Transcript Who gets septic arthritis?

The Red Hot Joint
James Bateman
Rheumatologist
One Real Case from UHNS which
tells you all you need to know
about hot joints
You are an FY1 in GP
• 31 year old presents to his with a 1 day
history of painful clavicle/sternum.
• Temporary patient at the surgery
Differential Diagnosis at this
stage?
What do you think?
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HPC
PMHx
Drug History
Social History
Systemic enquiry
• What are you going to do?
In A&E
• What are you going to do?
What are you sending the fluid
for?
What will it tell you?
Gram positive cocci
Other Imaging…
Diagnosis: Septic arthritis
Whats missing?
Pathogenesis
FY1 in GP
• 70 year old lady,
– Painful knee
– AF on warfarin
– DM type II
– Hypertensive on BFZ and ACEi
– Left knee is painful and swollen
– Struggling to weight bear
– What are you going to do?
In ED what are you going to do?
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History
Investigations
Treatments?
Procedures?
Imaging?
In what order?
What Now?
• Do you need to do anything else?
What’s if you see this?
92 year old female with swollen
knee
21 year old students with a swollen
ankle and tenosynovitis
Case 1
• 82 year old lady
• Admitted acute on chronic knee pain 3-4 days
• Recent excision of shin BCC with skin graft
complicated by cellulitis
• Ex Not unwell afebrile MEWS O
• Warm, slightly tender knee effusion, tolerating 90
flexion
• ? Wound infection started on antibiotics
• CRP 187
Case 1
• Radiological
abnormality?
• Differential
diagnosis?
• Further
investigations?
• Management?
Example
• DB 45 year old man
• PMH RA on
sulphasalazine
• 4 day history painful
hot swollen red right
big toe
• Differential?
• Investigations?
Case 3
• 82 year old man
• PMH LVF,AF, TIA, BPH
• DH Aspirin, bumetanide, ramipril, digoxin,
statin
• Referred with acute on chronic wrist pain
needing MST
• WBC 13, CRP 155, Cr 143, XR OA
changes
• Diagnosis and plan?
What single investigation is going
to give you the answer?
• Joint Aspiration:
– Need: green needle
– Need: Sterile field
– Syringe
– Microbiologist
– White topped bottle
What are other differentials for
monoarticular pain?
Monoarthritis - differential
• Monoarticular sero-ve spondyloarthritis eg
psoriatic and reactive arthritis
• Monoarticular RA
Monoarthritis - differential
• Haemarthroses
(warfarin, bleeding
disorders)
• Trauma – fracture, internal
derangement,
haemarthroses
Others to think about
• Osteonecrosis/AVN
(steroids/alcohol/SLE)
• Prosthetic joint loosening, # or infection
Others to think about
• Periarticular pathology
• Cellulitis
Septic arthritis
• 15-30 per 100,000 population
• Fatal in 11% of cases in UK
• Delayed or inadequate treatment leads to
irreversible joint damage
How do you get septic arthritis?
Who gets septic arthritis ?
Who gets septic arthritis?
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pre-existing joint disease
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prosthetic joints
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low SE status, IV drug abuse, alcoholism
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diabetes, steroids, immunosuppression
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Skin lesions e.g. ulcers, particularly in context
RA often source of infection
• Which organisms cause septic arthritis?
Which organisms?
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common organisms Staphylococci or
Streptococcus
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Elderly & immunocompromised gram -ve
organisms
Which organisms?
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Anaerobes more common with
penetrating trauma
Pseudomonas - IV drug abusers
young adults - significant incidence
gonococcal arthritis
Who gets septic arthritis?
• poor prognostic features:
older
pre-existing joint disease & presence of synthetic
material within joint
What are the signs and
symptoms of septic
arthritis?
