Septic Arthritis Evaluation
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Questions and Answers

What is the primary purpose of serum uric acid in the evaluation of septic arthritis?

  • To rule out gout (correct)
  • To monitor therapeutic response
  • To diagnose Lyme arthritis
  • To determine the severity of the infection

    • What is the typical WBC count in synovial fluid analysis in septic arthritis?

  • 5,000-10,000 WBC/mm3
  • < 10,000 WBC/mm3
  • 10,000-50,000 WBC/mm3
  • > 50,000 WBC/mm3 (correct)

    • What is the purpose of Gram stain and aerobic and anaerobic bacterial culture in septic arthritis evaluation?

  • To identify the type of bacterial infection (correct)
  • To diagnose Lyme arthritis
  • To rule out gout
  • To monitor therapeutic response

    • What is the significance of PCR testing in septic arthritis evaluation?

    <p>To diagnose Lyme arthritis</p> Signup and view all the answers

    What is the primary consideration in the management of septic arthritis?

    <p>Urgent referral for treatment</p> Signup and view all the answers

    What is the approximate percentage of cases in which blood cultures are positive in septic arthritis?

    <p>25-50%</p> Signup and view all the answers

    What is the characteristic of non-inflammatory joint pain?

    <p>Typically worsens with activity</p> Signup and view all the answers

    Which of the following is a common cause of monoarticular joint pain?

    <p>Gout</p> Signup and view all the answers

    What is the characteristic of inflammatory joint pain?

    <p>Presents with redness, swelling, and warmth</p> Signup and view all the answers

    Which type of joint is commonly involved in ankylosing spondylitis?

    <p>Vertebral joints</p> Signup and view all the answers

    What is the characteristic of polyarticular joint pain?

    <p>Affects multiple joints in a symmetrical pattern</p> Signup and view all the answers

    Which of the following is a common cause of polyarticular joint pain?

    <p>Rheumatoid arthritis</p> Signup and view all the answers

    What is the importance of evaluating the number and types of joints affected in a patient's history?

    <p>To evaluate the symmetry of polyarthritis if present</p> Signup and view all the answers

    Which of the following is a common cause of oligoarticular joint pain?

    <p>Reactive arthritis</p> Signup and view all the answers

    What is the primary purpose of the 2015 ACR-EULAR Gout Classification Criteria?

    <p>To identify subjects for clinical studies</p> Signup and view all the answers

    What is the gold standard for diagnosing gout?

    <p>Joint aspiration and microscopy analysis</p> Signup and view all the answers

    What is the characteristic appearance of monosodium urate crystals under microscopy?

    <p>Needle-like appearance and strong negative birefringence</p> Signup and view all the answers

    What is the term for the condition characterized by high serum uric acid levels?

    <p>Hyperuricaemia</p> Signup and view all the answers

    What is the name of the joint commonly affected in gout flares?

    <p>First metatarsophalangeal joint</p> Signup and view all the answers

    What is the imaging modality shown in the image depicting monosodium urate crystal deposition?

    <p>Dual-energy CT</p> Signup and view all the answers

    What is the significance of periarticular erosions in radiography for the diagnosis of Rheumatoid Arthritis?

    <p>It is a characteristic finding of Rheumatoid Arthritis</p> Signup and view all the answers

    What is the minimum score required on the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?

    <p>6</p> Signup and view all the answers

    What is the significance of joint involvement in the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?

    <p>It contributes 0-5 points to the total score</p> Signup and view all the answers

    What is the significance of acute phase reactants in the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?

    <p>It contributes 0-2 points to the total score</p> Signup and view all the answers

    What is the significance of duration of symptoms in the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?

    <p>It contributes 0-1 point to the total score</p> Signup and view all the answers

    What is the significance of serology markers in the ACR/EULAR 2010 Diagnostic Criteria for Rheumatoid Arthritis?

    <p>It contributes 0-3 points to the total score</p> Signup and view all the answers

    What is the primary purpose of complete blood count in the evaluation of septic arthritis?

    <p>To detect elevated WBC count</p> Signup and view all the answers

    What is the significance of a normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in septic arthritis?

