Rheumatolgic Emergencies

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Rheumatolgic Emergencies
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Conflicts

• None
• Errors - Mine.
• Thanks to
• Dr. Walker
• Dr. Hadley
• Dr. Del Castilho

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Table of Contents

• What is that!?
• What unites them all?
• Questions/Discussion

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(knee)
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Acute Monoarthritis

• Inflammatory
• Crystals
• Bacteria
• Rheumatiod Arthritis
• Spondyloarthropathy
• SLE
• Sarcoidosis
• Bursitis

• Non-Inflammatory
• Trauma
• HbS
• Osteonecrosis

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Acute Monoarthritis

• Septic joint in RA overlooked
• Delay of Dx 1-3 weeks
• Significant joint damage
• Mortality 20 - 33

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Acute Monoarthritis

• What blunts identification?
• Often insidious onset
• 'Unrewarding physical exam'
• Absence of fever 50
• Polyarticular pattern in 25 of pts
• Immunosuppression
• Plausible reason for red, sore knee

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Red and Hot

• 'The most important laboratory test in evaluating
  monarticular joint pain is synovial fluid
  analysis.' UTDOL.

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WBC not enough
Normal Noninflammatory Inflammatory Septic
WBC/mm3 lt200 200 -2,000 2,000-100,000 15,000-gt100,000
PMN lt25 lt25 gt50 gt75
Colour Clear Yellow Yellow to opalescent Yellow to purulent
Gl mg/dL .serum .serum May be low Very low
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What to order

• Look at it
• Xantho, clear, cloudy, purulent
• Total leukocyte count and diff
• Gram stain and culture
• Crystals (polarizing micro)
• Glucose

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WBC not enough
Normal Noninflammatory Inflammatory Septic
WBC/mm3 lt200 200 -2,000 2,000-100,000 15,000-gt100,000
PMN lt25 lt25 gt50 gt75
Colour Clear Yellow Yellow to opalescent Yellow to purulent
Gl mg/dL .serum .serum May be low Very low
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Tx

• Depends on most likely cause
• No RTC of ABx in septic arthritis
• Red knee, no infection
• Intraarticular steroids
• Polyarthritis increase oral steroid, control
  flare

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http//www.medscape.com/viewarticle/706761
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http//www.medscape.com/viewarticle/706761
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Ankylosing Spondylitis

• Pathologically rigid spine becomes osteoporotic
• 10 c-spine in lifetime
• Neuro complications common
• 2/3 may not completely recover Neurologically.

Unstable fracture through disc space C6/7
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Ankylosing Spondylitis

• Most common presentation
• Pain, usu localized.
• Aggravated by movement.
• Different from inflammatory pain of AS.
• Mass effect
• Bleeding and edema
• May present as radiculopathy and myleopathy.

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Ankylosing Spondylitis

• MC Site?
• C6-7
• How is it missed?
• Not considered.
• Plainfilm XR
• No Hx major spinal trauma 50!
• Nature of
• Often non-displaced
• Small size (Syndesmophytes)

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C5-C6

• Inverted radial reflex

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Predicted Problems
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Ankylosing Spondylitis

• When to order Imaging?
• If pain is new, out of ordinary.
• Neurologic complaints or findings.
• XR, CT /- MRI
• What to do?
• Cautious immobilization.
• Ortho.

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Sceroderma
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Sceroderma
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Scleroderma Renal Crisis

• 10-20 develop it.
• 20 mortality.
• 20 will need HD after crisis.

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Scleroderma Renal Crisis

• How to identify it?
• Acute onset renal failure, progressive azotemia.
• New HTN (from normal to malignant).
• gt150/85 2x/24hrs, mean peak 178/102.
• Headache
• Microangiopathic anemia c thrombocytopenia
• Urine normal or mild prot c cells or casts
• /- Flash pulmonary edema

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Scleroderma Renal Crisis

• Steroids?

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Scleroderma Renal Crisis

• What to do?
• ACEi (Grade 1A).
• Captopril (Grade 2B) no CNS s/s.
• Add Nitroprusside WITH CNS s/s.
• Nephro.

