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Interhospital Meeting YCH

Interhospital Meeting YCH. Dr Patrick Lee. Case 1. F/58 NSND NKDA Known Amyopathic Dermatomyositis FU in rheumatology clinic

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Interhospital Meeting YCH

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  1. Interhospital Meeting YCH Dr Patrick Lee

  2. Case 1 • F/58 • NSND NKDA • Known AmyopathicDermatomyositis FU in rheumatology clinic • Presented with malaise, symmetrical joint pain, typical heliotrope rash over eyelid, gottron papules over hands, mechanic hands +/- vasculitic lesions over fingers • PET scan was –ve • ANA interference Anti-dsDNA –ve RF -ve • Now on Methotrexate/ Hydroxycholoroquine/ Prednisolone

  3. Last FU on 7/3/2013: complain of bilateral wrist pain • Clinically arthritis over both wrist • ESR 48  73 CK 246  33 • MTX 12.5mg 15mg while keeping Prednisolone 7.5mg/day • Attended A&E on 1/4/2013, c/o: right knee pain • Also neck pain and shoulder pain • Unable to bend her right knee • No history of trauma • No fever • Provisional diagnosis in A&E: Arthritis/ Dermatomyositis

  4. P/E: afebrile chest clear CVS: HS Dual abdomen soft tenderness on palpitation of cervical spine tenderness over both shoulder improving skin rash over hand right knee effusion+ swelling+ but no erythema and no increased temp decreased ROM of right knee

  5. Xray film

  6. Blood test • CBP: WCC 7.8 Neutrophil 7.2 lymphocyte 0.4 • RFT: Na 125 K 4.0 Cr 50 albumin 26 globulin 46 • ESR/ CRP not a/v (Public holiday)

  7. Rheumatology team was consulted the next day, • Knee tap was done under aseptic technique, yield ~ 1ml pus like substance only

  8. Fluid sent for urgent Gram stain, C/ST, Cell count, AFB C/ST, crystal • Start on IV cloxacillin and Rocephin • Orthopaedics Urgent consulted, would like to proceed to EOT • Joint fluid cell count: not done, pus like fluid received, unfit for microscopy • Joint fluid Urgent Gram stain: Gram Positive cocci+

  9. Arthroscopy of knee and therapeutic washout of joint performed • 5ml of thick pus drained • Diffuse synovitis over all three compartments of knee • Later C/ST: grow staph aureus

  10. Lesson 1 • A patient can suffer from septic arthritis despite normal white cell counts and afebrile status.

  11. Case 2 • M/63 • Social drinker • Known Seropositive RA FU in rheumatology clinic • Hx of HT • Now on Methrotrexate 15mg/week, Prednisolone 10mg/day • Last FU in rheumatology clinic 4/13 • DAS-28 -> 2.71

  12. Blood test during last FU • normal WBC/ALT • RFT normal • ESR 120->98->120 -->55->29 • CRP 121->38 -->18->4.1

  13. Attended A&E for right foot pain x 2 days • Swelling over 1st MTJ • No history of trauma • No fever • Difficulty in walking • P/E: right 1st MTJ erthythema+ swelling+ tenderness+ • Other joints including hands joints, knee joints are OK • Afebrile

  14. Provisional diagnosis of A&E • Right foot arthritis • ?Flare up of RA • ?Gouty attack

  15. Blood test • WCC 17.1 • CRP 306 ESR 120 • Normal RLFT • Rheumatology team was consulted

  16. Aspiration yielded pus like substance • O&T consulted and suggested to proceeded to EOT • Arthrotomy + drainge of foot done • Findings: 20 ml of pus over MTPJ and surrounding subcutaneous layer, MPTJ erosion with necrotic bone, articular surface eroded already • Later Pus C/ST: Heavy growth of Staphylococcus aureus

  17. Lesson 2 • Septic arthritis can mimic gouty arthritis, even in typical sites

  18. Case 3 • An urgent Orthopaedics consultation at 1:00am for assessment +/- take over for suspected CNS infection • F/ 69 • Known Hx of DM, Fatty liver, obesity, hypertension, OA knee • Left TKR on 25/4/13 • Brought into A&E on 24/5/2013 due to LOC at home for ?5 min, noticed ?confusion by relatives • No preceding chest pain • No head injury