    <p>It does not provide any information about the diagnosis</p> Signup and view all the answers

    What is the primary indication for imaging studies in septic arthritis?

    <p>To rule out other conditions</p> Signup and view all the answers

    What is the significance of a positive PCR test in synovial fluid analysis?

    <p>It suggests Lyme arthritis</p> Signup and view all the answers

    What is the significance of a WBC count of 50,000 WBC/mm3 in synovial fluid analysis?

    <p>It is a diagnostic criterion for septic arthritis</p> Signup and view all the answers

    What is the primary consideration in the management of septic arthritis?

    <p>Urgent referral for treatment</p> Signup and view all the answers

    What is the sensitivity of an elevated C-reactive protein (>100 mg/L) in diagnosing septic arthritis?

    <p>77%</p> Signup and view all the answers

    What is the specificity of an elevated erythrocyte sedimentation rate (>30 mm/h) in diagnosing septic arthritis?

    <p>53%</p> Signup and view all the answers

    What is the primary indication for using the 2015 ACR-EULAR Gout Classification Criteria in clinical practice?

    <p>To identify subjects who may be eligible for entry into clinical studies</p> Signup and view all the answers

    What is the characteristic appearance of monosodium urate crystals under microscopy?

    <p>Needle-like appearance with strong negative birefringence</p> Signup and view all the answers

    What is the primary role of serum uric acid levels in the evaluation of gout?

    <p>To identify hyperuricaemia</p> Signup and view all the answers

    What is the imaging modality shown in the image depicting monosodium urate crystal deposition?

    <p>Dual-energy CT</p> Signup and view all the answers

    What is the characteristic skin finding observed in patients with tophaceous gout?

    <p>Mottled hypopigmentation</p> Signup and view all the answers

    What is the gold standard for diagnosing gout?

    <p>Joint aspiration and microscopy analysis</p> Signup and view all the answers

    What is the primary purpose of joint aspiration in the evaluation of gout?

    <p>To identify the presence of monosodium urate crystals</p> Signup and view all the answers

    What is the name of the joint commonly affected in gout flares?

    <p>First metatarsophalangeal joint</p> Signup and view all the answers

    What is the characteristic of calcium pyrophosphate dihydrate crystals under birefringent microscopy?

    <p>Polymorphic, weakly positive</p> Signup and view all the answers

    What is the approximate prevalence of Rheumatoid Arthritis worldwide?

    <p>0.5-1%</p> Signup and view all the answers

    Which of the following is a genetic predisposition for Rheumatoid Arthritis?

    <p>HLA-DR1 and HLA-DR4</p> Signup and view all the answers

    What is the typical duration of flares in calcium pyrophosphate dihydrate crystal deposition?

    <p>Days to weeks</p> Signup and view all the answers

    Which of the following is a common feature of Rheumatoid Arthritis?

    <p>Symmetrical, polyarticular pain and stiffness</p> Signup and view all the answers

    What is the percentage of osteoarthritis in people aged 65 and older?

    <p>50%</p> Signup and view all the answers

    What is a common feature of osteoarthritis in the hands?

    <p>Heberden nodes on proximal interphalangeal joints</p> Signup and view all the answers

    What is the typical morning stiffness in Rheumatoid Arthritis?

    <p>&gt; 1 hour</p> Signup and view all the answers

    What is a characteristic of joint pain in osteoarthritis?

    <p>Worsened by movement or activity</p> Signup and view all the answers

    What is the characteristic appearance of affected joints in Rheumatoid Arthritis?

    <p>Both A and B</p> Signup and view all the answers

    What is a risk factor for developing osteoarthritis?

    <p>Family history</p> Signup and view all the answers

    What is the significance of cytokines in Rheumatoid Arthritis?

    <p>They drive chronic synovial inflammation</p> Signup and view all the answers

    What is crepitus typically felt and heard in?

    <p>Knees</p> Signup and view all the answers

    What is a common feature of osteoarthritis in the joints?

