Rheumatolgic Emergencies

Conflicts

None Errors - Mine. Thanks to:

Dr. Walker Dr. Hadley Dr. Del Castilho

Table of Contents

What is that!? What unites them all? Questions/Discussion

(knee)

Acute Monoarthritis

Non-Inflammatory Trauma HbS Osteonecrosis

Inflammatory Crystals Bacteria Rheumatiod Arthritis Spondyloarthropathy SLE Sarcoidosis Bursitis

Acute Monoarthritis

Septic joint in RA – overlooked Delay of Dx 1-3 weeks Significant joint damage Mortality 20 - 33%

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

Red and Hot

'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

Look at it Xantho, clear, cloudy, purulent

Total leukocyte count and diff Gram stain and culture Crystals (polarizing micro) 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

Depends on most likely cause No RTC of ABx in septic arthritis Red knee, no infection

Intraarticular steroids Polyarthritis – increase oral steroid, control flare

http://www.medscape.com/viewarticle/706761

http://www.medscape.com/viewarticle/706761

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

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.

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)

C5-C6

Inverted radial reflex

Predicted Problems

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.

Sceroderma

Sceroderma

Scleroderma Renal Crisis

~10-20% develop it. ~20% mortality. ~20% will need HD after crisis.

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

Scleroderma Renal Crisis

Steroids?

Scleroderma Renal Crisis

What to do? ACEi (Grade 1A). Captopril (Grade 2B) – no CNS s/s.

Add Nitroprusside – WITH CNS s/s. Nephro.

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

Lit review up to 2004 23 studies, 2036 pts, 5 languages. May be helpful, caution with test results.

The future

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

Giant Cell Arteritis- Aortitis

GCA – 27% pt large artery complications. Ascending aortic aneurysms 17x AAA 2.5x Suspect it

Hx, RF CT / MRI

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%

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

Atlantoaxial subluxation

Anterior atlantodens interval

McRae's Line McGregor's Line

Atlantoaxial subluxation

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?

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.

Adrenal Insufficiency

Tx NS Glc Hydrocortisone 100 mg IV Or: (dexamethasone 4 mg IV – no impact on ACTH

test or cortisol level)

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