Monoarticular arthritis
Septic Arthritis
Gonococcal Arthritis
Healthy, young sexually active adults
Women > men
Suppurative monoarthritis (may be preceded by polyarthralgias)
Knee, wrist, ankle
Arthritis-Dermatitis Syndrome
-Triad: dermatitis, tenosynovitis, migratory polyarthritis (hematogenous spread of bacteria and immune complexes)
-Skin lesions: scattered small painless erythematous macules or petechiae-->pustular -->necrotic lesions
-Transient painful extensor tenosynovitis (writs, hands, ankles)
-Asymmtric polyarthralgia of extremity joints
DiagnosisCx everything - jt, mucosal surfaces, lesions
TreatmentCTX 1gIV qd OR
Cefotax 1g q8
Empirically treat Chlamydia
Nongonococcal Arthritis
Fulminant presentation (abrupt, swelling, toxicity and fever) unless elderly
-Hematogenous
-Contiguous
-Direct traumatic implantation
-Postop
CausesBacterial
Mycobacterial
Spirochete (lyme, syphilis)
Fungal
VIral (HIV, Hep B, Rubella, etc)
Postinfectious
DiagnosisSynovial fluid aspiration
Cx - if only one test, use BCx bottles (may enhance yield)
Grm stain - 80% positive in gram-positive infxn; less sens in gram-negative
Cell count with dif - >50,000-150,000; PMN > 90%
TreatmentPCN-ase resistant synthetic PCN:
Nafcillin 1-2g
Cefazolin 1-2g
AND
3rd gen ceph
OR
Vanc*
- new evidence suggests significantly increased rate of MRSA septic arthritis
- cell counts are as low as 20,000 in MRSA Cx + synovial fluid
Crystal-Induced Monoarthritis
Gout
Monosodium urate crystals - needle shaped negative birefringence
Swelling, redness, warmth evolving rapidly over hours todays
First MTP (podagra) 60% > ankle > midfoot > knee
May have constitutional complaints
Precipitants: purine-rich food, EtOH, trauma, chemo, diueretic use, RI
DiagnosisSynovial fluid aspiration (above)
Note: serum uric acid levels unhelpful; ESR/CRP may be elevated
TreatmentNSAIDS eg Naproxen 500mg po bid x 3d and taper over 4-7d
Colchicine 0.6mg po qh x 3 or 1mg PO f/b 0.5mg q1h until relif, GI upset, or 8mg max
Can give 1-2mg IV over 30mins
- No further doses after initial load
- avoid NSAIDS, Colchicine in RF
Steroids
-Prednisone 40-60mg po qd x 3d f/b 7d taper
Pseudogout
Calcium pyrophosphate dihydrate (CPPD) - rhomboid shaped positive birefringence
chondrocalcinosis
acute attacks of mono or oligoarticular inlammatory arthritis
progressive joint deenerative changes similar to OA
Evolves over days
Age > 50
Knee, wrists, ankles, elbows
Systemic illness, surgery, trauma triggers
Assoc with hyperparathyroidism and hemochromatosis
Traumatic
- Fracture
- ligamentous
- Overuse
Ischemic
- Avascular necrosis
- Decompression illness
- Spontaneous osteonecrosis
- pain in abscence of trauma
- femoral head, medial conyle of knee
Hemorrhagic
- Posttraumatic
- Joint aspiration if tense
- RICE
- Hemophilia
- Systemic anticoagulation
Neoplastic
- Mets
- Osteochondroma
- Osteoid osteoma
- Pigmented villonodular synovitis
Systemic Disease
- Remote infxn, infectious endocarditis
- Rheumatic fever
- Seronegative (no RF) spondyloarthropathies (AS, IBS, psoriatic, reactive or Reiter's)
- Rheumatoid arthritis, SLE
- Sarcoidosis, amyloidosis
Periarticular
these conditions mimic joint involvement...
- Cellulitis
- Tendonitis
- Bursitis
Peds
don't forget about...
- Acute Transient Synovitis
- Children 3-10yo
- 1-3 wks after viral illness
- Self-limited
- SCFE (portly pubescent)
- Leff-Calve-Perthes (young school-age children)
Source
H-N