful diagnostic test?

Gonococcal. Urethral, cervical or pharyngeal culture.

20

Patient with joint aspirate that reveals numerous leukocytes and PMNs but no organisms on gram stain. Few negatively birefringent crystals. Treatment?

Not enough information to rule out infection. Treat with IV antibiotics

21

Causes for gouty attacks?

##Overproduction
#Increased cell turnover (cancer, chemo, hemolysis, psoriasis)
# enzyme deficiency (Lesch-Nyhan, glycogen storage disease)

##underexcretion
#renal insufficiency
#Acidosis
#thiazides
#ASA

22

Uric acid levels in gout pts?

#elevated at some point in 95% of patients
#a single level during an attack is elected in 75% of patients

23

Which is better - NSAIDs vs steroids vs colchicine in acute attack?

When steroids?

NSAIDs better then steroids then colchicine

#No response to NSAIDs
#renal insufficiency

24

Side effects of colchicine?

Diarrhea and bone marrow suppression (neutropenia)

25

Drug for gout pt with HTN?

HTN Drug to stop?

Losartan lowers uric acid (stop thiazides)

26

Gout medications contraindicated with renal insufficiency?

Safe to give?

#NSAIDS
#probenecid
#sulfinpyrazone

Allopurinol

27

Drugs for chronic management of gout?

#Colchicine
#allopurinol or febuxostat
#pegloticase (dissolves Uric acid)
#probenecid or sulfinpyrazone (increase renal uric acid secretion)

28

Risk factors for pseudogout?

#Hemochromatosis
#Hyperparathyroidism
#Diabetes
#Wilson disease
#hypothyroidism

29

Treatment of pseudogout? For ppx?

NSAIDs or steroids

Colchicine got ppx

30

Patient with suspected osteomyelitis – best initial test? Most accurate test? If normal x-ray, next step in management? (If contraindicated, get?

X-ray; biopsy

MRI; bone scan

31

Patient with osteomyelitis – role of ESR?

Follow response to therapy

32

Only oral therapy for osteomyelitis?

Ciprofloxacin

33

For quinolones contraindicated in?

Pregnancy and children (interfere with bone growth)

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