Acute hot swollen joint

Dr Edward Roddy Senior Lecturer in Rheumatology and Consultant Rheumatologist Acute monoarthritis: differential diagnosis

• Septic arthritis • Crystal arthritis (gout, pseudogout) • Haemarthrosis • Reactive arthritis • Monoarticular presentation of inflammatory arthritis • Traumatic synovitis Acute monoarthritis: differential diagnosis

• Septic arthritis • Crystal arthritis (gout, pseudogout) • Haemarthrosis • Reactive arthritis • Monoarticular presentation of inflammatory arthritis • Traumatic synovitis Septic arthritis

• The most serious cause of monoarthritis

• A medical emergency

• Mortality 10%

• Persistent pain, joint damage, functional impairment 30%

Weston Ann Rheum Dis 1999 Septic arthritis: risk factors

• Extremes of age • Low socioeconomic status • Immunosuppression • alcoholism, diabetes mellitus • Any joint pathology (esp RA) • Joint prosthesis • Previous ia steroid injection • Cutaneous ulcers

• iv drug abuse Mathews Ann Rheum Dis 2007 Mathews Lancet 2010 Septic arthritis: clinical features

• Sub-acute onset over 1-2 weeks • Painful, swollen, red, tender joint(s) • 85% present as monoarthritis • Knee most common • Fever absent in 50% • Features of infection elsewhere?

Mathews Ann Rheum Dis 2007 Mathews Lancet 2010 Septic arthritis: which joint?

35

30

25

20 % 15

10

5

0

Weston Ann Rheum Dis 1999 Septic arthritis: diagnosis

• Refer prosthetic joints to orthopaedics • Aspirate the (native) joint • frank pus, Gram stain, WCC, culture & sensitivity • as soon as possible • prior to starting antibiotics • Blood cultures • Markers of infection may be absent • X-rays of limited value acutely

Coakley Rheumatology 2006 Mathews Ann Rheum Dis 2007 Markers of infection

100 90 80 70 60 % 50 40 30 20 10 0 Fever Elevated WCC ESR>20mm/hr CRP>20mg/l SF WCC > 50000/mm3 Weston Ann Rheum Dis 1999 Coutlakis J Clin Rheumatol 2002 Septic arthritis: organisms

Staph aureus MRSA Staph epidermidis Strep spp Gram negative spp

Gupta Rheumatology 2001 Septic arthritis: management

• Medical resuscitation • iv antibiotics • following joint aspiration • according to local guidelines • modify with results of Gram stain & cultures • typically 2 weeks iv, then 4 weeks oral • Analgesia!! • Daily aspiration/arthroscopic washout

• Surgical removal of implant Coakley Rheumatology 2006 Mathews Ann Rheum Dis 2007 Acute gout [Na] + [Urate] Male gender Family history Alcohol excess Dietary purines Metabolic syndrome Obesity BP Acute arthritis Chronic gouty Tophi arthritis Renal impairment Diuretics Osteoarthritis Acute gout: clinical features

• Typical features of crystal inflammation • Rapid onset (<24 hours) • Severe pain, heat, swelling, (erythema) • Exquisite tenderness • Skin desquamation • May be systemic upset • 1st attack 1st MTPJ in 50-70% • 1st MTPJ = gout likely

Zhang Ann Rheum Dis 2006 Roddy J Foot Ankle Res 2011 “The patient goes to bed and sleeps quietly till about two in the morning, when he is awakened by a pain which usually seizes the great toe…The pain resembles that of a dislocated bone…and this is immediately succeeded by a chillness, shivering and a slight fever. The pain grows gradually more violent every hour, and comes to a height towards evening…becomes so exquisitely painful as not to endure the weight of the clothes nor shaking of the room from a person’s walking briskly therein”

Thomas Sydenham (1624-89) Acute gout - other sites

Roddy J Foot Ankle Res 2011 Acute gout: diagnosis

• Crystal identification is the gold standard

• Not necessary when classical podagra

• Consider when: • presentation atypical • affects joints other than 1st MTPJ

Zhang Ann Rheum Dis 2006 Acute gout: lab tests

• Serum uric acid: • Acute phase reactant: normal during attack in 25-49% • Hyperuricaemia does not equal gout • But useful for monitoring therapy

