approach to patient with monoarthritis dr maryum khalil ho mu1 hfh
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APPROACH TO PATIENT APPROACH TO PATIENT WITH MONOARTHRITISWITH MONOARTHRITIS
Dr Maryum khalil HO MU1 HFH
MONOARTHRITIS
“Inflammation of a single joint”
*Acute
*Chronic
CAUSES OF ACUTE CAUSES OF ACUTE MONOARTHRITISMONOARTHRITIS
IN A PREVIOUSLY NORMAL JOINT:IN A PREVIOUSLY NORMAL JOINT: Septic arthritis Crystal synovitis
Trauma Haemarthrosis Foreign body
reaction
Monoarticular presentation of oligo- / polyarthritis
R.A
Erythema nodosum
Juvenile Idiopathic arthritis
Reactive, Psoriatic or other Seronegative spondarthritis
IN A PREVIOUSLY ABNORMAL JOINTIN A PREVIOUSLY ABNORMAL JOINT
DAMAGED JOINT:
Pseudogout in assc with O.A
Bone disease Cartilage disease Haemarthrosis Septic arthritis
EXISTING INFLAMMATORY DISEASE ( WITH OR WITHOUT DAMAGE):
Septic arthritis Exacerbation of underlying
disease
CAUSES OF CHRONIC CAUSES OF CHRONIC MONOARTHRITISMONOARTHRITIS
Foreign body Infection Ch. Sarcoidosis Enteropathic Arthritis (mainly Crohn’s) Amyloidosis Pigmented villonodular synovitis Synovial pathology (sarcoma, chondromatosis) Monoarticular presentation of oligo- / poly
articular disease
HISTORY & PHYSICAL HISTORY & PHYSICAL EXAMINATIONEXAMINATION
Acute monoarthritis can be the initial manifestation of many joint disorders. The first step in diagnosis is to verify that the source of pain is the joint, not the surrounding soft tissues. The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. A careful history and physical examination are important because diagnostic studies frequently are only supportive.
DIAGNOSTIC CLUESDIAGNOSTIC CLUES
Clues from history and physical examination
Sudden onset of pain in seconds or minutes
Onset of pain over
several hours or one to two days
Insidious onset of pain over days to weeks
Diagnoses to consider
Fracture, internal derangement, trauma,
Infection, crystal deposition disease, other inflammatory arthritic condition
Indolent infection, osteoarthritis, infiltrative disease, tumor
Intravenous drug use, immunosuppression
Previous acute attacks in any joint, with spontaneous resolution
Recent prolonged course of corticosteroid therapy
Coagulopathy, use of anticoagulants
Urethritis, conjunctivitis, diarrhea, and rash
Psoriatic patches or nail changes such as pitting
Septic arthritis
Crystal deposition disease, other inflammatory arthritic condition
Infection, avascular necrosis
Hemarthrosis
Reactive arthritis
Psoriatic arthritis
Use of diuretics, presence of tophi, history of renal stones
Eye inflammation, low back pain
Young adulthood, migratory polyarthralgias, inflammation
Hilar adenopathy, erythema nodosum
Gout
Ankylosing spondylitis
Gonococcal arthritis of the tendon sheaths of hands and feet, dermatitis
Sarcoidosis
DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES
1-SYNOVIAL FLUID EXAM: Arthrocentesis is required in most patients with
monoarthritis and is mandatory if infection is suspected. In some instances, obtaining as little as one or two drops of synovial fluid can be useful for culture and crystal analysis.
A) Cell countsB) MicroscopyC) C/S
Categorization of Synovial Categorization of Synovial FluidFluid
Noninflammatory: <2,000 WBC per mm3
Osteoarthritis Trauma Avascular necrosis Charcot's arthropathy Hemochromatosis Pigmented villonodular
synovitis
Inflammatory: >2,000 WBC per mm3
Septic arthritis Crystal-induced
monoarthritis (e.g., gout, pseudogout)
Rheumatoid arthritis Spondyloarthropathy SLE Juvenile R.A Lyme disease
MICROSCOPY:
C/S:
Synovial fluid cultures are more likely to be positive in patients with nongonococcal arthritis (90 percent) than in those with gonococcal arthritis (less than 50 percent).
2- CBC & ESR
4- BLOOD CULTURE Blood cultures should be obtained in
patients with suspected septic arthritis. Cultures are positive in about 50 percent of nongonococcal infections but are rarely positive (about 10 percent) in gonococcal infection.
Pharyngeal, urethral, cervical, and rectal swabs are necessary if gonococcal infection is suspected
5-RADIOGRAPHY: Although plain-film radiographs
often show only soft tissue swelling, they are indicated in patients with a history of trauma or patients who have had symptoms for several weeks. Occasionally, unsuspected bony lesions, such as osteomyelitis or malignancy, may be detected.
5-MRI:
Magnetic resonance imaging is superior in detecting ischemic necrosis, occult fractures, and meniscal and ligamentous injuries.
6-RADIONUCLIDE SCANS:
Radionuclide scanning can detect infection in deep-seated joints.
7- OTHERS:
Other diagnostic procedures, such as synovial biopsy or arthroscopy, may be useful to rule out deposition diseases (e.g., hemochromatosis, atypical infections) and intra-articular tumors.
SEPTIC ARTHRITISSEPTIC ARTHRITIS Bacterial Gonococcal Non-gonococcal(Staphylococcus
aureus , non group-A beta-hemolytic streptococci, gram-negative bacteria, and Streptococcus pneumoniae)
Viral – HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus
Fungal
MANAGEMENTMANAGEMENT
1- Hospitalization
2- Gen. Supportive care
3- I/V Antibiotics
4- Repeated Arthrocentesis
5- Surgical Drainage
CRYSTAL INDUCED CRYSTAL INDUCED SYNOVITISSYNOVITIS
A- GOUT:
ACUTE:
NSAIDs, Glucocorticoids,Colchicine
CHRONIC:
Allopurinol, Uricosuric Drugs
B- PSEUDOGOUT: - May present as acute mono- or
oligoarthritis mimicking Gout, or as a chronic polyarhthritis mimicking R.A & O.A
- NSAIDs, Glucocorticoids, Colchicine
C- APATITE DISEASE: - May present with periarthritis or
tendinitis - Rx same as Pseudogout
QUESTIONSQUESTIONS
A 67 year old male presents with his first A 67 year old male presents with his first episode of knee pain and swelling episode of knee pain and swelling together with the following x-ray.together with the following x-ray.
Which of the following investigations is the next investigation indicated diagnostically?
(a) Thyroid function tests (b) Serum urate (c) Knee aspiration (d) Serum iron (e) Skeletal survey
The following pelvic x-ray displays The following pelvic x-ray displays radiographic features of which of the radiographic features of which of the
following rheumatic disorders?following rheumatic disorders?
(a)Rheumatoid arthritis
(b) Paget’s disease
(c) Osteonecrosis
(d) Osteoarthritis
(e) None of the above
Which of the following types of joint Which of the following types of joint involvement is not seen in psoriatic involvement is not seen in psoriatic
arthritis?arthritis?
(a) Symmetrical small joint arthropathy
(b) Jaccoud’s arthropathy
(c) Sacroiliitis
(d) Monoarthritis
(e) DIP joint arthropathy
In septic arthritis which one of the In septic arthritis which one of the following pairings is most commonly following pairings is most commonly
found in hospital practice?found in hospital practice?
(a) Ankle joint and Staph Aureus
(b) Knee joint and MRSA
(c) Wrist joint and Beta haemolytic streptococci
(d) Knee joint and Staph Aureus
(e) Hip joint and Staph Aureus
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