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Acute Hot Joint RCP Specialty Registrar Teaching GIM Session
Rheumatology Topics
29th January 2016
Dr Sharmin Nizam
Consultant Rheumatologist
Why is it important to know?
O Acute medical emergency
O Septic arthritis- mortality 11 %
O Important to make the diagnosis early
O Difference between…
O Recovery to normal ROM vs damaged
joint, reduced mobility, disability
Audit: Management of The Acute Hot Swollen Joint: An Audit of Medical Inpatients
e poster BSR 2015 Narayan N. Klocke R, Dudley UK
O 3 month case note review
O 23 in-patients–referred to rheum SpR
O Hx 18/23,
O Examination 2/23
O 16/23 “appropriate blood tests”
O No aspiration of joints other than knees prior to knee swelling
O 15/23 had knee swelling
O 3 aspirated by orthopaedics, 1 by renal CMT (with prior experience of rheumatology rotation)
O Median time to referral to rheumatology 4 days
O Lack of awareness and aspiration
AUDIT OF MANAGEMENT OF THE ACUTE HOT SWOLLEN JOINT AT A UK DISTRICT GENERAL HOSPITAL
D. Khan1, J. Noake1, N. Palihawadana1, R.S. Wijesurendra2, A. Jenkins3, L. Ragunathan4, R.W.
Smith3. Milton Keynes, United Kingdom
Retrospective analysis
O Ref: UK intercollegiate guidelines(1)
O 1st cycle (n=25) 3 mths Oct. 2008.
O Re-audit (n=28) 3 mths Aug 2009
O 5 cases “proven septic arthritis” in 1st cycle & 6 cases in re-audit cycle
O 2 pts died 1st cycle
O 100% recovery re-audit
O Re-audit : O ↓ time to aspiration &
antibiotics
O documentation & imaging concerns
1. Coakley, G. et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot
swollen joint in adults. Rheumatology (Oxford) 45, 1039-1041
Case Scenario 1
O 79 year old female
O Unwell , SOB, Hx of heart failure & RA
O Moderate CKD
O Leg ulceration
O Temperature 38oC
O Painful, swollen knee –unable to move
How would you approach this?
O diagnosis
O management
Consider
O Is this an acute monoarthritis/swollen joint ? O Consider other possibilities
O Skin/ soft tissue swelling/oedema O Cellulitis, bursitis, thrombophlebitis
O Differentials for hot, swollen joint?
O Septic arthritis…. Until proven otherwise? O Crystal arthritis (Gout/CPPD) O Trauma O Haemarthrosis O 1st presentation/ flare of underlying inflammatory
condition – reactive arthritis, RA, PsA
Golden Rules “Acute Hot Joint”
O Take a GOOD history
O Preceding/ predisposing factors O infection, penetrating skin trauma, ulcers, age
O Comorbidities O Renal disease
O ?Heart problems (diuretics)
O ?Previous joint problems
O (GI/GU risk factors)
O Medication (immunosuppression, anticoagulation, etc)
O Trauma
O Prosthetic joint
Golden Rules “Acute Hot Joint” Examination
O Appearance O Erythema/discolouration, swelling
O Palpation O ROM –active and passive
O Joint pain (sensitivity 0.85)
O Joint swelling (sensitivity 0.78)
O Other joints ?normal/abnormal
O Systemic
O Fevers (sensitivity 0.57)
O Tophi ,nodules
O Nails , skin
Golden Rules “Acute Hot Joint” Management
O Investigations -what’s useful and what’s not?
O Can depend on predisposing factors but
O ASPIRATE FIRST…unless some really good reason not to!
O Aseptic/sterile technique ideally
O Anticoagulation not contraiindication O Ahmed, Imdad, Gertner, Elie; Safety of Arthrocentesis in
Patients on Chronic Warfarin Therapy with Therapeutic INR. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :910 O 514 anticoagulated pts; only 1 complicated by bleeding
O If prosthetic joint refer to orthopaedics
Joint aspiration e.g. knee
O Medial/lateral approach
O Identify bony landmarks (patella)
O Comfortable position
O patient & you!
