Dec 4, 2020
This podcast presents, Dr. Michael Edwards, a rheumatologist with Ridgeview Specialty Clinics, who provides a discussion some unique arthritis cases.
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CASE 1 - Psoriatic
For our first case, our 77 year old male ended up with psoriatic arthritis. Key points of the work up include ruling out a septic joint, looking for articulation problems or soft tissue concerns like chronic infections, skin lesions, or breakdown and assessing for polyarthritis. Further work up includes sedimentation rate, C-reactive protein, and imaging, starting with x-rays.
Key points of the work up include ruling out a septic joint, looking for articulation problems or soft tissue concerrns like chronic infections, skin lesions or breakdown and assessing for polyarthritis. Further work up includes sedimentation rate, C-reactive protein, and imaging - starting with x-rays.
To tap or not to tap? That is the question for joint complaints. Arthrocentesis through an area of cellulitis or inflamed soft tissue is generally contraindicated. However, if a tap is feasible, the three C's: culture, WBC count, and crystals should be send. A cell count greater than 10,000 would be indicative of an inflammatory effusion. In the acute setting, the pros and cons should be weighted as to whether or not to inject steroids. If you suspect infection, though, do NOT inject corticosteroids.
Long-term treatment of psoriatic arthritis is individualized to the patient. Some patients manage with methotrexate, while others might need a biologic. Cost is a barrier in prescribing biologics, requiring referrals, and prior insurance authorization. Biologics target a specific part of the immune system. Contraindications would be patients who are already immunosuppressed, have TB, hepatitis or multiple sclerosis, or are in late stages of CHF. Other contraindications include breast, lung or melanoma cancer with a high risk of recurrence. When running a fever or prior to surgery, biologic doses should be delayed or paused.
CASE 2 - Ankylosing
In case number 2, a young man with a long history of back pain ended up with ankylosing spondylitis. Again, the history becomes important in the diagnosis, keying us to be suspicious of this patient's chronic pain. For this case, though lab work was normal, an AP x-ray of the pelvis showed narrow and sclerotic sacroiliac joints with erosion.
Like psoriatic arthritis, this diagnosis falls under the category of seronegative spondylarthropathy. When tested, the patient will not have antibodies or positive rheumatoid factor. It is a reactive condition: sacroiliitis causes inflammatory changes and therefore pain. Inflammatory bowel conditions like Crohns and Ulcerative colitis fall into this same family of reactive conditions.
First line treatment for ankylosing spondylitis is NSAIDS taken on a scheduled basis to protect the joints. Long term management includes physical therapy and back education. Biologics can be used for pain refractory to NSAIDS.
This pain can go undiagnosed for years, and cause irreparable fusion of the spine, otherwise known as a bamboo sign as seen on x-ray. Again, a thorough history is key to catching and diagnosing these patients early, and preventing long-term complications.
CASE 3 -
Out last patient is a woman with a swollen knee, normal wbc, and elevated sed rate. Due to her history, and RA flare up would be considered in the differential, but unlikely due to a monoarthritic presentation. Following a similar work up as the first two cases, labs and imaging are obtained and the knee is tapped. The three C's mentioned earlier: culture, WBC count and crystals are sent and the results are positive for needle-like crystals which are negative birefringent when examined with polarizing microscopy. The patient has gout.
Treatment includes NSAIDS like Naprosyn or indomethacin. In an acute setting, oral steroids can be prescribed. Dosing for gouty monoarthritis is 20-30mg for 3-5 days. For patients already on baseline steroids, include a steroid taper back to baseline.
Additional work up could include uric acid levels. While not diagnostic, a uric acid greater than 9 may help identify patients at risk for future episodes. If the patient has 2 or more gout attacks a year. Allopurinol can be prescribed.
To sum up all our cases today; a thorough history and exam are critical, keep the differential broad, and management is weighing the pros and cons of NSAIDS, steroids and whether or not to tap that joint. Septic arthritis can not be overlooked. Early recognition and diagnosis is key.
Thanks for listening.