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Giant Cell Arteritis

• Granulomatous arteritis of thoracic aorta and its
  branches.
• Classic symptoms
• Usu gt50, new headache, tender scalp, fluctuating
  vision, jaw claudication, constitutional
  symptoms.
• Temporal artertis
• Prednisone 60 mg/d biopsy within 1 week
• Polymyalgia Rheumatica

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• Lit review up to 2004
• 23 studies, 2036 pts, 5 languages.
• May be helpful, caution with test results.
• The future

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Giant Cell Arteritis- Vetebro-Basilar
Insufficiency

• TA new defects of vetebro-basilar territory
• Untreated risk of bilateral vetebral artery
  occlusion, mortality 75.
• ESR
• MR angio
• Tx high dose steroids
• ??OTHER

vertebral angiogram
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Giant Cell Arteritis- Aortitis

• GCA 27 pt large artery complications.
• Ascending aortic aneurysms 17x
• AAA 2.5x
• Suspect it
• Hx, RF
• CT / MRI

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Instability of C-Spine

• 71 of pts with RA have C-spine involvement
• 70 may have subluxation
• 25 of these -gt frank dislocation
• 11 cord compression
• 5 yr survival 80
• 10 yr survival - 28

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Atlantoaxial subluxation

• MCC Neck/occiput/forehead pain in RA?
• Atlantoaxial subluxation
• MCC
• Atlantoaxial subluxation 70
• Synovium of C1-C2 articulation
• Synovial C2 Transverse ligament articulation
• Subaxial subluxation 20
• Synovium below C2

Decision making in spinal care  By Alexander R.
Vaccaro, D. Greg Anderson
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Atlantoaxial subluxation

• Anterior atlantodens interval
• McRae's Line
• McGregor's Line

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Atlantoaxial subluxation
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Atlantoaxial subluxation

• General Precautions?
• Suspect it RA pt with new onset occipital pain
  and/or tingling of fingers.
• Caution with Passive flexion of C-Spine.
• Caution with intubation. (Stabilize)
• When to order Flex/Ex?
• What to do if gt3.5mm ADI?

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Adrenal Insufficiency

• What unites most rheumatic diseases?
• Steroid dependence
• Can be
• Medical or surgical stress
• Stopping of Rx
• S/S
• Hypotension, lethargy, change to mental status,
  hypoGlc.

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Adrenal Insufficiency

• Tx
• NS
• Glc
• Hydrocortisone 100 mg IV
• Or (dexamethasone 4 mg IV no impact on ACTH
  test or cortisol level)

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Questions

• Bibliography
• Adam Grainger Allison's Diagnostic Radiology,
  5th ed
• Barr, W et al. Principles of Critical Care - 3rd
  Ed. (2005), Ch 104
• Current Diagnosis Treatment in Orthopedics -
  4th Ed. (2006)
• Firestein Kelley's Textbook of Rheumatology, 8th
  ed.
• Fotini B. Karassa et al. Meta-Analysis Test
  Performance of Ultrasonography for Giant-Cell
  Arteritis. Ann Intern Med. 2005142359-369.
• Ginsberg Lawrence E, "Chapter 13. Imaging of the
  Spine" (Chapter). Chen MYM, Pope TL, Jr., Ott DJ
  Basic Radiology http//www.accessmedicine.com/con
  tent.aspx?aID2271105.
• Mettler Essentials of Radiology, 2nd ed.
• P A Nee, J Benger and R M Walls. Airway
  management doi10.1136/emj.2005.030635. Emerg.
  Med. J. 20082598-102
• Physical examination of the spine By Todd J.
  Albert, Alexander R. Vaccaro
• Steen, VD, Medsger, TA. Case-control study of
  corticosteroids and other drugs that either
  precipitate or protect from the development of
  scleroderma renal crisis. Arthritis Rheum 1998
  411613.
• http//emedicine.medscape.com/article/238545-overv
  iew
• http//education.yahoo.com/reference/gray/illustra
  tions/figure_yltAiXwKBJ25LQJ0A7brQ1WBY9tHokC?id
  86
• http//www.ucl.ac.uk/news/news-articles/0709/07092
  002
• http//emedicine.medscape.com/article/331864-media
  
• http//www0.sun.ac.za/ortho/webct-ortho/arthritis/
  aspirate-knee-s.jpg
• https//www.bcbsri.com/BCBSRIWeb/images/mayo_popup
  /Scleroderma.jsp
• http//emedicine.medscape.com/article/1265682-over
  view