Transcript Acute_Monoarthralgia - Ipswich-Year2-Med-PBL-Gp-2

Acute Monoarthralgia
Presentation
Marilyn
67 y.o. woman
Presents to GP with red painful right big toe which has kept her
awake most of last night.
She was well when she went to bed.
No recent illnesses.
Issues to consider.
1. How is arthritis described in terms of joint involvement?
2. What are the causes of acute monoarticular arthritis?
3. Can they be distinguished on history and examination?
Joint involvement
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Number of joints – mono, oligo, poly arthritis
Symmetrical or not
Small or large joints
Peripheral or axial
Joint involvement
Monoarthritis
Oligoarthritis
(≤5 joints)
Symmetrical
Polyarthritis
Asymmetrical
Polyarthritis
Septic arthritis
Crystal arthritis
Rheumatoid
arthritis
Reactive arthritis
Crystal arthritis
(gout, CPPD)
Psoriatic arthritis
Osteoarthritis
Trauma, eg
haemarthrosis
Psoriatic arthritis
Osteoarthritis
Reactive arthritis,
eg Yersinia,
Viruses (eg
Salmonella,
hepatitis A, B &
Campylobacter
C; mumps)
Ankylosing
spondylitis
Osteoarthritis
SLE, Sarcoidosis, leukaemia,
endocarditis, haemochromatosis,
sickle-cell anaemia, familial
Mediterranean fever, Behçet’s.
Acute monoarticular arthritis
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Trauma
Bleed
Infection (Danger!)
Gout / pseudogout
Septic arthritis
• Uncommon but dangerous
• Risk factors
– Existing joint disease
– Prosthetic joint
– Immunosuppresed
– Diabetes
– Chronic renal disease
– Skin infection, cutaneous ulcers
– IV drug abuse, alcoholism
– Previous intra-articular corticosteroid injection
Septic arthritis
• Joint pain, swelling, warmth, and restricted
movement
• Patient usually has a fever. Not always
• Most common (>50%) in knee joint
• Wrists, ankles, hips also common
• 20% have infection in more than one joint.
• Usually haematogenous, eg from
endocarditis, UTI, or STD (particularly
gonorrhea)
Uptodate.com
Haemarthrosis
• Presents with considerable swelling
• Trauma
• Bleeding diatheses
• Pigmented villonodular synovitis
Crystal arthropathies
Gout
CPPD
(Pseudogout)
Others
hyperucemia → uric
acid crystals
Calcium
pyrophosphate
dihydrate disease
Basic calcium
phosphate associated
disease
Can present similarly
to gout, but less
commonly
Calcium oxalate
arthritis
Typically male >40yo
70% first in big toe
Also in ankle, foot,
knee, wrist, elbow
Often in knee
(olecranon bursa), and
the small joints of the
hands
History
Marilyn says she has had similar episodes twice in
the past 18 months but never this severe and
they have settled in 2 or 3 days with some
Ibuprofen.
She tried two doses over night with no relief.
Examination
On examination Marilyn is afebrile and is
obviously in significant pain. Your examination
of the toe shows a swelling which is localised to
the first metatarsophangeal joint of the right
great toe. It is red, slightly warm and
exquisitely tender to palpation and painful with
any attempted passive movement. She is
completely unwilling to perform any active
movement.