    <p>Pain on range of motion and limited range of motion</p> Signup and view all the answers

    According to the ACR/EULAR 2010 diagnostic criteria, what is the minimum score required for a diagnosis of Rheumatoid Arthritis?

    <p>6</p> Signup and view all the answers

    What is the significance of periarticular erosions in radiography for the diagnosis of Rheumatoid Arthritis?

    <p>It is a characteristic radiographic finding</p> Signup and view all the answers

    What is the significance of serology markers in the ACR/EULAR 2010 diagnostic criteria for Rheumatoid Arthritis?

    <p>It indicates the presence of RF or ACPA</p> Signup and view all the answers

    According to the ACR/EULAR 2010 diagnostic criteria, what is the significance of joint involvement in Rheumatoid Arthritis?

    <p>It is scored based on the number and type of joints involved</p> Signup and view all the answers

    What is the significance of acute phase reactants in the ACR/EULAR 2010 diagnostic criteria for Rheumatoid Arthritis?

    <p>It indicates the presence of abnormal C-reactive protein or erythrocyte sedimentation rate</p> Signup and view all the answers

    What is the significance of duration of symptoms in the ACR/EULAR 2010 diagnostic criteria for Rheumatoid Arthritis?

    <p>It indicates the duration of symptoms as ≥ 6 weeks</p> Signup and view all the answers

    What is the first step in the transition from normouricemia to clinically evident gout?

    <p>Development of hyperuricemia</p> Signup and view all the answers

    Which of the following factors can contribute to the development of hyperuricemia?

    <p>All of the above</p> Signup and view all the answers

    What is the relationship between monosodium urate (MSU) crystal deposition and clinically evident gout?

    <p>Only some individuals with MSU crystal deposition develop clinically evident gout</p> Signup and view all the answers

    What is the clinical manifestation of gout that is characterized by the presence of tophi?

    <p>Tophaceous gout</p> Signup and view all the answers

    Which of the following is a risk factor for the development of hyperuricemia?

    <p>All of the above</p> Signup and view all the answers

    What is the relationship between hyperuricemia and clinically evident gout?

    <p>Only some individuals with hyperuricemia develop clinically evident gout</p> Signup and view all the answers

    Which of the following factors can contribute to the transition from hyperuricemia to clinically evident gout?

    <p>Multiple factors, including genetic variants, chronic kidney disease, and high body mass index (BMI)</p> Signup and view all the answers

    Which of the following is a significant complication of Rheumatoid Arthritis?

    <p>Osteoporosis</p> Signup and view all the answers

    What is the primary goal of treatment in Rheumatoid Arthritis?

    <p>To prevent irreversible joint damage</p> Signup and view all the answers

    What is the characteristic of Zain's case that increases the suspicion for Rheumatoid Arthritis?

    <p>All of the above</p> Signup and view all the answers

    What is the consequence of a 12-week delay in treatment in Rheumatoid Arthritis?

    <p>Reduced chance of achieving drug-free remission</p> Signup and view all the answers

    What is the common cause of knee pain that must be considered in Zain's case?

    <p>Osteoarthritis</p> Signup and view all the answers

    What is the significance of achieving long-term clinical remission in Rheumatoid Arthritis?

    <p>It prevents irreversible joint damage</p> Signup and view all the answers

    What is the complication of Rheumatoid Arthritis that increases the risk of coronary artery disease?

    <p>Accelerated atherosclerosis</p> Signup and view all the answers

    What is the primary purpose of the 2015 ACR-EULAR Gout Classification Criteria?

    <p>To identify subjects who may be eligible for entry into clinical studies</p> Signup and view all the answers

    What is the characteristic appearance of monosodium urate crystals under microscopy?

    <p>Needle-like appearance with strong negative birefringence</p> Signup and view all the answers

    What is the significance of dual-energy CT in the evaluation of gout?

    <p>It is used to identify monosodium urate crystal deposition in joints</p> Signup and view all the answers

    What is the characteristic skin finding observed in patients with tophaceous gout?

    <p>Mottled hypopigmentation on the dorsa of the hands</p> Signup and view all the answers

    What is the primary role of joint aspiration in the evaluation of gout?

