orthopaedic blunder · history • 24/02- n.m- 24 year old black male • orthopaedic...
TRANSCRIPT
ORTHOPAEDIC BLUNDER
• WARD 5F• EDENDALE
HOSPITAL
HISTORY
• 24/02- N.M- 24 YEAR OLD BLACK MALE
• ORTHOPAEDIC WARD-CONSULT-ON SKIN TRACTION X2/52…..??ARTHRITIS
• C/O- PAINFUL SWOLLEN JOINTS X2/12• -UNABLE TO WALK• - LOSS OF FUNCTION>> L HAND
• ON ENQUIRY- EARLY MORNING STIFFNESS-FIRST EPISODE- LOW , NO LOA, NIGHTSWEATS- NO HX TB/ TB CONTACTS
- NO HX OF CONJUNCTIVITIS; VISUAL PROBLEMS
-NO PENILE D/C, INCONTINENCE
• PAST MEDICAL HX/ SURGICAL HX-NAD
• SOCIAL HX- NO ROH, SMOKING, TOXIC SUBSTANCES
ON EXAMINATION
• IN BED, UNABLE TO WALK; PALLOR+;ORAL CANDIDIASIS; SHOTTY CERVICAL L/N; NO JAUNDICE; NOT EMACIATED; NO SKIN LESIONS.
• CHEST= CLEAR; NORMAL CHEST EXP• C.V.S= NAD• ABDOMEN= SNT; NO SPLENOMEGALY; NOI
PENILE D/C
• CNS= GCS- 15/15; PEARL; NO CONJUNCTIVITIS
• SENSORY SYSTEM= DECREASED VIBRATION SENSE; JOINT POSITION SENSE LOWER LIMBS
• MOTOR SYSTEM- NO FASICULATIONS; NO MUSCLE WASTING; TONE= NORMALPOWER- L.L= 3/5; U.L= 4/5; DECREASED REFLEXES- L.L NO CLONUS OR BABINSKI.
• MUSCULOSKELETAL SYSTEM- SWOLLEN TENDER JOINTS- DIP, PIP,
WRIST,ELBOW, ANKLE- SYMMETRICAL, NO EFFUSIONS-DECREASED POWER ACTIVE +
PASSIVE .- NO DEFORMITIES
ASSESSMENT
• R.V.D----ORAL CANDIDIASIS---L/N’S
• POLYARTHRITIS—SYMMETRICAL• PERIPHERAL NEUROPATHY
INVESTIGATIONS
• X-RAY– L HAND; KNEE;CXR• FBC- HB= 10; MCV=101; WBC=5;
PLT=259;TLC=1100• U+E= NAD• LFT- TP=88; ALB= 14• LDH= 680; CK= 140• ESR=105MM/HR]
• COLLAGEN VASCULAR SCREEN = NEGATIVE
• RHEMATOID FACTOR = NEGATIVE• HIV=ELISA POSITIVE• VIT B12<<100• FOLATE=4.8• U/S ABDOMEN = NAD
FINAL DIAGNOSIS
• HIV +• VITAMIN B12 DEF-----SUBACUTE
DEGENERATION OF SPINAL CORD• SERONEGATIVE SYMMETRICAL
POLYARTHRITIS?? HIV RELATED
TREATMENT
• FOLATE; VIT B12; DIFLUCAN• NSAID- INDOCID 25MG TDS• PRENISOLONE 40MG DAILY• INH; VIT B6• O.T• ******IMPROVEMENT ----after 2/52
function of hand back; able to walk
DISCUSSION
• APPROACH TO ARTHRITIS• MANAGEMENT OF ARTHRITIS• HIV + ARTHRITIS• HIV + MACROCYTIC ANAEMIA
MUSCULOSKELETAL COMPLAINT
• 1. ARTICULAR ?• 2.ACUTE / CHRONIC• 3. INFLAMMATION• 4.HOW MANY JOINTS• 5. SYMMETRICAL ??
ARTICULAR-complaint >>6/52
• ACUTE• Acute arthritis• Infectious arthritis• Gout• Pseudogout• Reiters syndrome• Initial presentation
• CHRONIC• Is there inflammation
no yes
HOW MANY JOINTS??
• <3• INDOLENT INFXN• PSORIATIC• REITERS• PAUCIARTICULAR
J.A
• > 3• CHRONIC
INFLAMMATION• ASYMMETRICAL--PSORIATIC--REITERSSYMMETRICAL--R.A
• ESTABLISH DIAGNOSIS OF R.A
• DOCUMENT BASELINE DX ACTIVITY + DAMAGE
• ESTIMATE PROGNOSIS
INITIATE THERAPY
• EDUCATE• START DMARD WITHIN 3/12• CONSIDER NSAID• CONSIDER LOCAL/ SYSTEMIC
STEROIDS• OT
PERIODICALLY ASSESS DX ACTIVITY
• ADEQUATE RESPONSE WITH DECREASING DX ACTIVITY
• INADEQUATE RESPONSE—ONGOING ACTIVE DX AFTER 3/12 RX
• CHANGE / ADD DMARD
• MULTIPLE DMARD FAILURE/ STRUCTURAL JT DAMAGE =SURGERY
MUSCULOSKELETAL MANIFESTATIONS OF HIV
• MYOPATHIES- PYOMYOSITIS- POLYMYOSITIS- RX S/E
INFLAMMATORY ARTHROPATHIES# ARTHRALGIA- 45% OF PTS- ?? CYTOKINES/ TRANSIENT BONE
ISCHAEMIA
• -ANY STAGE OF HIV • 50 TO 70% OF ACUTE HIV• ACUTE ONSET , SEVERE PAIN• 4 OR FEWER JOINTS• << 24 HRS; SELF-LIMITING• LATE STAGES OF HIV- 10% OF AIDS• RX= NSAID
ACUTE SYMMETRICAL POLYARTHRITIS
• RESEMBLES POLYARTHRITIS• SMALL JTS OF HAND ACUTE ONSET;
R.F= NEGATIVE• X- RAY MIMICS R.A• GOLD THERAPY
HYPERTROPHIC OSTEOARTHROPATHY
• SYSTEMIC D/O AFFECTING BONES, JTS, SOFT TISSUES WITH PCP
• SEVERE PAIN LOWER EXTREMITIES; DIGITAL CLUBBING; ARTHRALGIAS; NON PITTING OEDEMA; PERIARTICULAR SOFT TISSUE INVOLVEMENT OF ANKLE, KNEE, ELBOW
• REITERS SYNDROME• PSORIATIC ARTHRITIS• AVASCULAR NECROSIS
HIV ASSOCIATED ARTHRITIS
• 1ST DESCRIBED 1988• 2 THEORIES-RXN TO IMMUNE
COMPLEXES WITHIN SYNOVIUM; DIRECT HIV INFXN OF SYNOVIUM–HIV + ASSAY SYNOVIAL FLUID
• >> MALES• ACUTE ONSET; SEVERE PAIN,
DISABILITY >>KNEES + ANKLES
• X RAY= OSTEOPAENIA, NO ERROSIONS
• HLA B27, R.F = NEGATIVE• SYNOVIAL BIOPSY= CHRONIC
MONONUCLEAR INFILTRATES• RX = NSAID
HIV + MACROCYTIC ANAEMIA
• MALABSORPTION• ACHLORYDIA
THE END• RHEMATIC DX AND
AIDS- JOSEPH GOLBUS 1994
• GUIDELINES MX R.A-2002 UPDATE-AMERICAN COLLEGE
• HARRISONS-15TH
• MUSCULOSKELETAL MANIFESTSTIONS OF HIV- AIDS READER 2003