The perils of chicken vindaloo Re-active arthritis

Linda Nazarko MSc, PgDip, PgCert, BSc(Hons), RN, NIP, OBE, FRCN

Consultant Nurse West London Mental Health Trust Nurse Prescribing; LSBU 15th March 2017

Aims and objectives To be aware of:

The value of listening to the patient

The importance of history taking

The value of physical examination

How to nail the diagnosis

How to work within scope of practice

Determining treatment options

The value of nurses practicing at advanced

level

Clinical presentation 30 year old single

man

Had a chicken vindaloo three weeks ago, hasn’t been the same since.

Feels as if he’s been “hit by a truck”

Calgary- Cambridge Model

Formulating the diagnosis

Medical and social history

Single, has a steady girl friend planning to get engaged next year.

Sharing a flat with a colleague

Works as a web designer

Normally fit and well diarrhoea after a chicken vindaloo. Now settled.

Did 10 kilometre runs and was training for the London Marathon.

Presenting problems

Red sore eyes - difficult to read, bright light hurts & eyes are watering a lot.

Stiff sore swollen knees walking is a struggle, feels like “an old man”

Dysuria – difficulty passing urine & painful to pee

Mr McKenzie’s perspective

“ I was fine till I had that vindaloo. Nobody else was ill but I was the only one who had chicken”

“I was fit and healthy and now I feel like I’ve been hit by a truck”

“ I don’t think I have an STD Lucy is my only partner..”

Mr McKenzie’s hopes and aspirations

“ I want to know what is wrong with me and I want to get better”.

Physical examination

HENT= normal

Cranial nerves intact

Eyes red and sore, optic discs normal. Examination difficult

Chest clear, heart sounds normal unable to detect any indication of aortic regurgitation.

Genito-urinary examination - meatal oedema, no discharge, tender testes.

Mild back pain.

Knees hot, red, swollen and there were small effusions. Observations of temperature, blood pressure, pulse, respirations, and 02 saturations were within normal limits. Slightly elevated pulse.

Weight 77kg. BMI 23.

Possible red flags

Anterior Uveitis

Hot swollen joints with effusions

Dysuria and mild meatal oedema

Testicular tenderness

Differential diagnosis- reactive arthritis

History and clinical examination suggest that he has re-active

arthritis (ReA) but we need to rule out other possible causes. These

are:

Gonorrhea with gonococcal arthritis and other types of infectious

urethritis. A urethral swab can be used to check. It’s important to be

aware that gonococcal arthritis does not affect the spine.

Rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.

Exacerbation of existing ankylosing spondylitis preceded by

diarrhoea is reported to have similar clinical features

Septic arthritis and pyogenic arthritis can mimic ReA. Septic arthritis

must be ruled out if suspected as failure to treat septic arthritis

appropriately in a timely manner could result in joint destruction

What is reactive arthritis?

Reactive arthritis was describe by Reiter in 1916 and was formerly known as Reiter’s syndrome. This autoimmune condition can occur post infection typically genito-urinary infections and gastro-intestinal infections. It is associated with the HLA-B27 haplotype. This protein is found on the surface of white blood cells and predisposes to certain auto-immune diseases.

It is associated with a number of symptoms including the classic triad of non-infectious urethritis, arthritis and conjunctivitis. Around a third of patients demonstrate all three classical features "can't see, can't pee, can't climb a tree"

It is underdiagnosed and researched & is thought to affect between 0.6-27 people per 100,000.

Diagnosis No diagnostic tests to confirm, dx based on history & clinical

examination. Investigations that are often performed are:

Full blood count & CRP

Blood, urine and stool and wound cultures to detect any causative organisms which may require treatment such as gastro-intestinal or genito-urinal infection.

Urinalysis

Human leukocyte antigen (HLA)–B27. On average 75% of people with ReA are positive to HLA-B27.

HIV testing. People with HIV are at increased risk of inflammatory arthritis and ReA and likely to have severe symptoms that require specific treatment

Echocardiography. Around 1-2% of people with ReA develop aortic regurgitation.

Treatment options

• To treat triggering infection if necessary

Antibiotic

• To settle inflammation and treat pain- NSAIDS

• Corticosteroids may be used topically, intra-articularly and systemically.

Corticosteroids

• May be used when NSAIDs are ineffective or contraindicated

Disease-modifying anti-rheumatic drugs

(DMARDs)

Treatment Antibiotic therapy may be used to treat the

triggering infection No specific treatment for ReA Management is based on symptom severity.

Standard treatment normally consists of Nonsteroidal anti-inflammatory drugs (NSAIDs). Corticosteroids may be used topically, intra-articularly and systemically. Disease-modifying anti-rheumatic drugs (DMARDs) – may be used when NSAIDs are ineffective or contraindicated

Around 2/3 of patients recover spontaneously however around 30% develop chronic symptoms.

Anterior uveitis.

“Uveitis is inflammation of the uveal tract, with or without inflammation of neighbouring structures”

Occurs in 12-37% of patients with ReA.

Is one of the leading causes of preventable

severe visual loss in developed countries

Anterior uveitis & conjunctivitis How to differentiate

Anterior uveitis Conjunctivitis

Red eye Red eye

Pain that worsens when

trying to read

Mucoid discharge

Progressive - occurs over

a few hours/days.

Feeling of grittiness

Blurred vision.

Photophobia.

Excess tear production

Abnormally shaped pupils

Diagnosis & treatment of anterior uveitis

Slit lamp examination of the posterior segment of the eye is required to check for the presence of posterior uveitis.

ReA associated uveitis can lead to the adhesion of the iris to the surface of the lens or vitreous body and the development of angle-closure glaucoma and blindness.

Those with suspected uveitis must be referred to an ophthalmologist within 24 hours, delay in appropriate management can lead to the development of significant complications and irreversible loss of vision.

Management of ocular complications is dependent on the type of uveitis, whether it is secondary to infection, whether it is likely to threaten sight and severity of symptoms. Treatment may include topical, oral and/or intravenous steroid treatment.

Scope of practice

The nurse is required to work within the limits of competence and make a timely and appropriate referral to another practitioner when it is in the best interests of the individual requiring care and treatment

Emergency referral

Mr McKenzie was seen in the emergency ophthalmic clinic.

He was treated with oral and topical steroids.

Was it the chicken vindaloo?

Possibly – he may have developed ReA following a campylobacter infection caused by eating chicken. He was positive to HLA-B27 and genetically susceptible to ReA

Patient progress

Responded well to oral and

topical steroids.

Now fully recovered and

running again

Has decided to stick to

Chinese food when eating out

and to avoid chicken!

Take home messages

ReA can be difficult to diagnose unless clinicians are alert to its clinical features

Careful history taking and examination can help ensure accurate diagnosis

Most cases resolve spontaneously though causative infections may require treatment

Most cases are managed with symptomatic treatment such as NSAIDS

Clinicians should be alert to complications, work within their sphere of competency and refer appropriately.

The value of advanced practice

Nurses practicing at advanced level:

Raise the bar for all nurses

Are able to see, diagnose and treat

Are registered, educated and accountable

Reduce pressures in acute and primary care

Improve quality of care

So why are physician's assistants being considered as the solution in primary care?

Thank you for listening

Any questions?