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Rheumatolgic Emergencies
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Conflicts
None Errors - Mine. Thanks to:
Dr. Walker Dr. Hadley Dr. Del Castilho
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Table of Contents
What is that!? What unites them all? Questions/Discussion
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(knee)
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Acute Monoarthritis
Non-Inflammatory Trauma HbS Osteonecrosis
Inflammatory Crystals Bacteria Rheumatiod Arthritis Spondyloarthropathy SLE Sarcoidosis Bursitis
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Acute Monoarthritis
Septic joint in RA – overlooked Delay of Dx 1-3 weeks Significant joint damage Mortality 20 - 33%
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Acute Monoarthritis
What blunts identification? Often insidious onset 'Unrewarding physical exam' Absence of fever 50% Polyarticular pattern in 25% of pts Immunosuppression Plausible reason for red, sore knee
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Red and Hot
'The most important laboratory test in evaluating monarticular joint pain is synovial fluid analysis.' UTDOL.
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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
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What to order
Look at it Xantho, clear, cloudy, purulent
Total leukocyte count and diff Gram stain and culture Crystals (polarizing micro) Glucose
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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
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Tx
Depends on most likely cause No RTC of ABx in septic arthritis Red knee, no infection
Intraarticular steroids Polyarthritis – increase oral steroid, control flare
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http://www.medscape.com/viewarticle/706761
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http://www.medscape.com/viewarticle/706761
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Ankylosing Spondylitis
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
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Ankylosing Spondylitis
Most common presentation: Pain, usu localized. Aggravated by movement. Different from inflammatory pain of AS.
Mass effect: Bleeding and edema May present as radiculopathy and myleopathy.
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Ankylosing Spondylitis
MC Site? C6-7
How is it missed? Not considered. Plainfilm XR No Hx major spinal trauma 50%! Nature of #:
Often non-displaced Small size (Syndesmophytes)
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C5-C6
Inverted radial reflex
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Predicted Problems
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Ankylosing Spondylitis
When to order Imaging? If pain is new, out of ordinary. Neurologic complaints or findings. XR, CT +/- MRI
What to do? Cautious immobilization. Ortho.
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Sceroderma
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Sceroderma
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Scleroderma Renal Crisis
~10-20% develop it. ~20% mortality. ~20% will need HD after crisis.
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Scleroderma Renal Crisis
How to identify it? Acute onset renal failure, progressive azotemia. New HTN (from normal to malignant).
>150/85 2x/24hrs, mean peak 178/102. Headache Microangiopathic anemia c thrombocytopenia Urine – normal or mild prot c cells or casts +/- Flash pulmonary edema
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Scleroderma Renal Crisis
Steroids?
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Scleroderma Renal Crisis
What to do? ACEi (Grade 1A). Captopril (Grade 2B) – no CNS s/s.
Add Nitroprusside – WITH CNS s/s. Nephro.
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Giant Cell Arteritis
Granulomatous arteritis of thoracic aorta and its branches.
Classic symptoms: Usu >50, new headache, tender scalp, fluctuating
vision, jaw claudication, constitutional symptoms. Temporal artertis
Prednisone 60 mg/d biopsy within 1 week Polymyalgia Rheumatica
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Lit review up to 2004 23 studies, 2036 pts, 5 languages. May be helpful, caution with test results.
The future
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Giant Cell Arteritis- Vetebro-Basilar Insufficiency
TA + new defects of vetebro-basilar territory Untreated – risk of bilateral vetebral artery
occlusion, mortality 75%. ESR MR angio Tx: high dose steroids
??OTHER
vertebral angiogram
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Giant Cell Arteritis- Aortitis
GCA – 27% pt large artery complications. Ascending aortic aneurysms 17x AAA 2.5x Suspect it
Hx, RF CT / MRI
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Instability of C-Spine
71% of pts with RA have C-spine involvement 70% may have subluxation
25% of these -> frank dislocation 11% cord compression 5 yr survival – 80% 10 yr survival - 28%
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Atlantoaxial subluxation
MCC: Neck/occiput/forehead pain in RA? Atlantoaxial subluxation
MCC: Atlantoaxial subluxation ~70%
Synovium of C1-C2 articulation Synovial C2 – Transverse ligament articulation
Subaxial subluxation ~20% Synovium below C2
Decision making in spinal care By Alexander R. Vaccaro, D. Greg Anderson
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Atlantoaxial subluxation
Anterior atlantodens interval
McRae's Line McGregor's Line
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Atlantoaxial subluxation
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Atlantoaxial subluxation
General Precautions? Suspect it: RA pt with new onset occipital pain
and/or tingling of fingers. Caution with Passive flexion of C-Spine. Caution with intubation. (Stabilize)
When to order Flex/Ex?
What to do if >3.5mm ADI?
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Adrenal Insufficiency
What unites most rheumatic diseases? Steroid dependence
Can be Medical or surgical stress Stopping of Rx
S/S Hypotension, lethargy, change to mental status,
hypoGlc.
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Adrenal Insufficiency
Tx NS Glc Hydrocortisone 100 mg IV Or: (dexamethasone 4 mg IV – no impact on ACTH
test or cortisol level)
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Questions
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.
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 http://emedicine.medscape.com/article/1265682-overview