Transcript Approach to Patient with Monoarthritis by Dr Maryam khalil
APPROACH TO PATIENT WITH MONOARTHRITIS
Dr Maryum khalil HO MU1 HFH
MONOARTHRITIS
“
Inflammation of a single joint” * Acute *Chronic
CAUSES OF ACUTE MONOARTHRITIS
IN A PREVIOUSLY NORMAL JOINT: Septic arthritis Crystal synovitis Trauma Haemarthrosis Foreign body reaction Monoarticular presentation of oligo- / polyarthritis R.A
Erythema nodosum Juvenile Idiopathic arthritis Reactive, Psoriatic or other Seronegative spondarthritis
IN A PREVIOUSLY ABNORMAL JOINT
DAMAGED JOINT: EXISTING INFLAMMATORY DISEASE ( WITH OR
Pseudogout in assc with O.A
WITHOUT DAMAGE):
Bone disease Cartilage disease Haemarthrosis Septic arthritis Exacerbation of underlying disease Septic arthritis
CAUSES OF CHRONIC MONOARTHRITIS
Foreign body Infection Ch. Sarcoidosis Enteropathic Arthritis (mainly Crohn’s) Amyloidosis Pigmented villonodular synovitis Synovial pathology (sarcoma, chondromatosis) Monoarticular presentation of oligo- / poly articular disease
HISTORY & PHYSICAL EXAMINATION
Acute monoarthritis can be the initial manifestation of many joint disorders. The first step in diagnosis is to verify that the source of pain is the joint, not the surrounding soft tissues. The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. A careful history and physical examination are important because diagnostic studies frequently are only supportive.
DIAGNOSTIC CLUES
Clues from history and physical examination
Sudden onset of pain in seconds or minutes
Onset of pain over several hours or one to two days
Insidious onset of pain over days to weeks Diagnoses to consider
Fracture, internal derangement, trauma,
Infection, crystal deposition disease, other inflammatory arthritic condition
Indolent infection, osteoarthritis, infiltrative disease, tumor
Intravenous drug use, immunosuppression
Previous acute attacks in any joint, with spontaneous resolution
Recent prolonged course of corticosteroid therapy
Coagulopathy, use of anticoagulants
Urethritis, conjunctivitis, diarrhea, and rash
Psoriatic patches or nail changes such as pitting
Septic arthritis
Crystal deposition disease, other inflammatory arthritic condition
Infection, avascular necrosis
Hemarthrosis
Reactive arthritis
Psoriatic arthritis
Use of diuretics, presence of tophi, history of renal stones
Eye inflammation, low back pain
Gout
Ankylosing spondylitis
Young adulthood, migratory polyarthralgias, inflammation
Gonococcal arthritis of the tendon sheaths of hands and feet, dermatitis
Hilar adenopathy, erythema nodosum
Sarcoidosis
DIAGNOSTIC STUDIES
1-SYNOVIAL FLUID EXAM: Arthrocentesis is required in most patients with monoarthritis and is mandatory if infection is suspected. In some instances, obtaining as little as one or two drops of synovial fluid can be useful for culture and crystal analysis.
A) B) C) Cell counts Microscopy C/S
Categorization of Synovial Fluid
Noninflammatory: <2,000 WBC per mm 3 Inflammatory: >2,000 WBC per mm 3
Osteoarthritis Trauma Avascular necrosis Charcot's arthropathy Hemochromatosis Pigmented villonodular synovitis Septic arthritis Crystal-induced monoarthritis (e.g., gout, pseudogout) Rheumatoid arthritis Spondyloarthropathy SLE Juvenile R.A
Lyme disease
MICROSCOPY: C/S:
Synovial fluid cultures are more likely to be positive in patients with nongonococcal arthritis (90 percent) than in those with gonococcal arthritis (less than 50 percent).
2- CBC & ESR 4- BLOOD CULTURE
Blood cultures should be obtained in patients with suspected septic arthritis. Cultures are positive in about 50 percent of nongonococcal infections but are rarely positive (about 10 percent) in gonococcal infection.
Pharyngeal, urethral, cervical, and rectal swabs are necessary if gonococcal infection is suspected
5-
RADIOGRAPHY:
Although plain-film radiographs often show only soft tissue swelling, they are indicated in patients with a history of trauma or patients who have had symptoms for several weeks. Occasionally, unsuspected bony lesions, such as osteomyelitis or malignancy, may be detected.
5-
MRI:
Magnetic resonance imaging is superior in detecting ischemic necrosis, occult fractures, and meniscal and ligamentous injuries.
6-
RADIONUCLIDE SCANS:
Radionuclide scanning can detect infection in deep-seated joints. 7-
OTHERS:
Other diagnostic procedures, such as
synovial biopsy
or
arthroscopy
, may be useful to rule out deposition diseases (e.g., hemochromatosis, atypical infections) and intra-articular tumors.
SEPTIC ARTHRITIS
Bacterial Gonococcal Non-gonococcal( Staphylococcus aureus , nongroup-A beta-hemolytic streptococci, gram negative bacteria, and Streptococcus pneumoniae) Viral – HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus Fungal
MANAGEMENT
1- Hospitalization 2- Gen. Supportive care 3- I/V Antibiotics 4- Repeated Arthrocentesis 5- Surgical Drainage
A-
GOUT:
CRYSTAL INDUCED SYNOVITIS
ACUTE: NSAIDs , Glucocorticoids,Colchicine CHRONIC: Allopurinol, Uricosuric Drugs
B- PSEUDOGOUT:
- May present as acute mono- or oligoarthritis mimicking Gout, or as a chronic polyarhthritis mimicking R.A & O.A
NSAIDs, Glucocorticoids, Colchicine
C- APATITE DISEASE:
- May present with periarthritis or tendinitis - Rx same as Pseudogout
QUESTIONS
A 67 year old male presents with his first episode of knee pain and swelling together with the following x-ray.
Which of the following investigations is the next investigation indicated diagnostically?
(a) Thyroid function tests (b) Serum urate (c) Knee aspiration (d) Serum iron (e) Skeletal survey
The following pelvic x-ray displays radiographic features of which of the following rheumatic disorders?
(a)Rheumatoid arthritis (b) Paget’s disease (c) Osteonecrosis (d) Osteoarthritis (e) None of the above
Which of the following types of joint involvement is not seen in psoriatic arthritis?
(a) Symmetrical small joint arthropathy (b) Jaccoud’s arthropathy (c) Sacroiliitis (d) Monoarthritis (e) DIP joint arthropathy
In septic arthritis which one of the following pairings is most commonly found in hospital practice?
(a) Ankle joint and Staph Aureus (b) Knee joint and MRSA (c) Wrist joint and Beta haemolytic streptococci (d) Knee joint and Staph Aureus (e) Hip joint and Staph Aureus