O Slightly flexed knee can help
O Training
O Observe, get supervised training
O Injection models
www.aviva.co.uk
www.seattlechildrensorg.
Synovial fluid Analysis
Naked Eye Colour Viscosity Turbidity
Microbiology
Gram Stain Culture & Sensitivity & Crystal examination
Synovial fluid characteristics
Normal Non-inflammatory e.g.
OA
RA Gout/
Pseudogout(CPPD)
Septic
Appearance Clear
/transparent
transparent Translucent
/straw
coloured
Translucent/purulent/oc
casionally reddish
Purulent
Viscosity high high low low variable
WCC (x109 ) <0.2 0.2-2 2-10 2-40 >50
Neutrophils (%
of leucocytes)
<25 <25 >50 >50 >75
Crystals Negative Negative Negative Positive
(gout – urate, CPPD –
calcium pyrophosphate)
Negative
Golden Rules “Acute Hot Joint” Management
O Other investigations
O Laboratory
O Acute phase reactants (CRP, ESR)
O Full infection screen including blood cultures
O Urate?
O Urea & electrolytes, liver function
?compromised (implications for medication
choice/dosage)
O Others : ECHO
Golden Rules “Acute Hot Joint” Management
O Imaging
O Plain film Yes/ No?
O Possible indications/uses
O Cases of trauma
O Chondrocalcinosis
O Ultrasound
O Difficult aspiration
O Loculated collection
Boneandspine.com
Case scenario 1
O 79 year old female
O Unwell , SOB, Hx of heart failure and RA
O Moderate CKD
O Leg ulceration
O Temperature 38oC
O Painful, swollen knee –unable to move
Diagnosis : O Septic arthritis high probability
O Differential : CPPD/gout/flare of RA
Management O Post aspiration commence antibiotics
O Analgesia
O Supportive
Not always an RA flare
O Incidence of septic arthritis in general population 2 to 5/
100, 000
O 46 % pre-existing jt disease (UK study)
O 14 % RA
O Other studies – increased risk
O ?estimated prevalence 0.3 % to 3%
O Risk factors for septic arthritis in patients with RA
O Increasing age
O Skin ulceration
O Oral carriage of S aureus
O Diabetes
O ? Medication
Treatment of septic arthritis
O Which antibiotics?
O Ideally post aspiration (don’t delay if high clinical
suspicion or risk factors)
O Local microbiology protocol
O Usually need to cover for S. Aureus
O Consider MRSA
O Gonococcal cases - ceftriaxone
O Optimal duration?