    <p>To identify monosodium urate crystals in the synovial fluid</p> Signup and view all the answers

    What is the gold standard for diagnosing gout?

    <p>Joint aspiration and microscopy analysis</p> Signup and view all the answers

    What is the primary basis of diagnosing osteoarthritis?

    <p>Clinical diagnosis based on history and physical examination</p> Signup and view all the answers

    What is the term for the condition characterized by high serum uric acid levels?

    <p>Hyperuricaemia</p> Signup and view all the answers

    What is the name of the joint commonly affected in gout flares?

    <p>First metatarsophalangeal joint</p> Signup and view all the answers

    When is X-ray imaging typically used in the evaluation of osteoarthritis?

    <p>When diagnosis is in doubt or strong suspicion for other etiology</p> Signup and view all the answers

    What is the primary role of CT or MRI in the evaluation of osteoarthritis?

    <p>To rule out other conditions or when diagnosis is in doubt</p> Signup and view all the answers

    What is the primary indication for ultrasonography in the evaluation of osteoarthritis?

    <p>To rule out other conditions or when diagnosis is in doubt</p> Signup and view all the answers

    What is the characteristic radiographic finding in osteoarthritis?

    <p>All of the above</p> Signup and view all the answers

    What is the primary role of laboratory testing in the evaluation of osteoarthritis?

    <p>Not usually required</p> Signup and view all the answers

    What is the typical feature of joint destruction in osteoarthritis?

    <p>Erosion of the joint</p> Signup and view all the answers

    What is the primary indication for referral for joint replacement in osteoarthritis?

    <p>When imaging studies show advanced disease</p> Signup and view all the answers

    Study Notes

    Septic Arthritis – Evaluation

    • Complete blood count: elevated WBC count
    • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): can be normal, used to monitor therapeutic response when elevated
    • Serum uric acid: should not be elevated, used to rule out gout
    • Blood cultures: positive in 25-50% of cases

    Septic Arthritis – Arthrocentesis

    • Synovial fluid analysis: WBC count > 50,000 WBC/mm3, differential >90% polymorphonuclear cells
    • Gram stain, aerobic and anaerobic bacterial culture
    • Borrelia burgdorferi cannot be cultured from synovial fluid; PCR testing if suspecting Lyme arthritis (positive in 85% of patients)

    Septic Arthritis – Imaging

    • X-ray, ultrasonography, MRI may be considered

    Septic Arthritis – Management

    • Medical emergency: needs immediate diagnosis and urgent referral for treatment
    • Types of joints involved: vertebral, sacroiliac, wrists, carpometacarpals, MCP, PIP, DIP, ankle, MTP, shoulders, elbows, hips, knees

    Inflammatory Joint Pain vs. Non-Inflammatory Joint Pain

    • Inflammatory joint pain: characterized by redness, swelling, warmth, tenderness, morning stiffness, and worsens with inactivity
    • Causes: infection, gout, rheumatoid arthritis, calcium pyrophosphate deposition disease, juvenile RA, systemic lupus erythematosus
    • Non-inflammatory joint pain: may or may not present with swelling and tenderness, but other signs are absent; worsens with activity
    • Causes: osteoarthritis, trauma, polymyalgia rheumatica, sarcoidosis, spondyloarthritides, reactive arthritis, psoriatic arthritis, ankylosing spondylitis, enteropathic arthritis

    History

    • Evaluate number and types of joints affected and symmetry if polyarthritis is present
    • Onset: sudden vs. gradual

    Gout – Evaluation

    • Based on clinical diagnosis, classification criteria, and microscopy-based diagnosis of synovial fluid
    • 2015 ACR-EULAR Gout Classification Criteria: not meant for diagnosis, but can help inform the clinician; intended for research purposes
    • Serum uric acid levels: identify hyperuricaemia
    • Gold standard for diagnosis: joint aspiration and microscopy analysis showing presence of monosodium urate crystals