  19. P/E: Temp 38.3 at A&E • GCS 15/15 • Chest clear CVS: HS dual • Head: no external wound • Left knee swelling + redness+ hotness • Admitted to O&T ward for suspected left knee infection

  20. Blood test by Orthopaedics: • WCC 6.7 Hb 8.7 platelet 188 ESR cancelled • CRP not a/v • CT brain: unremarkable • During my assessment, patient was on restrain, afebrile, no active complaints, a little bit sleepy and slow in response (at 1:20am) • P/E: no neck stiffness, no other sign of meningism left knee swelling, increased in temperature but no tenderness • Medications: none!! (No antibiotics)

  21. What will you do? • A) Take over the case and put a needle into L3/4 space to obtain CSF for suspected CNS infection • B) Put patient on empirical antibiotics • C) Put in a needle into patient’s left knee and try to see if it is infected • D) Other suggestions?

  22. Joint fluid aspirate: Gram stain showed gram positive cocci • EOT was done: Findings: acute infected TKR with turbid intraarticular joint (20ml) and grossly inflammedsynovium, no bony erosion, skin and arthotomy wound intact, no sinus • Removal of implanted device from bone and synovectomy was done • C/ST: Staph aureus and strep Group G

  23. Lesson 3 • There may be atypical presentations of septic arthritis, patient may not complain of pain/ joint swelling.

  24. Case 4 • M/67 • Hx of DM, Hyperlipidaemia FU GOPD, Hx of Right shoulder rotator cuff tear with OT done 2010 • Attended A&E on 14/3/2013 • Right shoulder pain x 3 day • Decreased ROM • No Hx of trauma

  25. OA changes, no fracture seen, discharged with NSAIDs

  26. Reattended A&E 3 days later • c/o: right hand swelling, still shoulder pain • Fever x 1/7 • Cough with sputum+ • P/E by A&E colleagues: Temp 39.1 • Tenderness over shoulder, reduced ROM • Diffuse swelling down to elbow and fingers • Chest clear, CVS: HS dual • Diagnosis: Fever x Ix, ?Right UL DVT

  27. Investigation • WCC 16.2 Hb 11.6 • Na 127 K 4.0 Cr 103 • albumin 26 • Spot glucose 17.7 • USG doppler: no signs of DVT shown on USG • Rheumatology team was consulted, noticed diffuse swelling of upper limb, but more severe near shoulder joint

  28. Again, we put in a needle over shoudler to aspirate • Yield pus like substance again • Joint fluid microscopy/ Gram stain: Gram +vecocci present • Orthopaedic consulted: arthoscopic washout of joint structure performed, 2ml of pus, degenerative change at GH joint • C/ST: streptococcus

  29. Lesson 4: Septic arthritis is not that rare. Atypical presentation of septic arthritis: mimics DVT

  30. Septic arthritis • Medical Emergency • A hot, swollen and tender joint should be regarded as septic arthritis until proven otherwise, even in the absence of fever, leucocytosis, elevated ESR or CRP. • Septic arthritis can present as monoarthritis (80-90%), oligoarthritisor polyarthritis. • Delay in diagnosis and treatment can result in irreversible joint destruction. • Knee most commonly affected joint (approximately 50%) followed by hip, shoulder, then elbow

  31. Incidence • Incidence of septic arthritis 10 cases per 100,000 patient-years in general population in Europe • incidence of septic arthritis in patients with rheumatoid arthritis • based on prospective British Society for Rheumatology Biologics Register • 1.8 cases per 1,000 patient-years in 3,673 patients taking nonbiologicdisease-modifying antirheumaticdrugs • 4.2 cases per 1,000 patient-years in 11,881 patients taking anti-tumor necrosis factor therapy Reference Ann Rheum Dis 2011 Oct: 70 1810 • incidence of septic arthritis following joint-invasive procedures • based on nationwide retrospective study in Iceland from 1990-2002 • 0.14% incidence following arthroscopy • 0.037% incidence following arthrocentesis Reference Ann Rheum Dis 2008 May; 67 (5) 638

  32. Risk factor • Rheumatoid arthritis • DM • Joint prosthesis • Cutaneous ulcers • Alcoholism • Low socioeconomic status • Intravenous drug abuse • Previous intra-articular corticosteroid injection Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. Lancet. 2010 Mar 6; 375: 846-55

  33. Causative organisms • Staphylococcus aureus most frequent causative agent • Streptococcus • Neisseria gonorrhoeae • Gram-negatives, Haemophilus in older patients • In injection drug users • MRSA isolated in 50% of specimens in series of 12 cases in patients presenting at urban California emergency department • mixed infections • fungal infections • unusual organisms

  34. Pathogenesis: Infection can be introduced into a joint either as a result of haematogenous spread or by direct inoculation, occurring with trauma or iatrogenically.

