GOUT VS SEPTIC ARTHRITIS
- Cannot clinically separate the two based on joint sxs, fever, elevated WBC, or elevated CRP/ESR.
- The two can co-exist!
- Recommendation: aspirate an acute monoarticular arthritis in all patients with known crystal-proven gout except for those patients who have only the first MTP involved and no other risk factors for a septic MTP joint.
- Failure to aspirate, prepare to litigate.
BEST THERAPY FOR ACUTE CRYSTAL ARTHRITIS IN PT WITH RENAL INSUFFICIENCY?
- If normal renal function: NSAIDs (indomethacin, naproxen); colchicine 1.2 mg followed by 0.6 mg 1 hour later (works as well as the old “take until diarrhea” method); corticosteroids (IA, PO – 30mg QD x 5d or 30mg x 1-2 d then taper over 7-10 d) or parenteral (Kenalog 60mg IM x 1, may repeat in 24h if less than 20-50% improvement); ACTH 25-40 IU SQ.
- In those with renal insufficiency:
- Corticosteroids: IA, PO, IM
- What if they have a systemic infx? IA or IM
- What if they have diabetes? IA or IM + increase insulin
- What if they’re anticoagulated? IA up to INR of 4.5 or IM + increase insulin
DOES THIS PATIENT HAVE SOME KIND OF VASCULITIS? (THE SKV CONSULT)
- Suggested by constitutionally ill patient with multisystem inflammatory disease.
- Large vessels = GCA, Takayasu’s – neuro (HA, visual loss, stroke); limb ischemia (claudication, bruit, asymmetric BP/pulse).
- Medium vessels = polyarteritis nodosa (PAN) – neuro (mononeuritis multiplex, strokes (GACNS)); skin (livedo reticularis, ulcers, nodules, digital gangrene); renal (HTN, microhematuria, abd pain).
- Small vessels = ANCA vasculitis vs non-ANCA cryos, HSP, HUVS
- Pulmonary-renal syndromes (ANCA dz): DAH, RPGN
- EENT-pulmonary syndromes (ANCA dz): scleritis, sinusitis, lung nodules, mass lesions (pseudotumor orbiti, subglottic stenosis)
- Skin: palpable purpura, urticaria lasting > 24 h
- Approach to vasculitis:
- Is this a condition that can mimic a vasculitis? Infection, cancer, connective tissue disease, drugs/meds.
- Suspect a vasculitis mimic or secondary cause if:
- New heart murmur, unusually high fever, or splinter hemorrhages (SBE)
- Prominent liver dysfunction (hep C with cryos)
- Drug abuse (HIV, hep B/C, cocaine, amphetamines, etc.)
- Prior hx of cancer (lymphoma, myelodysplastic dz)
- Prior hx of CTD (SLE, Sjogren’s, PAPS)
- Meds (PTU, hydralazine, many others)
- Tests establishing systemic inflammation: CBC – low WBC and/or low plt counts never seen in PRIMARY vasculidities! Look for thrombocytosis, leukocytosis or abnormal cells.
- ESR and CRP – if both > 10x ULN with no evidence of infection, acute crystalline arthritis, or cancer…then vasculitis is a likely diagnosis.
- Tests to rule out etiologies not responsive to immunosuppressive meds: Blood cultures (SBE), PTT (APLA), LDH (if > 2-3x ULN consider lymphoma, heme malignancy, MDS), infectious serologies (hep B, hep C, HIV, parvo IgM…)
- Tests to rule out etiologies responsive to immunosuppressive meds: RF and ANA – should NOT be positive in primary vasculidities; complement levels – if low, r/o SLE, cryos, HUVS. Tests suggesting ANCA vasculitis: cANCA (GPA>MPA), pANCA (MPA>GPA). pANCA not against myeloperoxidase unlikely to be a vasculitis.
- Histologic or radiologic proof is needed before treatment is initiated in patients with vasculitis
- Small vessel vasculitis – idiopathic 50%, infection 15-20%, CTD 15-20%, drugs 10-15%, malignancy 5-10%
- Only ANCA vasculitis can be diagnosed without a biopsy – clinical involvement of ENT, lung, kidney with cANCA against PR3.
- What to biopsy?
- Nerve biopsies are positive in 45% of medium vessel vasculitis (PAN); also could biopsy skin nodule, testes or involved organs.
- Large vessel: temporal artery biopsy abnormal in 85% of those with cranial/visual sxs, less than 50% if no cranial symptoms. Takayasu’s – hard to get histology.
- Angiography? Mesenteric angiogram only if abnormal exam (abd pain, HTN with hematuria), labs abnormal (Cr, UA), spleen or renal infarcts on CT.
- Imaging for GCA – PET scan can be helpful.
FEVER AND RHEUMATIC DISEASE
- 20% of FUO patients have a rheumatic etiology.
- Most common: Adult-onset Still’s disease, large-vessel vasculitis (GCA, Takayasu’s).
- Rheumatic diseases that can cause sustained fever:
- Monoarthritis and fever: gout, pseudogout…and many others.
- Rheumatic diseases and periodic fevers:
- Consider infx, heme malignancies, meds first.
- AOSD: recurrent fevers, non-pruritic evanescent rash on trunk, polyarthritis/arthralgias, leukocytosis (>10K with 80% PMNs); minor criteria – HSM, ST, LAD
- Supportive dx criterion: ferritin > 1000 or high procalcitonin.
- Lupus and fever:
- Fever is common at disease onset and with flares. More likely due to SLE if part of their usual flares, serositis, WBC low, C3/C4 low, elevated ds-DNA.
- Fever more likely due to infection if: atypical for their flares, WBC higher than normal, serologically inactive or unchanged, CRP > 6x ULN, elevated procalcitonin.
- Macrophage activation syndrome: life-threatening complication in AOSD and SLE patients. Can be triggered by EBV, CMV or parvovirus. Sxs: high fever and HSM, no rash or arthritis. Labs show pan-cytopenias, elevated LFTs, high triglycerides, high PT/PTT, low fibrinogen, low ESR. Definitive dx: bone marrow bx shows hemophagocytosis by macrophages.
SURGERY AND RHEUMATIC DISEASE
- Do your usual CV risk assessment – but remember, pts with rheum dz have CAD risk ACCELERATED BY 10 YEARS!
- RA: consider C-spine XR, assess lung function (CXR, PFTs) if rales or pulm sxs
- Ank Spond: C-spine XR if clinically involved
- SLE – if (+) lupus anticoagulant or high titer ACLA/anti-B2GP1 antibodies – need compression stockings and prophylactic anticoagulation perioperatively and for seven days after surgery EVEN IF NO PRIOR DVT HX.
- Medication management
- NSAIDs: stop 5 half-lives before surgery
- Prednisone: stress dose protocol – solucortef 100mg IN on call to OR, 100mg during surgery, 100mg 8 h post-op. Decrease by half IV or PO equivalent each day until on usual dose.
- MTX: controversial. Stop week of surg and week after.
- DMARDs: Stop 1 day preop and start 3 days post-op.
- Biologics: Stop 2 half-lives prior to surgery. [missed when to resume]
From Rocky Mountain Hospital Medicine conference, 2016, West