Rheumatologic Emergencies

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Rheumatologic Emergencies

• Sarah McPherson
• May1, 2002

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MONOARTICULAR ARTHRITIS

• Case 70 year old man presents with a red hot
  swollen knee x 24 hr. He tells you that the
  affected knee is a prosthetic joint.
• What is the likely diagnosis?
• How should you manage this case?

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Septic Arthritis

• Common joints involved
• Adult Knee, wrist, ankle
• Children Knee, Hip
• IVDU axial skeleton (vertebral, SI, sternoclav)
• Risk Factors
• Very old and young
• Chronic debilitating disease
• IVDU
• Immunosuppressive therapy
• Prosthetic joint or post arthrocentesis

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Septic Arthritis

• Joint aspiration
• A must do!!!!
• KNEE
• Extend knee, insert needle from the medial side
• between posterior surface of the patella and
  intercondylar femoral notch at midpoint to
  superior pole of the patella
• WRIST
• Flex wrist with ulnar deviation. Insert needle
  distal to Listers tubercle ulnar to extensor
  pollicus longus

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Septic Arthritis

• ELBOW
• Flex elbow . Insert needle from lateral side
  distal to lateral epicondyle and direct medially
• ANKLE
• Plantar flex foot. Insert needle into hollow at
  anterior edge of the medial malleolus medial to
  anterior tibial tendon. Will have to insert
  needle 2-3 cm
• NORMAL SYNOVIAL FLUID ANALYSIS
• Clear lt 200 WBC/mm3 lt 25 PMN no
  crystals

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Septic Arthritis

• Management
• Non-prosthetic joint
• Daily aspiration
• Iv Ancef for 3 weeks
• Prosthetic joint
• Daily aspiration or ID
• IV vancomycin and po Ciprofloxacin

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Gout

• Risk factors
• Obesity
• Hypertension
• Diabetes
• Alcohol consumption
• Loop diuretics
• Lead exposure

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Gout

• Management
• NSAIDs
• Indomethacin 50 mg tid X 3-5 days
• Colchicine
• 0.6 mg q1h until pain subsides max 4-6 mg
• Side Effects GI upset,
• Steroids
• If resistant to above 40 mg qd X 3-5 days

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POLYARTHRITIS

• Case 26 yr old woman presents with myalgias and
  arthritis of the right wrist and left knee X 1
  wk. She notes that 2 days ago she also had pain
  in her left hand but that had resolved. On exam
  she is febrile and you notice red pustular
  lesions on the sides of her fingers.

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Gonnococcal Arthritis

• Fever, chills, arthralgia progressing to
  arthritis
• Wrist, knee, and ankle most commonly affected
• 2/3 will have characteristic rash (necrotic
  pustules on distal extremities fingers)

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Gonococcal Arthritis

• Diagnosis initially clinical diagnosis
• Confirm with CS from urethral, rectal and
  pharyngeal swabs
• Treatment
• Ceftriaxone 1 gr iv X 24-48 hr
• Follow with Cefixime 400mg bid or Cipro 500mg bid
  to complete 7 days antibx

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• Case 65 yr old man presents with a headache
  and achy joints for just over 24 hrs. He
  describes a red lesion on his thigh that has been
  growing in size for the past 3 days.

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Lyme disease

• From tick bites in areas where Borrelia
  burdorferi is endemic
• 50 of people remember bite
• Presentation
• Lesion at bite site that rapidly grows in size
  and multiplies
• Red boarder with central clearing
• Fever, migratory tenosynovitis, polyarthrits,
  headache
• At 4 weeks may have neurologic and cardiac
  abnormalities
• 50-60 arthritis at 6 months, may be recurrent

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Lyme disease

• Treatment
• Shortens duration of symptoms and prevents later
  disease
• Doxycycline 100mg bid X 2-4 weeks
• Amoxicillin 500mg tid X 2-4 weeks (pregnant and
  lactating women, children lt 5 yrs)

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Reiters Syndrome

• Reactive arthritis from GI/GU infections
  (Chlamydia, Shigella, Salmonella, Yersinia,
  Campylobacter)
• Asymmetric polyarthritis mainly of weight bearing
  joints 2-6 weeks post urethritis or dysentery

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Reiters Syndrome

• Physical exam
• Polyarthritis
• Ocular findings (conjuntivitis, uveitis, corneal
  ulcers)
• Oral ulcers (10 of patients)
• Sores on glans penis (20 patients)
• Saugelike fingers and toes
• Low back pain

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Reiters syndrome

• Management
• Indomethacin up to 250 mg/d
• If Chlamydial tetracylines may shorten duration
• Will last 4-7 months
• May be recurrent

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Bursitis Tendinitits

• Shoulder major causes of pain
• Subacromial bursitis, supraspinatuns tendinitits,
  bicipital tendinitis, rotator cuff
• Elbow
• Lateral epicondylitis, olecranonbursitis
• Hip
• Trochanteric, ischial, iliopsoas bursitis
• Knee
• Prepatellar, infrapatellar, anserine bursitis

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Bursitis Tendinitis

• MANAGEMENT
• Conservative
• Ice, rest, NSAIDs
• Early ROM exercises for shoulder and elbow
• Olecranon and prepatellar bursitis
• Aspirate
• Cefazolin 1g iv q8hr

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SLE the diagnosis (need gt 4)

• Malar rash
• Discoid rash
• Photosensitivity
• Oral ulcers
• Arthritis
• Serositis
• Pleuritis
• Percarditis
• Renal disorder

• Neurologic disorder
• Seizures
• Psychosis
• Hematologic disorder
• Anemia
• Leukopenia
• Thrombocytopenia
• Blood tests
• ANA, anti-Sm Ab, anti-DNA Ab, False VDRL/RPR

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SLE - treatment

• NSAIDs first line (dont use if low platelets,
  GI involvement, renal disease)
• Corticosteroids
• Minor Prednisone 0.5 mg/kg/d
• Major Prednisone 1g/kg/d
• Cerebritis or worsening glomerulonephritis
  methylprednisolone 1 g iv
• Antimalarial
• Immunosuppression agents

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SLE complications of immunosuppressive agents

• Cyclophosphamide
• Hemorragic cystitis
• Bladder carcinoma
• SIADH
• GI distress
• Alopecia
• Myelosuppression
• Neoplasia
• Infection

• Azathioprine
• GI distress
• Myelosuppression
• Hepatitis
• Pancreatitis
• Aseptic meningitis
• Neoplasia
• Infection

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Drugs that can cause a Lupus-like Syndrome

• Procainamide
• Quinidine
• Hydralazine
• Isoniazid
• Penecillin
• Sulphonamides
• Tetracycline
• Dilantin
• And the list goes on..

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Vasculides

• Wegeners
• Medium vessel disease
• Upper resp tract, Lower resp tract, then
  glomerulonephritis (85), ocular findings and
  cerebral vasculitis (33)
• Diagnosis elevated ESR, c-ANCA, - ANA,
  hematuria, active urine sediment
• CXR sharply demarcated pulmonary nodules
• Management steroids cyclophosphamide, iv
  steroid for flares of glomerulonephritis

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Vasculides

• Henoch-Schonlein Purpura
• Usually affects children
• Triggers viral infections, insect stings, drugs
• Presentation purpuric rash, lower limb
  arthralgia, GI complaints (80),
  gomerulonephritis (50)
• Management conservative, severe arthralgia or
  abdo pain give 1mg/kg/d prednisone, admit with iv
  steroids if renal involvement