Symptoms & signs of septic arthritis
• Symptoms usually
present for < 2/52
• Typically hot, swollen, red
tender joint with reduced
range of movement,
difficulty weight bearing
• Night and rest pain
• Large joints more
commonly affected than
small
• majority of joint sepsis in
hip or knee
• Systemic upset (MEWS)
Symptoms & signs of septic arthritis
• In pre-existing inflammatory joint disease
symptoms in affected joint(s), out of proportion
to disease activity in other joints.
• 10% of cases > one joint
• presence of fever not reliable indicator
• Features of gonococcal arthritis ?
Gonococcal arthritis
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Women>men
Menses, pregnancy
1-3% arthritis
1day- weeks after sexual
encounter
• Migratory (70%),
Tenosynovitis (70%),
monoarthritis (32%),
polyarthritis (10%)
• Fever, Dermatitis
(pustules, vesicular,
haemorrhagic bullae,
mac.papular)
What investigations are useful
in septic arthritis?
Investigations
• Synovial fluid aspiration
– gram stain/m,c,s
– Absence of organism does
not exclude septic arthritis
– polarised light microscopy
(crystals)
– NB suspected prosthetic
joint sepsis should
ALWAYS be referred to
orthopaedics
Investigations
• Blood cultures
• Significant proportion blood cultures + ve
in absence of + ve synovial fluid cultures
• FBC ESR & CRP
• Absence of raised WBC, ESR or CRP
does not exclude diagnosis of sepsis
Other investigations
• CRP useful for monitoring response to
treatment
• Urate may be normal in acute gout
• U+E & LFT – prognosis and influence
antibiotic regime
Other tests?
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Gonococcal - skin pustule - skin swab,
urethral/cervical /rectal/throat swab,
blood culture, joint aspirate
genitourinary or respiratory tract infection
then culture sputum and CXR & MSU
If periarticular sepsis – appropriate
swabs and cultures
• Radiology ?
Imaging
• Plain X rays no benefit in diagnosis but form
baseline for any future joint damage. May
show chondrocalcinosis (pyrophosphate
arthritis).
• MRI sensitive for osteomyelitis and spinal
involvement
Imaging
• Ultrasound useful in guiding needle
aspiration eg hip
• White cell scanning helpful in diagnosing
prosthetic sepsis
• What are the radiological features
of infected prosthesis?
Prosthetic infection
Spinal infection
• Discitis – with destruction end plates
• Management?
• MEWS score?
• Shock?
• Multi-organ failure?
• RESUSCITATION
Antibiotic treatment of septic arthritis
• Local and national
guidelines
• Liaise with micro.
guided by gram stain
• Conventionally given
iv for 2 weeks or until
signs improve, then
orally for around 4
weeks
Joint drainage & surgical options
• medical aspiration, surgical aspiration via
arthroscopy or open arthrotomy
• Suspected hip sepsis – early orthopaedic
referral – may need urgent open
debridement
Recommendations specific to 1o care &
emergency department
• commonest hot joint to present in 1o care is 1st MTP
gout
• diagnosed on clinical grounds without needle
aspiration or referral to hospital. (Make referral if
inadequate recovery)
• Some GPs aspirate & inject joints for inflammatory
arthritis or osteoarthritis. If withdraw
pus/unexpected cloudy fluid should send sample
with patient to local emergency department
Recommendations specific to 1o care &
emergency department
• GPs & doctors in EAU should refer patients
with suspected septic arthritis to specialist
with expertise to aspirate joint.
• May be orthopaedic surgeon or
rheumatologist
• Admit if sepsis is suspected or confirmed.
Summary
• with a short history of a hot, swollen,
tender joint (or joints) plus restriction of
movement; septic arthritis until proven
otherwise
• If clinical suspicion high investigate &
treat as septic arthritis even in absence of
fever – always joint aspiration and blood
cultures
GOUT
• Definition and metabolism?
Gout
• An inflammatory arthritis caused by
hyperuricaemia
• Uric acid is formed from the
breakdown of purines (DNA)
• Excreted in the urine
• Characterised by the deposition of
urate crystals in the joints and soft
tissues
Gout Epidemiology
• Prevalence 1-2%
• Most common cause of inflammatory
arthritis in men 3-5:1 and postmenopausal women
• Usually presents between 40-60 years
• Risk factors?
