Case 1:

26 year old sexually active man

painful swollen left knee & right ankle

pain on dorsum of foot on flexion, extension of toes

pain in Achille tendon

low back pain worse in AM, relieved by activity for several months

bothersome urethral discharge for 2 days

...

Case 1 (cont):

P/E:

Arthrocentesis of knee yielded 20 ml hazy yellow fluid of poor viscosity;

WBC 35,000, 50% PMNs and 50% lymphs

No crystals

Gram stain does not show WBC or bacteria

Case 1:

2 main diagnostic possibilites?

HLA-B27

If positive, which is more likely?

What other lab tests would help distinguish between the two?

Which would you expect to grow if it was gonococcal arthritis?

Reactive arthritis?

Cultures of fluid from the joint, urethra, pharynx, rectum

Gram stain of pustule fluid

GC:all of the above

Reactive: screen for Chlamydia, joint aspiration and eval

Enteric: salmonella, Shigella, yersinia, campylobacter, clostridium

Urogenital: Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyicum

URI: B-hemolytic Strep, Chlamydia pneumoniae

MSK features of GC?

of Reactive?

GC: 

migratory arthritis and tenosynovitis

Reactive:

assymmetric peripheral oligoarthritis (LE)

dactylitis possible

enthesopathy

ASYMMETRIC SACROILITIS 

Are x-rays helpful?

why/why not?

ankle and knee films NOT helpful

SI joint film helpful 

(how?)

feet (calcaneous)

GC: responds better to antibiotic (48 hrs)

Reactive: responds best to NSAIDS (Abx +/-)

Case 2:

19 yr old female college student

CC: chest pain (dull, aching pain in midchest, developed over past week; worse with deep breathing and laying down)

Hx: 2-3 mo of declining energy, hair falling out in clumps, stiffness all over, esp in hands, elbows, knees; 

Tanning salon two weeks ago: skin burned and rash which has not yet cleared

Cold weather: fingers turn blue, white, red

Case 2 (cont):

Labs: 

Hgb ↓

Leukocyte count ↓

Platelet count ↓

UA: 1+ protein, 1+ blood, 10-15 RBCs and 5-10 leukocytes, no casts

skin burned at tanning salon

rash has not yet cleared

striking red rash in face over cheeks, bridge of nose and lower forehead, extening down to chin, neck, upper chest.

nasolabial folds are spared

areas of scalp completely bald

red, inflammatory lesions in her nasal septum and palate; pt. is unaware of them

alopecia

painless oral ulcers 

heart sounds distant, harsh sound which is present in both systole and diastole

wrists and all PIPs are swollen, tender

both knees have effusions

1+ pre-tibial pitting edema bilaterally

serositis of SLE

pericarditis

1.  Nephrotic syndrome due to lupus nephritis

2. Increased venous pressures due to pericardial tamponade

What's causing the anemia?

The patient has pancytopenia, which may occur in SLE.  This could be confused with drug or toxin exposure causing bone marrow depression, so a bone marrow aspirate may be in order.  

The anemia in SLE is an

autoimmune hemolytic anemia.

What diagnostic test confirms this?

Any tests to confirm lupus?

what about to strengthen the dx?

Confirm (aka SPECIFIC tests) =

anti-DNA, anti-Smith

Strengthen dx (SENSITIVE)= 

+ ANA

Case 3: 

63 retired school teacher

limping, complains of jt pain in knees for years, but worse in the past 6-10 months

keeps her awake at night

morning stiffness for about 10 min

knees "freeze" after sitting and take a few minutes to become limber again

P/E:

General: unremakable

MSK: good ROM of shoulders, elbows, wrists

Hands: square of base of thumbs, swelling PIP and DIP bilaterally

Hips: good ROM

Knees: painful to motion + crepitation; left has small effusion, mild genu varus (bowing)

    Decreased joint  space in medial compartment (left knee), osteosclerosis (increase bone density), and osteophyte formation

Non-inflammatory

Low cell count (WBC <200)

No crystals

normal viscosity, clear-straw colored

Generalized, Primary OA

rather than secondary OA

Non-inflammatory

Degeneration of cartilage

In familial OA, a genetic defect in cartilage collagen has been noted

Case 4:

23 yr old male student with CC of back pain for 1 year, getting worse, interferring with activities. 

