2/26/20 Overview • Patient scenarios • Labs/X-rays/joint fluid • Crystalline arthritis • Septic Joint – native, prosthetic • Conclusions The Hot Joint in the Elderly Mary Chester2017 TOWN Wasko, HALL MD, MSc 2 Case 1. Acutely swollen knee • 74 yo man with T2DM, HTN, R knee OA • Recent change in diuretic therapy • Prior history oF podagra • T 101, swollen painFul R knee • No tophi 1 2/26/20 Categories of synovial fluid Measure Normal Non- Inflammatory Septic Hemorrhagic Testing inflammatory Volume, mL (knee) <3.5 Often>3.5 Often3>3.5 Often>3.5 Usually>3.5 Clarity Transparent Transparent Translucent- Opaque Bloody • WBC 13.8, 80% PMN, 3% bands opaque Color Clear Yellow Yellow Yellow Red Viscosity High High Low Variable Variable • CMP wnl, Cr. 1.1 White blood cell, per <200 0 to 2000 >2000* >20,000¶ Variable microL • ESR 68 Polymorphonuclear <25 <25 >50 >75 50 to 75 Culture Negative Negative Negative Often positive Negative • 35 ml synovial fluid aspirated, cloudy *Inflammatory arthritis may include septic arthritis. – WBC 42K, 99% PMN ¶ Septic arthritis is typically associated with synovial fluid WBC >20,000 cells/microL, but lower counts may be observed, especially for arthritis due to disseminated GC. – Gram stain negative Adapted from UpToDate, 2020 6 Class III Synovial Fluid Normal Synovial Fluid Cloudy to Opaque, Low Viscosity Clear, Amber, High Viscosity >50,000 WBC/µl with <200 WBC/µl with neutrophil predominance mononuclear predominance 2 2/26/20 Urate Crystal: Needle shaped, often larger than WBCs, Strongly negative birefringence Treatment: Options for acute rx Treatment: Longterm • Colchicine 1-1.2 mg x1, repeat 0.6 mg in 1 h • When should you initiate longterm treatment to lower uric acid (urate lowering therapy, ULT), prevent • NSAIDs future attacks? • Intraarticular steroids Yes – if recurrent frequent attacks (>1/yr) • Medrol dose pack Yes – if tophi • Anakinra (IL-1 mAb, Kineret) for hospital use Yes – if multiple risk factors for recurrence Allopurinol is the DRUG OF CHOICE Wait for attack to subside before starting ULT Continue colchicine, NSAIDs or pred 5/d 3 2/26/20 Treatment: Longterm ULT Urate-lowering Therapy • Allopurinol is the DRUG OF CHOICE to lower uric • Allopurinol is a safe option with mild-moderate CKD acid • Initial dose depends upon GFR – if impaired (<50 • ULT can be started simultaneously w attack! ml/min), begin 50 mg daily. Otherwise, 100 mg qd. • It is IMPERATIVE to suppress recurrent attacks • Titrate dose monthly to asymptomatic uric acid of <6 when starting a urate-lowering rx mg/dl • After stable uric acid sustained at <6 mg/dl for 6 months, • Continue colchicine, NSAIDs or pred 5/d d/c colchicine or nsaid • You can precipitate a FLARE if add/adjust allopurinol Taylor TH et al. Am J Med 2012; 125:1126-1134, Hill EM. J Clin Rheum 2015; 21:120-5 without background anti-inflammatory rx. Correctible Causes of ↑ Uric Acid Case 2a • Alcohol, esp. beer • 60 yo man • High purine foods: venison, shellfish, liver • Psoriasis • 2 wk swollen knee • Low dose ASA • Well otherwise • Diuretics, esp. thiazides • ESR 40, cbc/cmp nl FAVORABLE DIET: milk/dairy products • DDx? 4 2/26/20 DDx: Subacute Knee Arthritis Case 2b Wrist acute monoarthritis • Crystalline: maybe – atypical for gout • 74 yo woman with swelling, pain R wrist • Autoimmune: age against this • Hx HTN, T2DM, hx MI; on ASA 81 mg qd if <40, consider reactive arthritis/PsA • No hx tophi, renal stones • Infection: immunocompromised – bacterial • No recent med changes immunocompetent – LYME, fungal CPPD of the wrist CPPD Crystals: Rhomboid shaped, smaller than WBCs, Weakly positive birefringence 5 2/26/20 Why not gout? • PMP woman on ASA – uric acid may be ↑ • However, 1st attack in upper extremity – atypical for gout • How to treat on ASA: avoid NSAIDs • Colchicine, COX-2 inhibitor, MDP CPPD: Chondrocalcinosis Longterm Approach to CPPD Case 3a • Check for a cause – • 60 yo man • If 1st attack is >age 50, check magnesium, • 2 d knee swelling,pain Ca/iPTH, alk phos • Well otherwise • No need for longterm rx with one attack • T 100.3 • Consider longterm colchicine if recurrent • ESR 55, WBC 13K attacks • DDx? 6 2/26/20 Considerations, w/u Treatment • Crystals – Gout? fever, leukocytosis • Antibiotics based upon clinical presentation, Gram Stain, and culture • Infection - ?bacterial in healthy man – Gram Stain: Gram Positive cocci • Vancomycin • W/u – joint fluid – Gram Stain: Gram Negative bacilli • Third generation cephalosporin (ceftazidime, ceftriaxone, WBC 66K, 99% PMN cefotaxime – Culture positive: modify the regime based upon Gram stain: GPC’s, PMNs sensitivities Lyme screen pending • Joint drainage surgically Case 4. TKR complication • 66 yo man with L TKR 3y prior (OA) • 2d severe pain, swelling in prosthetic knee, polyarthralgias elsewhere • Exam: vs nl, no fever/rash. • MSK: Bilateral wrist synovitis, L MCP 2-5 tenosynovitis > R MCP 2-5 tenosynoviits, Left knee swelling 7 2/26/20 URGENT ORTHO EVAL Further Course: IV Vanco Arthrocentesis Results: Irrigation Debridement, synovectomy of infected left knee L Knee: 162K Cells, rare Arthrocentesis L wrist, elbow, shoulder gram +, + CPP crystals Arthrocentesis R wrist, R elbow, R hip Arthrocentesis Results: L Knee: 162K cells, organism N.gonorrhoea R Hip: 133K, rare Ca crystals and uric acid crystals L elbow: 18 WBC Further Course: Disseminated Gonnoccocal Infection Transitioned to ceftriaxone for 4 wk, dose of azithromycin Colchicine added 0.6 mg BID Occurs in 0.5 to 3% of patients infected by N.gonorrhoeae Washout of hip performed Two major clinical phenotypes: At Discharge: 1) Arthritis-tenosynovitis-dermatitis Continue on ceftriaxone for 4 weeks total therapy via PICC line 2) Purulent arthritis Overall improved in regards to pain especially R wrist, elbows, R knee – L wrist still painful but less swollen Treatment (should respond quickly) 1) Can consider orals if sensitive 7 days 2) IV 7-14 days 8 2/26/20 © ACR Rheumatology Follow Up: Bilateral shoulder pain, not much stiffness. L wrist still painful with use, some stiffness and synovitis. R Wrist with similar symptoms but much less severe. L 5th PIP swelling. Bilateral ankle swelling R>L What does this patient have? N. gonorrhoeae has been linked Plan: with up to 16% of cases, as distinct Added colchicine 0.6 mg BID from its role in septic, GC arthritis. Considering steroids at short term follow up 9 2/26/20 Hot Joint: Take-home Messages Hot Joint: Take-home Messages • ALWAYS rule out infection w/tap, esp if a Infections occur at any age and in any joint medium or large joint Ø May co-exist with crystals • Consider CPPD (esp older woman) when Ø May be unusual bug suspect gout – may co-exist and have an underlying cause; a bit more indolent Ø Don’t forget Lyme disease in our area • Joint fluid is a key component to correct dx • X-rays can be helpful – chondrocalcinosis 37 38 10.