  35. Diagnostic Pitfall • Symptoms related to systemic infection are less common than might be expected. • In a prospective analysis of patients in whom bacteria were cultured from synovial fluid, a history of fever was recorded in 34%, sweats in 15%, and rigors in only 6% • Similarly, a fever (>37・5°C) at presentation is detected in only about 60% of cases, indicating that (contrary to popular medical opinion) raised temperature is not a prerequisite for diagnosis of septic arthritis. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001; 40: 24–30.

  36. Sensitivity of symptoms for septic arthritis in systematic review of 7 studies in adults • joint pain had 85% sensitivity in 2 studies • history of joint edema had 78% sensitivity in 2 studies • fever had 57% sensitivity in 7 studies • sweats had 27% sensitivity in 2 studies • rigors had 19% sensitivity in 4 studies Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis?JAMA. 2007 Apr 4; 297 (13): 1478-88

  37. sensitivity of signs for septic arthritis in systematic review of 32 studies in adults • pain with motion had 100% sensitivity • limited motion had 92% sensitivity • joint effusion had 92% sensitivity • joint tenderness had 68%-100% sensitivity • joint swelling had 45%-100% sensitivity • axial load pain had 36% sensitivity • fever > 37.5 degrees C (100 degrees F) had 34%-54% sensitivity • increased heat had 18%-92% sensitivity • redness had 13%-54% sensitivity Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. AcadEmerg Med. 2011 Aug;18:781

  38. Investigation • CBC with differentials, RFT, LFT, blood culture • X-ray of the joint. • Swabs of pharynx, urethra, cervix and anorectum if gonococcal infection suspected. • Prompt aspiration of the joint is warranted. Synovial fluid should be sent for: 􀁺Differential cell counts: Usually >50,000 WBC/ml and often >100,000/ml, predominantly neutrophils. 􀁺Gram stain 􀁺Culture and sensitivity 􀁺Polarising microscopy for crystals (septic arthritis may co-exist with crystal arthropathies)

  39. Start empirical IV antibiotics immediately according to suspected organisms and gram stain. Modify according to culture and sensitivity results. The handbook of Internal Medicine, 6th edition

  40. The handbook of Internal Medicine, 6th edition

  41. Consult orthopaedic surgeon for drainage especially for infected prosthetic joint. Open drainage is usually necessary for hip infection. • Start physiotherapy early. • NSAIDs for pain relief. • IV antibiotics for at least 2 weeks or until signs improved for non-gonococcalarthritis, then orally for an additional 2-4 weeks.

  42. Corticosteroids? • Suppression of an excessive immune response with corticosteroids could be a more effective treatment regimen for S aureusseptic arthritis than use of antibiotics alone. • In mice treated with intraperitonealcloxacillin together with intraperitonealcorticosteroid, prevalence, severity, and mortality associated with septic arthritis induced by S aureusinoculation was significantly reduced compared with mice treated with intraperitonealcloxacillinalone. Sakiniene E, Bremell T, Tarkowski A. Addition of corticosteroids to antibiotic treatment ameliorates the course of experimental Staphylococcus aureus arthritis. Arthritis Rheum 1996; 39: 1596–605.

  43. Corticosteroids? • 123 children were enrolled into a double-blind, randomised, placebo-controlled trial assessing dexamethasone treatment for haematogenousseptic arthritis. • A short course of low-dose dexamethasone (0.2 mg/kg intravenously every 8 h for 12 consecutive doses), given in conjunction with antibiotic treatment, reduced duration of disease course and extent of residual joint damage and dysfunction compared with antibiotics alone. Odio CM, Ramirez T, Arias G, et al. Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children. Pediatr Infect Dis J 2003; 22: 883–88.

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