Acute Monoarthritis (Adult) on AMU

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Acute Monoarthritis (Adult) on AMU Document Examinations Findings Consider Potential Causes Articular Features (pain, tenderness Septic Arthritis Swelling, redness, warmth) Gout Other joint involvement Pyrophosphate Crystal Deposition Extra-articular features (pseudogout) Tophi Reactive Arthritis SEW Score Monoarticular Onset Polyarthritis Precipitating factors (e.g trauma) Traumatic Synovitis& Mechanical Evidence of other disease (incl. post fracture) Haemarthrosis Inflammatory OA Investigations Aspiration from an area of clear skin must be performed as part of initial investigations (must be done by/under supervision of experienced clinician) DO NOT ASPIRATE PROSTHETIC JOINTS WITHOUT ORTHOPAEDIC SUPPORT: • microbiology sample in a universal container (cell count & crystals) • blood culture bottles • If gonococcus suspectd request PCR • Phone the microbiology MLSO to inform of sample for crystals Peripheral Blood Cultures (x 2 if clinical sepsis and/or pyrexia) Full blood count & biochemistry PV & CRP X-ray joint INR if on warfarin Any other investigations suggested by history/examination to determine cause D/W Rheumatology on call when possible Suspicion of Septic Reactive Arthritis Gout Pyrophosphate or Arthritis pseudogout Uncomplicated Full dose NSAID 1. Full dose NSAID with As per gout (likely gram + ve) with gastric gastric protection or * Flucloxacillin IV 2g protection Bed-rest & local QID 2. Colchicine steroid injection * Clindamycin 600mg Treat precipitating 500micrgrams 2-3 QID if penicillin-allergic factor (e.g. times daily until pain doxycycline for relieved D/W Rheumatology & Chlamydia) Not suitable if ID significant renal/hepatic ≥ 6 weeks therapy – impairment consider OHPAT If not suitable for Complicated colchicine please refer (recent surgical or GI to the Tayside procedure) Rhuematology Likely gram – ve guidelines on Staffnet (linked from our page) D/W rheumatology & ID or med micro for antimicrobial advice If gonococcal refer to GUM Adapt antibiotic therapy according to culture yield Consider therapeutic aspiration/drainage with orthopaedic surgeons Rheumatology Team guidance developed 2000 & revised 2006 Updated for AMU 2009 (Acute Medical Team) .

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Acute < 6 Weeks Subacute ~ 6 Weeks Chronic >
Pain Articular Non-articular Localized Generalized . Regional Pain Disorders . Myalgias without Weakness Soft Tissue Rheumatism (ex., fibromyalgia, polymyalgia (ex., soft tissue rheumatism rheumatica) tendonitis, tenosynovitis, bursitis, fasciitis) . Myalgia with Weakness (ex., Inflammatory muscle disease) Clinical Features of Arthritis Monoarthritis Oligoarthritis Polyarthritis (one joint) (two to five joints) (> five joints) Acute < 6 weeks Subacute ~ 6 weeks Chronic > 6 weeks Inflammatory Noninflammatory Differential Diagnosis of Arthritis Differential Diagnosis of Arthritis Acute Monarthritis Acute Polyarthritis Inflammatory Inflammatory . Infection . Viral - gonococcal (GC) - hepatitis - nonGC - parvovirus . Crystal deposition - HIV - gout . Rheumatic fever - calcium . GC - pyrophosphate dihydrate (CPPD) . CTD (connective tissue diseases) - hydroxylapatite (HA) - RA . Spondyloarthropathies - systemic lupus erythematosus (SLE) - reactive . Sarcoidosis - psoriatic . - inflammatory bowel disease (IBD) Spondyloarthropathies - reactive - Reiters . - psoriatic Early RA - IBD - Reiters Non-inflammatory . Subacute bacterial endocarditis (SBE) . Trauma . Hemophilia Non-inflammatory . Avascular Necrosis . Hypertrophic osteoarthropathy . Internal derangement Chronic Monarthritis Chronic Polyarthritis Inflammatory Inflammatory . Chronic Infection . Bony erosions - fungal, - RA/Juvenile rheumatoid arthritis (JRA ) - tuberculosis (TB) - Crystal deposition . Rheumatoid arthritis (RA) - Infection (15%) - Erosive OA (rare) Non-inflammatory - Spondyloarthropathies
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Variation in the Initial Treatment of Knee Monoarthritis in Juvenile Idiopathic Arthritis: a Survey of Pediatric Rheumatologists in the United States and Canada
Variation in the Initial Treatment of Knee Monoarthritis in Juvenile Idiopathic Arthritis: A Survey of Pediatric Rheumatologists in the United States and Canada TIMOTHY BEUKELMAN, JAMES P. GUEVARA, DANIEL A. ALBERT, DAVID D. SHERRY, and JON M. BURNHAM ABSTRACT. Objective. To characterize variations in initial treatment for knee monoarthritis in the oligoarthritis sub- type of juvenile idiopathic arthritis (OJIA) by pediatric rheumatologists and to identify patient, physi- cian, and practice-specific characteristics that are associated with treatment decisions. Methods. We mailed a 32-item questionnaire to pediatric rheumatologists in the United States and Canada (n = 201). This questionnaire contained clinical vignettes describing recent-onset chronic monoarthritis of the knee and assessed physicians’ treatment preferences, perceptions of the effective- ness and disadvantages of nonsteroidal antiinflammatory drugs (NSAID) and intraarticular corticos- teroid injections (IACI), proficiency with IACI, and demographic and office characteristics. Results. One hundred twenty-nine (64%) questionnaires were completed and returned. Eighty-three per- cent of respondents were board certified pediatric rheumatologists. Respondents’ treatment strategies for uncomplicated knee monoarthritis were broadly categorized: initial IACI at presentation (27%), initial NSAID with contingent IACI (63%), and initial NSAID with contingent methotrexate or sulfasalazine (without IACI) (10%). Significant independent predictors for initial IACI were believing that IACI is more effective than NSAID, having performed > 10 IACI in a single patient at one time, and initiating methotrexate via the subcutaneous route for OJIA. Predictors for not recommending initial or contin- gent IACI were believing that the infection risk of IACI is significant and lacking comfort with per- forming IACI. Conclusion. There is considerable variation in pediatric rheumatologists’ initial treatment strategies for knee monoarthritis in OJIA.
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Concurrent Onset of Adult Onset Still's Disease and Insulin Dependent Diabetes Mellitus
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Biological Treatment in Resistant Adult-Onset Still's Disease: a Single-Center, Retrospective Cohort Study
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