    Rheumatoid Arthritis (RA) – Evaluation

    • Classification criteria: ACR/EULAR 2010 criteria replaced the 1987 ARA criteria
    • Lab findings:
      • Radiography: periarticular erosions, osteopenia, joint space narrowing
      • Inflammatory markers: ESR, CRP
      • Serology markers: RF, ACPA, or both
    • Seropositive RA: 75-85% will test positive for RF, ACPA, or both

    ACR/EULAR 2010 Diagnostic Criteria for RA

    • At least 1 joint with definite clinical synovitis (swelling) not explained by another disease plus 1 of the following:
      • Presence of long-standing disease previously satisfying classification criteria
      • Presence of ≥ 2 typical periarticular erosions
      • Score ≥ 6 on the following criteria:
        • Joint involvement (0-5)
        • Serology (0-3)
        • Acute phase reactants (0-2)
        • Duration of symptoms (0-1)

    Septic Arthritis – Evaluation

    • Complete blood count: elevated WBC count
    • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): can be normal, but when elevated, used to monitor therapeutic response
    • Serum uric acid: should not be elevated, used to rule out gout
    • Blood cultures: positive in 25-50% of cases
    • Arthrocentesis for synovial fluid analysis: WBC count > 50,000 WBC/mm3, synovial fluid WBC differential > 90% polymorphonuclear cells
    • Gram stain, aerobic and anaerobic bacterial culture
    • Borrelia burgdorferi cannot be cultured from synovial fluid, PCR testing if suspecting Lyme arthritis (positive in 85% of patients)
    • Imaging may be considered: X-ray, ultrasonography, MRI

    Septic Arthritis – Management

    • Medical emergency: needs immediate diagnosis and urgent referral for treatment
    • Physical Exam:
      • Fever: sensitivity 46%, specificity 31%
      • Serum laboratory values:
        • Abnormal peripheral WBC count (>10,000/µL): sensitivity 90%, specificity 36%
        • Elevated erythrocyte sedimentation rate (>30 mm/h): sensitivity 95%, specificity 29%
        • Elevated C-reactive protein (>100 mg/L): sensitivity 77%, specificity 53%

    Gout – Evaluation

    • Based on clinical diagnosis, classification criteria, and microscopy-based diagnosis of synovial fluid
    • 2015 ACR-EULAR Gout Classification Criteria: not meant for diagnosis, but can help inform the clinician; intended for research purposes
    • Serum uric acid levels: to identify hyperuricaemia
    • Gold standard for diagnosis: joint aspiration and microscopy analysis showing presence of monosodium urate crystals
    • Other tests: ultrasonography, dual-energy CT

    Calcium Pyrophosphate Dihydrate Crystal Deposition (Pseudogout)

    • Aka pseudogout
    • Persons > 65 years old
    • Onset: sudden
    • Duration: flares lasting days to weeks
    • Morning pain or stiffness usually present
    • Calcium pyrophosphate dihydrate crystals: polymorphic, weakly positive under birefringent microscopy

    Rheumatoid Arthritis (RA)

    • 0.5-1% worldwide prevalence
    • Higher risk in women (2-3x higher than men), smokers, patients with family history of RA
    • Genetic predisposition: HLA-DR1 and HLA-DR4
    • Systemic autoimmune inflammatory disease
    • Chronic/relapsing destructive synovitis: local inflammation, cartilage destruction, bone erosion
    • Cytokines (TNF-α, IL-1, IL-6) drive chronic synovial inflammation

    Rheumatoid Arthritis (RA) - Clinical Features

    • Symmetrical, polyarticular pain and stiffness: most often affecting wrists, PIP, MCP, MTP joints
    • Morning stiffness > 1 hour
    • Systemic symptoms: fatigue, weight loss, anemia
    • Visible boggy swelling caused by synovitis
    • Palpable synovial thickening
    • Affected joint painful if pressure applied on palpation or with movement
    • Advanced disease: ulnar deviation, MCP joint subluxation, swan neck deformity, Boutonniere deformity
    • Extra-articular manifestations: accelerated atherosclerosis, pericarditis, keratoconjunctivitis sicca, episcleritis/scleritis, interstitial lung disease, pulmonary nodules, rheumatoid nodules, pleural effusion, vasculitis