Past week: knees and ankles hurt; feels stiff all over.

Case 4 (cont):

symptoms worse in early morning with 1-2 hr "warm-up" period

Severe back pain at night keeping him awake; must walk the pain off

Stiffness after sitting

If his father and uncle (who has one blind eye) have "spine issues"

what dx do you suspect?

Determine mobility of lumbar spine with Schober’s test, costovertebral joints with chest expansion.  Examine other joints for swelling, effusion, tenderness, and range of motion.  Look for signs of enthesopathy

SI joint tenderness, dacytylitis, cardiac AR, pulm fibrosis

P/E:

diastolic murmur heardover second right intercostal space

AR (common finding; 5-10% of ankylosing spondylitis patients)

PE (cont)

lumbar lordosis is decreased, flexion of lumbar spine is decreased (Schober's test)

Chest expansion is 1 cm

Bilat knee effusions, both ankles are swollen and tender

marked tenderness in plantar aspect of right heel

decreased chest expansion: costovertebral joint involvement

knee/ankle findings: not typical

tenderness in heel? enthesitis

Anterior uveitis

Patient is at risk for developing it, too.

NO, but can be prognostic

About 5-10% of North Americans has HLA-B27.  Only around 2-10% of these will have ankylosing spondylitis (AS).  Thus, the vast majority of HLA-B27+ individuals do not have AS.  However, 90% or more of people with AS are HLA-B27+.

mild anemia

elevated ESR

(non-specific)

Case 5:

45 yr old man with increased swelling, erythema, moderate pain in right knee for 3-4 days

PMHx shows chronic EtOH abuse (>12 beers/day X 20 yrs) and DM

PE: afebrile pt with swollen knee that is tender, slightly warm

no other joints involved, no systemic symptoms

routine lab studies are normal except for elevated glucose, mildly elevated AST/ALT, ESR of 60, WBC of 9,000 with 60%PMNs and 40% lymphocytes

classify the arthritis:

acute, chronic, mono, polyarticular...

next step?

Arthrocentesis!

45 cc of hazy yellow fluid with poor viscosity and 95,000 WBC (90% PMN)

gram stain is negative

no crystals

Dx?

tx?

Infection arthritis

Septic arthritis

drain and give empirical antibiotics

Case 6:

41 yr old housekeeper 

joint pain for a couple years affecting hands

crooked

elbow, knee, ankle, and feet involvement

worse in the morning (stiff)

needs to "warm-up" for 4 hrs each morning

Characterize the arthritis: acute, chronic, mono, poly, asymmetric, symmetric..

Mouth has been dry all the time

lost taste of food, lost sense of smell

gritty sensation in eyes

Characterize these symptoms

secondary Sjogren's

HEENT: poor dentition and advanced dental caries

swelling in PIP and MCP

ulnar deviation

both wrists, left elbow are swollen and tendor

non-adherent subcutaneous nodules about 1 cm each

left hip painful to internal and external rotation 

ankles and sub-talar joints are tender and swollen

MTPs all tender

RA

These are rheumatoid nodules.  Cause is unknown, but they occur over bony prominences, and sites of pressure.  Pathology shows a granuloma.  Nodules are associated with a more severe prognosis 

3rd and 4th fingers have persistent flexion at PIP and extension at DIP

what is this called?

Boutonierre's

What is swan's neck?

Note: DIP not swollen, but the ligament causes deformaties

what does DIP involvement distinguish RA from?

1.            .  A serum rheumatoid factor and some x-rays of the hands would remove all doubt.

Juxta-articular demineralization, soft tissue swelling, decreased joint space and bony erosions

Erosions IN the joint

Erosions OUTside of joint with "overhanging edges" = gout