Gout
Definition
Is a true crystal deposit disease(monosodiom urate crystals).it may present as acute
arthritis,bursitis,tenosynovitis,cellulitis or
tophaceous deposit .
Prolonged hyperuricemias necessary but alone is not enough to develop gout
Types of gout
Primary gout
Secondary gout
Etiology
1/3 of body uric acid pool is derrived from diet 2/3 of body uric acid pool is from endogenous purine metabolism.
Elemination of uric acid by the kidney (2/3) and gut (1/3)
Xanthine oxidase enzyme catalyses the end conversation of hypoxanthine to xanthine and to uric acid
Risk factors
1- hyperuricemia
2-obesity
3-high alcohol intake
4-hypertension
5- IHD
6-inhereted alteration of tissue factors
Clinical features
1-acute gouty arthritis
2-intercritical
3-Chronic
4-Urolithiasis
Foods helps to protect or reduce the risk of gout
Foods to be avoided
INVESTIGATIONS
MSU crystals in aspirate
serum uric acid
24 hour urine uric acid
- blood urea and serum creatinine
fasting lipid profile
-full blood count and ESR
-CRP
-radiograghs
MANAGEMENT
1- during THE ACUTE ATTACK
2- long term management
Hyperuricemic drug therapy
Allopurinol
The aim of treatment
Uricosuric drugs
Asymptomatic hyperuricemia
FIBROMYALGIA
is a very common cause of multiple regional MSK pain and disability .
It commonly associates with medically unexplained symptoms in other
Aetiology
1-Sleep abnormality 2-Abnormal pain
processing.
Clinical features
multiple regional pain.
Fatigability
The pain
The patients may be unable to perform daily
tasks such as shopping, housework or gardening
SYMPTOMS OF FIBROMYALGIA
Non-Locomotor Symptoms
Clinical Examination usually reveals no abnormality of the MSK
Investigations
CBC
ESR, CRP
Thyroid function
Calcium, alkaline phosphatase
Antinuclear antibody
Treatment
1-Education
2-Low-dose amitriptyline
3- aerobic exercise
BONE AND JOINT INFECTION
SEPTIC ARTHRITISSeptic arthritis is a medical emergency. It is the most rapid and destructive joint disease and
has a significant morbidity and a mortality of
10%.
The incidence is 2-10 per 100 000 in the general population and 30-70 per 100 000 in those with pre-existing
joint replacement joint disease
Risk factors for septic arthritis
Clinical featuresThe usual presentation is with acute or subacute monoarthritis.
The joint is usually swollen, hot and red and is held in the 'loose-pack' position, with rest pain and stress pain on
movement.
the lower limb, particularly knee and hip, is the most common site
Investigations
Joint aspiration
Blood cultures
Synovial fluid culture
Management
Hospitalisation is essential
pain relief
- parenteral antibiotics
- adequate drainage
- early active rehabilitation
BRUCELLOSIS BRUCELLOSIS is a bacterial zoonosis transmitted
directly or indirectly to humans from infected animals.
- The disease is known as undulant fever
because of its remittent character
Human brucellosis is caused by strains of Brucella:
B. melitensis, which is the commonest cause of ,
symptomatic disease in humans
B. abortus, is acquired from cattle or buffalo:
B. suis, acquired from swine
B. canis, is acquired from
dogs.
The incubation period varies from 1 week to several months, and
the onset of fever and other symptoms may be
abrupt or insidious
Focal features are present in the majority of patients.
The most common focal findings are
1musculoskeletal pain and physical findings in
the peripheral and axial skeleton (40 % of
cases).
2-discitis: more commonly involves
the lumbar and lower thoracic vertebrae than
-the cervical and high thoracic spine.
3-septic arthritis:the most commonly affected
joints are the knee, hip,& sacroiliac joints, and
the pattern either monoarthritis or
.polyarthritis
4-Osteomyelitis may also accompany septic
arthritis
differential diagnosis
The diagnosis of brucellosis is based on the clinical features and the results of laboratory tests . The isolation
of Brucella species by culture is disappointing
since it requires special media and several
weeks of incubation, and is positive in only
about half of acute cases . Therefore, the
laboratory diagnosis of brucellosis is usually
based on serological tests.
Rose Bengal agglutination test
Tube agglutination test
Indirect fluorescent antibody test IFAT
2-mercaptoethanol test
C-reactive protein test
Combined tests in the diagnosis of brucellosisThe use of Tube agglutination test TAT with Coomb-like test CLT
was found to offer the best sensitivity (100%)
and a specificity of 97.2%, followed by RBT with
IFAT, which had a sensitivity of 100% and
specificity of 91.0%.
The diagnosis must be based on a
1-history of potential exposure,
2-Clinical Features of the disease,
3-supporting laboratory findings
TREATMENT The aims of antimicrobial therapy for brucellosis are:
1-to treat current infection
2-and relieve its symptoms
3-and to prevent relapse.
