Rheumatolgic Emergencies
Conflicts
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None
Errors - Mine.
Thanks to:
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Dr. Walker
Dr. Hadley
Dr. Del Castilho
Table of Contents
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What is that!?
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What unites them all?
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Questions/Discussion
(knee
)
Acute Monoarthritis
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Non-Inflammatory
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Trauma
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HbS
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Osteonecrosis
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Inflammatory
 Crystals
 Bacteria
 Rheumatiod Arthritis
 Spondyloarthropathy
 SLE
 Sarcoidosis
 Bursitis
Acute Monoarthritis
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Septic joint in RA – overlooked
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Delay of Dx 1-3 weeks
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Significant joint damage
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Mortality 20 - 33%
Acute Monoarthritis
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What blunts identification?
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Often insidious onset
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'Unrewarding physical exam'
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Absence of fever 50%
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Polyarticular pattern in 25% of pts
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Immunosuppression
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Plausible reason for red, sore knee
Red and Hot
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'The most important laboratory test in
evaluating monarticular joint pain is synovial
fluid analysis.' UTDOL.
WBC not enough
Normal
Noninflammatory
Inflammatory
Septic
WBC/mm3
<200
200 -2,000
2,000-100,000
15,000->100,000
PMN%
<25
<25
>50
>75
Colour
Clear
Yellow
Yellow to opalescent
Yellow to purulent
Gl mg/dL
.=serum
.=serum
May be low
Very low
What to order
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Look at it
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Xantho, clear, cloudy, purulent
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Total leukocyte count and diff
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Gram stain and culture
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Crystals (polarizing micro)
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Glucose
WBC not enough
Normal
Noninflammatory
Inflammatory
Septic
WBC/mm3
<200
200 -2,000
2,000-100,000
15,000->100,000
PMN%
<25
<25
>50
>75
Colour
Clear
Yellow
Yellow to opalescent
Yellow to purulent
Gl mg/dL
.=serum
.=serum
May be low
Very low
Tx
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Depends on most likely cause
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No RTC of ABx in septic arthritis
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Red knee, no infection
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Intraarticular steroids
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Polyarthritis – increase oral steroid, control flare
http://www.medscape.com/viewarticle/706761
http://www.medscape.com/viewarticle/706761
Ankylosing Spondylitis
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Pathologically rigid spine
becomes osteoporotic
~10% # c-spine in lifetime
Neuro complications
common
2/3 may not completely
recover Neurologically.
Unstable fracture through disc space C6/7
Ankylosing Spondylitis
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Most common presentation:
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Pain, usu localized.
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Aggravated by movement.
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Different from inflammatory pain of AS.
Mass effect:
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Bleeding and edema
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May present as radiculopathy and myleopathy.
Ankylosing Spondylitis
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MC Site?
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C6-7
How is it missed?
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Not considered.
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Plainfilm XR
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No Hx major spinal trauma 50%!
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Nature of #:
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Often non-displaced
Small size (Syndesmophytes)
C5-C6
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Inverted radial reflex
Predicted Problems
Ankylosing Spondylitis
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When to order Imaging?
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If pain is new, out of ordinary.
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Neurologic complaints or findings.
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XR, CT +/- MRI
What to do?
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Cautious immobilization.
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Ortho.
Sceroderma
Sceroderma
Scleroderma Renal Crisis
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~10-20% develop it.
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~20% mortality.
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~20% will need HD after crisis.
Scleroderma Renal Crisis
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How to identify it?
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Acute onset renal failure, progressive azotemia.
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New HTN (from normal to malignant).
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>150/85 2x/24hrs, mean peak 178/102.
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Headache
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Microangiopathic anemia c thrombocytopenia
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Urine – normal or mild prot c cells or casts
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+/- Flash pulmonary edema
Scleroderma Renal Crisis
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Steroids?
Scleroderma Renal Crisis
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What to do?
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ACEi (Grade 1A).
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Captopril (Grade 2B) – no CNS s/s.
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Add Nitroprusside – WITH CNS s/s.
Nephro.
Giant Cell Arteritis
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Granulomatous arteritis of thoracic aorta and its
branches.