• Associations?
Risk factors for Gout
• Genetics
• Gender, age, OA
• Diet – red meat, seafood
• Alcohol
• Drugs – diuretics, low dose aspirin, cyclosporin,
anti-TB drugs
Risk factors for Gout
• Renal disease
• Metabolic syndrome – hypertension,
obesity, dyslipidaemia and insulin
resistance
• Diagnosis of gout ?
Polarized microscopy - negatively
birefringent needle shaped crystals
Clinical - usually self-limiting
monoarthritis
• Usually resolves 7-10
days
Diagnostic criteria for gout – ACR
criteria
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> 1 attack of acute arthritis
Maximum inflammation within 1 day
Attack of monoarthritis
Redness over joints
Painful or swollen 1st MTP
Unilateral attack 1st MTP
Unilateral attack tarsal joint
Tophus
Hyperuricaemia
Asymmetric swelling within joint on x-ray
Subcortical cysts without erosions on x-ray
Joint fluid culture –ve for organisms
6 or more criteria
Chronic gout
• Up to 10 years to
develop
• Less painful
• Older age
• Tophi – hands, feet,
elbows, ears
• Erosions
• Poly/oligoarticular
Erosive gout
• Pyrophosphate arthritis features ?
Clinical
• Acute monoarthritis in elderly esp in
hospital
• Chronic polyarthritis with hypertrophic OA
changes
Chondrocalcinosis
• Polarized microscopy features?
• Metabolic Causes?
• Triggers?
Pyrophosphate Crystals
Metabolic Causes of
pyrophosphate arthritis
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Haemochromatosis
Hyperparathyroidism
Hypophosphatasia
Hypomagnasaemia
Triggers of pyrophosphate arthritis
• Management of gout?
Management of acute gout
• Analgesic
• NSAIDs
• ? increased risk of GI side-effects - coprescription of gastro-protective agents
• Colchicine in doses of 500 µg bd–qds
Management of acute gout
• Ct allopurinol if on it
• Steroids
• Alternative anti-hypertensive to diuretics
Non-Pharmacological
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Weight reduction
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skimmed milk and/or low fat yoghurt, soy
beans and vegetable sources of protein,
cherries encouraged
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Restrict red meat, offal, shellfish and yeast
extracts.
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Reduce alcohol
Management of recurrent, intercritical and chronic gout
• uric acid lowering drug therapy:
• second attack, or further attacks occur
within 1 yr
• with tophi
• with renal insufficiency
• with uric acid stones
Management of recurrent, intercritical and chronic gout
• uric acid lowering drug therapy:
• Commencement delayed until 1–2 weeks after
inflammation has settled
• allopurinol starting in a dose of 50–100 mg/day and
increasing by 50–100 mg increments every few weeks,
adjusted if necessary for renal function, until the
therapeutic target (SUA <300 µmol/l) is reached
(maximum dose 900 mg)
• NB renal impairment, elderly, azathioprine
• Febuxostat – new non-purine xanthine oxidase inhibitor
Management of recurrent, intercritical and chronic gout
• Uricosuric agents: second-line drugs, under-excretors of uric acid
and resistant/intolerant of allopurinol eg sulphinpyrazone in patients
with normal renal function or benzbromarone in patients with
mild/moderate renal insufficiency.
• Colchicine should be co-prescribed following initiation of treatment
with allopurinol or uricosuric drugs, and continued for up to 6 months
• In patients who cannot tolerate colchicine, an NSAID or Coxib can
be substituted provided that there are no contraindications, but the
duration of NSAID or Coxib cover should be limited to 6 weeks
Other drugs and diseases
• consider losartan and fibrate if
hypertensive and hyperlipidaemia
(uricosuric)
• Screen for and treat metabolic syndrome
THANK-YOU