Rheumatology [MONOARTICULOPATHIES]

When someone comes in with a single hot joint with a several

hours duration (acute) there are a few possibilities. It’s likely
either a septic joint caused by an infection or a crystal deposition
disease. To determine the diagnosis the history with risk factors
becomes vital. But no matter how clear the story is, you can’t miss
a septic joint so always do an arthrocentesis.

1) Septic Arthritis
A septic joint gets infected two ways: direct inoculation by
trauma or by hematogenous spread. It really comes down to: is
it Staph aureus / Nongonococcal or is it Gonococcal? Staph can
get in via trauma (hard to miss the arrow sticking out of the knee) You’re going to tap the joint either way.
or by hematogenous spread (think IVDA / Endocarditis septic
emboli). Gonococcus gets in by hematogenous spread only, so You’ll treat empirically based on risk factors.
look for the young sexually active adult with a urethral
discharge and a couple of days of constitutional symptoms who You’ll treat for BOTH if you don’t get a definitive diagnosis
now has a hot, swollen knee. Tapping the joint will show many on Tap.
polys (>50 WBC 90% Poly). Start empiric antibiotics, then alter
them as the stain, cultures, and sensitivities become available. If
the gram stain is negative do double coverage (ceftriaxone +
vancomycin).

2) Gout
Gout is caused by deposition of monosodium urate crystals in
the joint space and exacerbated by hyperuricemia. Too much ACUTE
uric acid happens either because of increased cell turnover NSAIDs ↓ inflammation 1st Line, Gastritis, CKD
(production of uric acid secondary to DNA lysis) or by decreased Colchicine ↓ inflammation 2nd line, Diarrhea
excretion (usually a result of decreasing renal function). It’s Steroids ↓ inflammation Last Line
usually caused by decreased excretion. Look for the old man who CHRONIC
drinks alcohol and is on a diuretic (all of these decrease the Allopurinol Xanthine-Oxidase Maintenance, can cause
excretion capacity of the kidney). During an acute flare diagnose Inhibitor acute flare
gout with an arthrocentesis; it’ll show negatively birefringent Probenecid Uricosurics Maintenance, can cause
needle-shaped crystals. The joint is exquisitely tender so a clear Uric Acid Stones
clinical history is sufficient - especially if podagra (inflammation
of the great toe) is present. Treat acute gouty attacks with
NSAIDs or Colchicine. Colchicine causes diarrhea so is dose-
limited by that side effect. Treat chronic gout with the xanthine-
oxidase inhibitor allopurinol (preferred) or the uricosuric
agent probenecid to keep the uric acid between <6. Starting
treatment may induce an acute gouty attack. Don’t stop chronic
therapy during this flare.

Gout can get so bad that renal failure may result. This occurs
during severe bouts that increase the production of uric acid. One
such example is Tumor Lysis Syndrome (where a bulky tumor
as in Leukemia or Lymphoma is blasted by Chemotherapy).
To avoid Tumor Lysis Syndrome, prophylax with vigorous
hydration and pretreat with Allopurinol. If the uric acid levels
have already risen, lessen the burden of uric acid with
Rasburicase.

If the arthrocentesis shows positively birefringent crystals, it’s

pseudogout. The pathogenesis is unknown but it can be treated
with NSAIDs and Steroids.

Follow along with the diagram on the next

page.

©OnlineMedEd. http://www.onlinemeded.org
 Rheumatology [MONOARTICULOPATHIES]

Trauma, IVDA, Endocarditis Nafcillin

Non-Gonococcal
Gram Stain shows Direct Inoculation
(aka Staph) vs
NOT gram-negative Hematogenous Spread Vancomycin
Gram in clusters
Septic Ceftriaxone
Joint Sexually Active young adult IV or IM
Hematogenous Spread Only DAILY
Gonococcal
Gram-negative Gram cocci in chains
>50 WBC Urethritis, Cervicitis then
90% Polys Presumptively
migratory polyarthralgias, Treat Chlamydia
Gram Stain
tenosynovitis and a rash with Doxy x 7d

ONE JOINT PPx IVF + Probenecid + Allopurinol

DISEASE Arthrocentesis ↑ Production Tx: Rasburicase

Hot, Swollen, Tender Tumor Lysis Syndrome

Gout Leukemia / Lymphoma
< 50 WBC Negatively Birefringent Chemotherapy
gram stain needle-shaped crystals
Crystals Monosodium Urate NSAIDS
Podagra Tx: Inflammation or Steroids
Colchicine
Crystal ↓ Excretion
Deposition EtOH, Diuretics, Aging Diet (Ø red meat, Ø EtOH)
Tx: Uric Acid Levels Allopurinol better than…
↑Cr, Chronic Kidney Dz
Positively Birefringent between 5-6 Probenecid
Rhomboid shaped crystals
Pseudogout NSAID or Colchicine
Calcium Pyrophosphate
Steroids
Unknown pathogenesis,
Risk Factors
Arthritis Risk Factors Joint Tap Gram Stain Culture Crystals Treatment
Non-Gonococcal IVDA, Endocarditis, >75 WBC Gram Cocci Staph Ø Nafcillin or Vancomycin
Staph Aureus Direct Trauma, Sepsis 90% Polys in clusters
Gonococcal Unprotected Sex, >75 WBC Gram Cocci in Gonococcus Ø Daily IV or IM
Urethritis, Discharge, 90% Polys chains Ceftriaxone
Ø Trauma
Gout ↑ Levels of uric acid 5-50 Ø Ø Urate Crystals NSAIDs or Colchicine
old man on EtoH + negatively birefringent Steroids
Diuretics, Podagra Needle Shaped Allopurinol maintenance
Probenecid maintenance
Pseudogout ↑ Calcium 5-50 Ø Ø Pyrophosphate Crystals NSAIDs or Colchicine
Pathogenesis Unknown Positively Birefringent Steroids
Rhomboid Shaped

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