O Lack of specific evidence
O Usually 6 weeks in total
O 1st 2 weeks usually IV then PO
Septic Arthritis
Key History Joint involvement Pathogen
Cellulitis/skin
infection
Mono/poly articular S.Aureus, Streptococcus
GU risk factors Poly/Mono ;
Large joints
N.Gonorrhoea
IV drug use Sternoclavicular
Sacroiliac/Pubic
symphysis
Pseudomonas, S Aureus
RA Monoarticular S Aureus
Anti-TNF/biologic Rx Mono/Poly S.Aureus, Salmonella,
Listeria
Travel e.g. US, South
America
knee Coccidioides
Tick bite Oligo arthritis (large
joints)
Borrelia burgdorferi
Aspiration vs washout
O Most can be managed via needle aspiration
O Ravindran V et al. Medical vs surgical treatment for
the native joint in septic arthritis: a 6-year, single UK
academic centre experience. Rheum
2009:48(10):1320-22
O 32 Medical (serial closed needle aspiration)
O 19 surgical (arthrotomy/arthroscopy)
O No sig difference in outcome
Arthroscopic Washout
O Possible indications
O Late presentation
O Loculation
O Unable to aspirate to dryness
O Poor response to initial treatment
O osteomyelitis
Case Scenario 2
• 22 year old male
• Right swollen knee
History
• Previously fit and well
• Recent holiday Cyprus “stag weekend”
Differentials Case 2: 22 year old male
• Reactive arthritis
• Gout
• Septic arthritis
• Psoriatic arthritis/seronegative arthritis
Case 2: 22 year old male Management
• Aspirate
– Fluid –MC& S, Gram stain, Crystals
• Can consider
• Culture screen, urate, FBC
– Autoantibody screen (RF, Anti –CCP)
– GU screen (if relevant)
Treatment – If infection still possibility
• Antibiotics as per local microbiology protocol
• 6 week course (1st 2 weeks iv)
– If infection unlikely options
• NSAIDs, Colchicine
• Steroids
• ICE, Physiotherapy
Reactive arthritis
O Typically younger adults
O often large joint involvement
O Reaction to initial GI/GU infection within
preceding 2-6 weeks
O No organisms in fluid
O HLA B27 positive association
O Usually good prognosis
O Can evolve to seroneg pattern arthritis
requiring DMARD
Case scenario 3
O 65 year old man
O Recent D&V
O Left big toe acutely swollen and painful
O ? Dx
O ?Management
www.medicine.net
Crystal arthropathy in a nutshell
O Gout & “pseudogout” /Calcium
pyrophosphate Deposition disease (CPPD)
O CPPD common in OA
O Acute flare – erythema, swelling, pain
O Easily mimics septic arthritis –can have
neutrophilia and fevers
O SF –CPPD/urate crystals (both can be
present!)
O Rx (acute) : Colchicine, NSAIDs, steroids
Summary Acute Hot Joint
O Safer to Rx as possible infection until proven
otherwise
O BSR, Intercollegiate Guidelines for standards
O Aspirate, aspirate, aspirate …whenever possible and
send for relevant tests
O Get trained in joint aspriation…at least for knee joint!
O Antibiotics as per protocol
O Adjuncts
O Depending on scenario and comorbidities
O NSAIDS, colchicine, steroids
Further reading & references
O Guidelines for management of the hot swollen joint in adults; British Society for Rheumatology
Standards, Guidelines and Audit Working Group (2006; reviewed and unchanged in 2012)
O Weston V, Coakley G; The British Society for Rheumatology (BSR) Standards, Guidelines and
Audit Working Group; British Society for Antimicrobial Chemotherapy; British Orthopaedic
Association; Royal College of General Practitioners; British Health Professionals in Rheumatology.
Guideline for the management of the hot swollen joint in adults with a particular focus on septic
arthritis. J Antimicrob Chemother. 2006 Sep;58(3):492-3. Epub 2006 Jul 19.
O Kherani RB, Shojania K; Septic arthritis in patients with pre-existing inflammatory arthritis. CMAJ.
2007 May 22;176(11):1605-8.
O Levine M, Siegel LB; A swollen joint: why all the fuss? Am J Ther. 2003 May-Jun;10(3):219-24.
O Margaretten ME, Kohlwes J, Moore D, et al; Does this adult patient have septic arthritis? JAMA.
2007 Apr 4;297(13):1478-88.
O Singhal R, Perry DC, Khan FN, et al; The use of CRP within a clinical prediction algorithm for the
differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br. 2011
Nov;93(11):1556-61. doi: 10.1302/0301-620X.93B11.26857.
O Main C; Treatment of septic arthritis. CMAJ. 2007 Oct 9;177(8):899; author reply 899-900
O Sharff KA, Richards EP, Townes JM. Clinical Management of Septic Arthritis Curr Rheumatol Rep
2013;15:332
O Margaretten ME, Kohlwes J, moore D, Bent S. Does this adult patient have sepitic arhritis? DARE
review York 2007
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