Classic symptoms:
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Temporal artertis
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Usu >50, new headache, tender scalp, fluctuating
vision, jaw claudication, constitutional symptoms.
Prednisone 60 mg/d biopsy within 1 week
Polymyalgia Rheumatica
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Lit review up to 2004
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23 studies, 2036 pts, 5 languages.
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May be helpful, caution with test results.
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The future
Giant Cell ArteritisVetebro-Basilar Insufficiency
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TA + new defects of vetebro-basilar territory
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Untreated – risk of bilateral vetebral artery
occlusion, mortality 75%.
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ESR
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MR angio
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Tx: high dose steroids
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??OTHER
vertebral
Giant Cell ArteritisAortitis
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GCA – 27% pt large artery complications.
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Ascending aortic aneurysms 17x
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AAA 2.5x
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Suspect it
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Hx, RF
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CT / MRI
Instability of C-Spine
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71% of pts with RA have C-spine involvement
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70% may have subluxation
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25% of these -> frank dislocation
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11% cord compression
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5 yr survival – 80%
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10 yr survival - 28%
Atlantoaxial subluxation
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MCC: Neck/occiput/forehead pain in RA?
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Atlantoaxial subluxation
MCC:
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Atlantoaxial subluxation ~70%
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Synovium of C1-C2 articulation
Synovial C2 – Transverse ligament articulation
Subaxial subluxation ~20%
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Synovium below C2
Decision making in spinal care By Alexander R. Vaccaro, D. Greg Anderson
Atlantoaxial subluxation
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Anterior
atlantodens
interval
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McRae's Line
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McGregor's Line
Atlantoaxial subluxation
Atlantoaxial subluxation
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General Precautions?
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Suspect it: RA pt with new onset occipital pain
and/or tingling of fingers.
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Caution with Passive flexion of C-Spine.
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Caution with intubation. (Stabilize)
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When to order Flex/Ex?
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What to do if >3.5mm ADI?
Adrenal Insufficiency
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What unites most rheumatic diseases?
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Steroid dependence
Can be
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Medical or surgical stress
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Stopping of Rx
S/S
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Hypotension, lethargy, change to mental status,
hypoGlc.
Adrenal Insufficiency
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Tx
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NS
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Glc
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Hydrocortisone 100 mg IV
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Or: (dexamethasone 4 mg IV – no impact on ACTH
test or cortisol level)
Questions
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Bibliography
Adam: Grainger & Allison's Diagnostic Radiology, 5th ed
Barr, W et al. Principles of Critical Care - 3rd Ed. (2005), Ch 104
Current Diagnosis & Treatment in Orthopedics - 4th Ed. (2006)
Firestein: Kelley's Textbook of Rheumatology, 8th ed.
Fotini B. Karassa et al. Meta-Analysis: Test Performance of Ultrasonography for Giant-Cell Arteritis. Ann Intern Med.
2005;142:359-369.
Ginsberg Lawrence E, "Chapter 13. Imaging of the Spine" (Chapter). Chen MYM, Pope TL, Jr., Ott DJ: Basic Radiology:
http://www.accessmedicine.com/content.aspx?aID=2271105.
Mettler: Essentials of Radiology, 2nd ed.
P A Nee, J Benger and R M Walls. Airway management doi:10.1136/emj.2005.030635. Emerg. Med. J. 2008;25;98-102
Physical examination of the spine By Todd J. Albert, Alexander R. Vaccaro
Steen, VD, Medsger, TA. Case-control study of corticosteroids and other drugs that either precipitate or protect from the
development of scleroderma renal crisis. Arthritis Rheum 1998; 41:1613.
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http://emedicine.medscape.com/article/238545-overview
http://education.yahoo.com/reference/gray/illustrations/figure;_ylt=AiXwKBJ25LQJ0A7brQ1WBY9tHokC?id=86
http://www.ucl.ac.uk/news/news-articles/0709/07092002
http://emedicine.medscape.com/article/331864-media
http://www0.sun.ac.za/ortho/webct-ortho/arthritis/aspirate-knee-s.jpg
https://www.bcbsri.com/BCBSRIWeb/images/mayo_popup/Scleroderma.jsp
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http://emedicine.medscape.com/article/1265682-overview
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