Acute Rheumatology Conundrums“as seen in AMU”

Prof. Tom Kennedy

Consultant Physician and Rheumatologist

Director of Medical Education Royal Liverpool Hospital

Learning objectives

Review common rheumatological conditions presenting to a busy emergency floor (AMU/ED)

01Describe how the service works

02Give an update of the management common rheumatological conditions

03

How does the clinic work.

1

Patients attending either AMU or ED over the previous week get “booked into” the Acute MSK clinic

2

Maximum 16 patients seen

3

Registrar (either AMU or rheumatology) attends

4

Great teaching opportunity

5

Opportunity to follow up patients in short term

Conditions seen

37

19

16

9

7

4

42 2

GIM

InflammagoryarthritisCrystals

PMR/GCA

Vasculitis

Cellulitis

Spine pain

VTE

Widespread pain

Hot swollen joint

“Mantra aspirate all hot swollen joints”

Would you attempt to aspirate this joint?

Hot swollen jointAspiration of joint is mandatory

Septic arthritis

Patient often toxic

Note risk actorspre-existing joint disease, usually RA or OA

prosthetic joints

low socio-economic status

intravenous drug abuse

Alcohol misuse

diabetes mellitus

Previous injection of steroid

ulcerated skin

Antibiotics – flucloxacillin / clindamycin

Blood cultures before antibiotics

Crystal arthritis

Often polyarticular

Commonest joint great toe

Usually history of attacks

Family history

High sugar/fructose diet

High alcohol /fat intake

Metabolic syndrome

Diuretic use esp. bfz and loop

What’s new -Gout

• Gout is associated with metabolic syndrome and patients should be screened for obesity, diabetes mellitus, hypertension, hyperlipidaemia and cardiovascular diseases

• A definite diagnosis of gout requires joint aspiration and polarised light microscopy of aspirated fluid

• Serum uric acid may be normal during an acute attack of gout

• Acute gout can be managed by rest, ice packs and low-dose colchicine or oral NSAIDs or corticosteroids.

• Aspiration and injection of corticosteroid is recommended as the fastest treatment for acute gout –20mg methylprednisolone for small joints, 40 for elbows and 80 for knees

• Advise patient to avoid fructose

Gout crystals

Urate lowering therapy

• When should ULT be commenced?• During an attack of gout or• Wait for 6 week gout free period?

• Indications for urate-lowering treatment (ULT) are:• more than one acute attack of gout in 12

months (in uncomplicated gout),• Complicated gout i.e. tophi, renal impairment,

uric acid nephrolithiasis or a need to continue on diuretics for heart failure.

• ULT should be discussed and considered with patients even around the time of first diagnosis

• ULT dose should be titrated gradually aiming for a serum uric acid (SUA) ≤320 μmol/L.

• What is there a role for surgery?

Calcium pyrophosphate disease

Associated with: HyperparathyroidismHypothyroidismHaemachromatosisHyposphatasiaHypomagnaemiaWilson’s diseaseMenisectomy

Management:

Hydrate wellJoint injection with steroidColchicine 500mcg x 3-4 dailyNSAID’s Oral prednisolone

Inflammatory arthritis

A disease of synovium

How to use the drugs

• NSAID’s

• Lowest dose for shortest period

• Usually with PPI cover

• 5-7 day courses of NSAID e.g. naproxen usually with PPI cover

• Simple Analgesia e.g. Cocodamol

• When pain is very bad OR

• Before activity OR

• Regularly 2 tabs 4 x daily OR

• Steroids

• Bridging therapy

• Control of flare up

• Before special occasions

• May increase risk of infection

• DMARDS

• To control disease activity – prefer Methotrexate

• Often Triple therapy is used

• Please stop whilst patient unwell – therapeutic holiday

Biological therapy

Changing the face of rheumatology

• However:

• Infection risk – Abatacept anti cd80 ? Lowest risk

• Check Quantiferon Gold spot test before starting biological therapy

• Hepatitis A, B and C may all be reactivated by biological therapy – seek specialist support

• If varicella develops – stop biological / DMARD therapy and commence intravenous anti-viral therapy.

• Consider TB in septic patients on biological therapy

10/10

Pain

Timedose Dose > 2 hrs

dose

Pain controlled

Out of control

Pain Graph

Sero-negative / Reactive Arthritis

• Sero-negative (rheumatoid factor/anti-CCP)• Look for Psoriasis

• Check HLA B27

• Dactylitis

• Iritis / conjuctivitis

• Common associations Bowel infection (upto) 6 weeks before: salmonella, yersinia, shigella, campylobacter, e-coli

GU infection – chlamydia

Post Viral arthritis - common

• Classic viruses causing arthritis• Parvo-virus 60%

• Hepatitis B 10-25%

• Hepatitis C 2-20%

• Rubella in adults

• Adeno virus

• Mumps

• Usually self-limiting

• Treat NSAID’s or steroids

Osteoarthritis – a disease of bone and cartilage• Framingham 28% OA symptomatic 7%

• Not always progressive• Control weight• Maintain muscle strength- prevent fixed flexion deformities especially knees

• AMU / ED attendance for flare up: exclude crystals, gout, flare of disease

• Aspirate and injection joint unless septic

• Education how to use analgesia / NSAID, explain risks

• Bakers cyst v DVT

Vasculitis

• Giant cell arteritis - Ultrasound

• Henoch Schonlein Purpura

• ANCA positive Vasculitis• Granulomatosis with polyangiitis (Wegener ‘s Granulomatosis)

• Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

• Polyarteritis nodosum

Henoch Schonlein purpura

• IgA Vasculitis• Common associated with infections e.g URTI, gastroenteritis

• Symptoms:• Rash

• Joint pains

• Abdominal pain

• Haematuria

• NSAID’s or Steroids

• Self limiting

Case 1 48 year not employed

old male

Case 2 55 year old male train

driver

Presentation testicular pain:

Case 1• USS Carcinoma of testis• Histology – infarcted testis• Empirically treated prednisolone 55 mg

orally for 3 weeks• Lost to follow up

• Case 2: presented to AMU with:• dusky red rash on legs, • some hilar lymphadenopathy • joint pains: • pANCA negative

Giant cell arteritis

Giant cell (temporal) arteritis if at least three of these five criteria are present.

1 Age at disease onset 50 years or more

2 New headache

3 Temporal artery abnormality

4 Raised ESR > 50 mm/hr

5 Abnormal artery biopsy:

Ultrasound of Temporal arteries

Osteoporosis:

• BMD >-2.5

• Check Vitamin D levels before starting Bisphophonates

• Bisphosphonates 5 yrs of steroid therapy

• Osteonecrosis of the jaw

• Unusual fractures hip

• Check BMD following treatment to determine on-going treatment.

• If “bad teeth” wait to start treatment till dentist review

• Teriparatide – if very low BMD

Thank you Any questionsTom.Kennedy@RL

BUHT.nhs.uk