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Rheumatology week 2 material
Terms in this set (38)
Yes, immediate referral for joint aspiration.
Treatment: prolonged course of IV and oral antibiotics
Is septic arthritis a medical emergency and if so what is the treatment?
Joint damage and death
What are complications of septic arthritis?
Seeding from systemic sepsis
-Direct inoculation after joint aspiration, injection... etc.
What are some triggers for septic arthritis?
80 years old
-Presence of diabetes mellitus
-Presence rheumatoid arthritis
-Presence of prosthetic joint (especially hip/knee)
-Recent joint surgery
-Recent skin infection
-Recent intraarticular injections (steroids)
IV drug use and alcoholism
What are some risk factors for septic arthritis?
Acute onset of pain (1 day - 2 weeks), swelling and decreased motion in one joint
-Affects one joint
-Large joints are affected more commonly than small joints
-Malaise and poor appetite
-Joint is warm and tender to touch
-History of RA, injections, trauma, DM or recent infection.
Note: Mortality is high in those with RA because incidence in those with RA is higher and it is difficult to distinguish septic arthritis from an acute flare.
What are the clinical features of septic arthritis?
Joint Aspiration (STAT)
-Purulent synovial fluid
-Elevated leukocyte count (>100,000 WBC/mm3)
-Gram stain and/or culture positive
-Crystal analysis negative
-Blood cultures - run if bacterial infection suspected even w/o fever
-Positive in 40-50% of cases
DO NOT delay treatment. Delay in treatment can mean death or permanent damage to the joint.
Antibiotic Therapy (1 - 6 weeks)
-Joint aspiration and drainage - generally done before ABX given
What are the diagnostic testing for septic arthritis?
What is naturopathic support for septic arthritis?
first metatarsal phalangeal (MTP) joint
What joints are affected most in Gout?
What is the most common diagnostic used for gout?
Uric acid is a byproduct of human purine metabolism
-Urate excretion occurs via the gut and the kidneys
-Underexcretion from renal insufficiency, systemic illnesses, dehydration, drug reactions, toxins
-Hyperuricemia drives precipitation of crystals which triggers an inflammatory response
What is the etiology for gout?
• Obesity and weight gain
• Purine rich food (meat, seafood)
• Medications (salicylates, diuretics, HTN meds)
• Toxicity (lead)
• Co-morbidities (HTN, psoriasis, diabetes)
• Insulin Resistance
What are risk factors for gout?
Fructose and alcohol
What non-purine foods increase urate?
1. Asymptomatic hyperuricemia
2. Acute (recurrent) gouty arthritis
• Single joint involved (first MTP joint, midfoot, ankles, knees)
• Explosive pain, usually starting in the evening or early morning
• Within hours (24), joint is hot, dusky red, swollen and tender
3. Chronic gouty arthritis (tophaceous)
• No pain-free periods
• Tophaceous deposits (usually painless)
• Marked limitations in joint movement
What are the three clinical features in Gout?
• The presence of urate crystals in synovial fluid (definitive Dx) OR
• Urate crystals identified in tophi OR
What is the diagnostic criteria for Gout?
• Treatment should begin AS SOON as the attack begins if possible (or at least within several hours).
• Treatment can stop within 2-3 days of complete cessation of symptoms.
• Joint should be rested and elevated; ice packs may help to reduce pain and swelling.
• NSAIDs - for mild to moderate pain prn
• Naproxen 500mg BID
• Colchicine - for mild/moderate pain when NSAIDs are contraindicated
• Most effective if administered within 12 - 24 hours of Sx onset
What is the treatment for gout in an acute attack?
-Allopurinol: titrate up 100mg/day to reach 200 - 600mg po qd (Max daily dose: 800mg po qd)
-Serum urate should be measured every 3 months during the first year, then annually
What are some preventative therapies for gout?
Eliminate alcohol consumption
-Reduce purine intake
-Meats: organ meats, seafood, red meats, poultry
-Yeast (brewer's and baker's)
-Reduce body weight
-Reduce refined carbohydrates
-Low fat intake
-Increase fluid intake
What are some dietary modifications that can be use in gout?
Note: High doses of vitamin C may increase uric acid levels
Homeopathy: Colchicum - Gout with great inflammation of joints and worse from least motion
What are some supplements and herbs that can be used in gout?
Calcium Pyrophosphate Dihydrate Deposition (CPPD)
What is pseudogout known as?
Is CPPD idiopathic?
wrist, elbow, knees, hips, and MTP
What joints are involved in CPPD?
Individuals over 55
Who are most affected by this condition?
• Previous joint trauma
• Presence of osteoarthritis (knee)
• Hemochromatosis (MCP joints)
• Hyperparathyroidism, hypomagnesemia, hypophosphatasia
What are the risk factors for CPPD?
• Asymptomatic CPPD
• Most common presentation
• Crystal deposition present on x-ray, but no symptoms.
What are the asymptomatic clinical features of CPPD?
• Large joints: knee most common
• Generally only one joint
• Excruciating pain, sudden onset, erythema, warmth and swelling
• Fever and chills may be present
What are the clinical features of acute CPP?
• MCP, wrists, elbows (joints spared by OA)
• Generally multiple joints involved
• Non-erosive, inflammatory arthritis with CPPD crystals
What are the clinical features of chronic CPPD?
• Joint aspiration!
• Acute CPPD will have turbid synovial fluid with neutrophils
• CPP crystals present
• Radiographic imaging or ultrasound
• Chondrocalcinosis is a common finding in the elderly and does NOT necessarily indicate clinical CPPD disease.
• Degenerative changes
What are the diagnostic testings used for CPPD?
• Removal of crystals through joint aspiration
• Intra-articular corticosteroids
• Ice or cool pack application (acute flares)
• Colchicine -
• Most effective when given within the first 24 hours of acute flare
What is the acute conventional treatment for CPPD?
• First line treatment:
• low-dose colchicine:
• Second line treatment:
What medications for prevention can be used for CPPD?
• Anti-inflammatory diet
• Fish Oils:
• Harpagophytum procumbens/Devil's claw-
• Boswellia serrata:
What are the Naturopathic treatments for CPPD?
What is the most common form of arthritis?
Defined mostly by degeneration, loss of cartilage and osteophyte formation, inflammation is generally a secondary component.
How is OA defined?
• Initiating mechanism is usually damage or stress to the normal articular cartilage
• Cytokines promote cartilage degradation:
• Basic calcium crystals influence cartilage calcification
• Inflammation is present, but is not the initial precipitating factor
What is the etiology of OA?
• Age >55
• Lack of osteoporosis
• Previous injury/trauma or overuse of the joint
What are the risk factors for OA?
• Insidious onset
• Joint pain worse with activity, better with rest
• Morning stiffness, relieved 30 min after waking
• Affects large and small joints: knee, fingers, hip, spine
• Tenderness to palpation of the joints
• Joint swelling may be present
• Crepitus is the most common finding
• Osteophytes may be palpable
What are the clinical features of OA?
leukocyte level low, calcium crystals may be seen.
What might appear on a joint aspiration of OA?
• Glucosamine Sulfate
• Chondroitin Sulfate
• Hyaluronic Acid
• Vitamin C
• Vitamin D
• Vitamin K
• Proteolytic Enzymes
What are some nutritional supplementation that can be used in OA?
• Boswellia serrata
• Zingiber officionalis
• Harpagophytum procumbens:
• Salix alba
What are some herbs that can be used in OA?
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