    Osteoarthritis

    • Prevalence increases with age: 7.3% in ages 18-44; 30% in ages 45-64; 50% in ages 65 and older
    • Women > men
    • Other risk factors: overweight/obese, previous joint injury, family history, frequent bending/squatting, repetitive impact
    • Degenerative disorder of articular cartilage associated with hypertrophic bone changes
    • Onset: gradual
    • Duration: lifelong with flares
    • Usually no morning pain or stiffness (or short-lived)

    Osteoarthritis – Clinical Features

    • Asymmetric joint pain and stiffness: commonly affecting hands, knees, hips, feet, spine
    • Joint pain worsened by movement/activity, especially following a period of rest
    • Joint swelling and tenderness
    • Bony enlargement in prolonged or severe OA
    • Pain on range of motion and limitation of range of motion
    • Crepitus (typically knee) may be felt and heard
    • Bouchard nodes on proximal interphalangeal joint
    • Heberden nodes on distal interphalangeal joints

    Gout

    • Gout occurs in several stages: hyperuricaemia, monosodium urate (MSU) crystal deposition, and clinical manifestations (gout flares, chronic gouty arthritis, and tophaceous gout)
    • Factors contributing to the transition from hyperuricaemia to clinically evident gout are not well understood
    • Hyperuricaemia can be caused by genetic variants, chronic kidney disease, high body mass index (BMI), medications, and dietary factors

    Diagnosis of Gout

    • Based on clinical diagnosis, classification criteria, and microscopy-based diagnosis of synovial fluid
    • 2015 ACR-EULAR Gout Classification Criteria not meant for diagnosis, but can help inform the clinician; intended for research purposes
    • Serum uric acid levels to identify hyperuricaemia
    • Joint aspiration and microscopy analysis showing the presence of monosodium urate crystals (identified by needle-like appearance and strong negative birefringence) is the gold standard for diagnosis
    • Other tests: ultrasonography, dual-energy CT

    Rheumatoid Arthritis (RA)

    • Classification criteria: ACR/EULAR 2010 criteria replaced the 1987 ARA criteria
    • Lab findings: radiography (periarticular erosions, osteopenia, joint space narrowing), inflammatory markers (ESR, CRP), serology markers (Rheumatoid factor, Anti-citrullinated protein antibodies (ACPA))
    • ACR/EULAR 2010 Diagnostic Criteria for RA: at least 1 joint with definite clinical synovitis plus 1 of the following:
      • Presence of long-standing disease previously satisfying classification criteria
      • Presence of ≥ 2 typical periarticular erosions
      • Score ≥ 6 on the following criteria:
        • Joint involvement (0-5)
        • Serology (0-3)
        • Acute phase reactants (0-2)
        • Duration of symptoms (0-1)

    Management of RA

    • Low threshold for referral to rheumatologist
    • Goals of treatment:
      • Early diagnosis and early initiation of treatment to prevent irreversible joint damage
      • Achieve long-term clinical remission
      • Optimize quality of life
      • Monitor for extra-articular complications
    • Complications of RA:
      • Osteopenia and osteoporosis → fracture
      • Lung manifestations
      • Accelerated atherosclerosis → coronary artery disease, peripheral vascular disease
      • Increased insulin resistance, diabetes mellitus
      • Vasculitis, thromboembolic disease
      • Depression
      • Anemia of chronic disease
      • Felty syndrome (RA, splenomegaly, neutropenia)

    Osteoarthritis

    • Primarily a clinical diagnosis based on history and physical examination
    • Imaging not required in patients with risk factors and typical symptoms
    • X-ray can confirm diagnosis and rule out other conditions; helpful before referral for joint replacement
    • May see joint space narrowing, osteophyte formation, subchondral sclerosis, and joint destruction on X-ray
    • CT or MRI when diagnosis is in doubt or strong suspicion for other etiology
    • Laboratory testing not usually required

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    Description

    This quiz covers the evaluation of septic arthritis, including complete blood count, ESR, CRP, serum uric acid, and arthrocentesis for synovial fluid analysis.

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