• WCC/ESR/CRP may well be elevated

Zhang Ann Rheum Dis 2006 Acute gout: management

• Aim: rapid relief of pain and inflammation • Main options: • NSAIDs • Colchicine • Corticosteroids Acute gout: NSAIDs

• No evidence for any particular NSAID • Any fast-acting NSAID at full dose • eg naproxen, diclofenac • Indomethacin best avoided • Gastrointestinal concerns: • PPI as indicated • etoricoxib 120mg daily Schumacher BMJ 2002 Sutaria Rheumatology 2006 Zhang Ann Rheum Dis 2006 Janssens Lancet 2008 Khanna Semin Arthritis Rheum 2014 Acute gout: colchicine

• Traditional dosing regime • 1mg initially then 500mcg every 2-3 hours • until pain abates or diarrhoea/vomiting occurs

• BNF since November 2008: • 500mcg two to four times daily • until symptoms relieved Ahern Aust NZ J Med 1987 Morris BMJ 2003 Sutaria Rheumatology 2006 Zhang Ann Rheum Dis 2006 Terkeltaub Arthritis Rheum 2010 Khanna Semin Arthritis Rheum 2014 Acute gout: other options

• Joint aspiration/injection • Oral/intramuscular steroids • eg prednisolone 20mg daily • when NSAIDs/colchicine inappropriate AND • joint injection not possible (site of attack, expertise, multiple joints) • Local application of ice-packs

Schlesinger J Rheumatol 2002 Sutaria Rheumatology 2006 Zhang Ann Rheum Dis 2006 Janssens Lancet 2008 Khanna Semin Arthritis Rheum 2014 What to do with allopurinol?

• Not normally started during attack • But not stopped if attack occurs • attack = “successful treatment” not a “side-effect” Don’t reinforce the myths

• Gout is: • Not funny • Not self-inflicted • Not a rich man’s disease • Commonly nothing to do with diet or alcohol Acute pseudogout Calcium pyrophosphate crystal deposition

• Common age-related phenomenon

• Very rare under 50 years

• Most common cause of cartilage calcification

• Acute pseudogout Acute pseudogout: clinical features

• Acute attack of synovitis at a single joint • Typical features of crystal inflammation • Rapid onset (<24 hours) • Severe pain, heat, swelling, (erythema) • Exquisite tenderness • Systemic upset common • Knee most common site • Most likely cause of acute arthritis of knee, wrist or shoulder >65 years

Zhang Ann Rheum Dis 2011 Acute pseudogout: diagnosis

• Crystal identification is the gold standard • Radiographic chondrocalcinosis • Common at the knee, wrist, symphysis pubis • Does not confirm acute pseudogout • Can be caused by other crystals too • Insensitive may miss small deposits • Diagnosis should be crystal-proven Acute pseudogout: management

• Aims for rapid relief of joint pain/swelling • Joint aspiration/injection is treatment of choice • NSAID – caution in elderly, consider PPI • Low-dose colchicine 500mcg bd-qds • im/oral steroid if: • joint difficult to inject eg mid-foot • oligo/polyarticular attacks • Topical ice therapy

Zhang Ann Rheum Dis 2011 Sepsis or crystals?

• History: speed of onset • Crystals: rapid (<24 hours) • Septic arthritis: sub-acute 1-2 weeks • Gout very likely if 1st MTPJ • Knee over 65 years suggests CPPD; less certain • Can’t rely on fever/WCC/ESR/CRP • Serum uric acid often normal in acute gout

• Joint aspiration is the investigation of choice When not to aspirate?

• Prosthetic joints • Overlying skin infection • Difficult joints – hip, mid-foot

Image courtesy of Prof M Doherty • Anticoagulation • Rapid onset of severe pain and tenderness at 1st MTPJ: aspiration probably not needed Key messages

Fever, WCC, ESR, CRP, uric Joint aspiration is the single acid are poor discriminators investigation of choice

Septic arthritis: Acute gout: • aspirate ASAP but • NSAID or low-dose before antibiotics colchicine first-line • high-dose iv antibiotics • don’t stop allopurinol

Acute pseudogout: • acute arthritis of knee, wrist, shoulder in over 65s • CC not reliable: aspiration needed • Low-dose colchicine/steroids first-line