Focal disease presentations may require surgical
intervention (e.g.,
cardiac valve replacement, abscess drainage,
-joint replacement)
in addition to more prolonged and tailored
antibiotic therapy The “gold standard” for
-the treatment of brucellosis in adults is
intramuscular streptomycin (750 mg to 1 g daily
for 14 to 21 days) together with doxycycline (100
mg twice
TUBERCULOSIS is Caused by bacteria belonging to the Mycobacterium tuberculosis complex
The disease usually affects the lungs, although
in up to one-third of cases other organs are
involved
Transmission usually takes place through the air
borne spread of
droplet nuclei produced by patients with active
ETIOLOGIC AGENT
pulmonary tuberculosis
the most frequent and important agent
of human disease is
M. tuberculosis . The complex includes:
M. bovis the bovine tubercle bacillus,
(the cause of a small percentage of cases in
developing countries),
M. africanum
M. microti
and M. canettii
SKELETAL TUBERCULOSIS
the pathogenesis is related to reactivation of
-hematogenous
foci or to spread from adjacent paravertebral
lymph nodes:
1-Weight-bearing joints (spine, hips, and knees—
-in that order) are affected
most commonly.
2-Spinal tuberculosis (Pott’s disease or
tuberculous spondylitis; often involves two or
more adjacent vertebral bodies. the upper
thoracic spine is the most
common site of spinal tuberculosis in children,
the lower thoracic and upper
lumbar vertebrae are usually affected in adults.
- From the anterior superior
or inferior angle of the vertebral body, the lesion
reaches the
adjacent body, also destroying the intervertebral
disk.
With advanced disease, collapse of vertebral
bodies results in kyphosis (gibbus)
A paravertebral “cold” abscess may also form.
In the upper spine, this abscess may track to the chest wall
as a mass;
in the lower spine, it
may reach the inguinal ligaments or present as a psoas
-abscess.
-(CT) or (MRI) reveals
the characteristic lesion and suggests its etiology, Aspiration
of the
abscess or bone biopsy confirms the tuberculous etiology, as
cultures
are usually positive and histologic findings highly typical
Mx
Skeletal tuberculosis responds to chemotherapy, but severe
cases may require surgery
the diagnosis is first suspected by chest radiograph .
it shows the typical picture
of upper lobe infiltrates with cavi
A presumptive diagnosis is commonly based on the finding of
AFB on microscopic examination of a diagnostic specimen
such as
1-a smear of expectorated sputum
2-or of tissue (for example, a lymph node biopsy).
TREATMENT
-Short-course regimens are divided into an initial, or bacte
ricidal, phase and a continuation, or sterilizing, phase.
During the initial phase, the majority of the tubercle bacilli
are killed, symptoms
resolve, and the patient becomes noninfectious.
The continuation phase is required to eliminate persisting
mycobacteria and prevent relapse. The treatment regimen
-of choice for virtually all forms of tuberculosis
in both adults and children consists of a 2-month initial
phase OF
- Isoniazid, Rifampin, Pyrazinamide, and Ethambutol
FOLLOWED BY 4 month continuation phase of Isoniazid and
.Rifampin
Treatment may be given daily throughout the course or
intermittently
either three times weekly throughout the course or twice
weekly following
an initial phase of daily therapy . extrapulmonary tuberculosis
can be treated with the
6 month regimen recommended for patients with pulmonary
disease
The American Academy of Pediatrics recommends that
children with
bone and joint tuberculosis, tuberculous meningitis, or
-miliary tuber
culosis receive 9 to 12 months of treatment
VIRAL ARTHRITIS
are self-limiting
The usual presentation is with acute polyarthritis, fever or viral
prodrome and rash.
Diagnosis is confirmed by a rise in specific IgM.
Polyarthritis may also rarely occur with hepatitis B and C, rubella
and HIV
JUVENILE IDIOPATHIC ARTHRITIS JIA (also JCA.JRA) is the most
common form of childhood arthritis.
-it is of unknown etiology. The Dx is by exclusion.
JIA is subdivided into many categories
1-Systemic(Still s)
2-17%
2-Polyarticular RF+ve
2-10%
3-Polyarticular RF-ve
10-28%
4-Oligoarthritis (persistant)12-30%
5-Oligoarticular (extended) 12-30%
6-Enthesitis related arthritis3-10%
7-Psoriatic arthritis
2-10%
8-Undifferentiated
2-20%
Systemic (or Still s disease)
it was discribed by Still in 1897
-arthritis + fever
- NON pruritic rash
-generalized LAP
-HSM
-serositis
-M:F 1:1
-leukocytosis
-vasculitis is a complication
- uveitis is rare
OLIGOARTHRITIS
-arthritis < 4 joints
-persistent and extended
F:M 4:1
-PERSISTENT carries high risk of uveitis 30-50%
-persistent remission rate 40-70%
-extended started in < 4 j/the first 6 months then involves > 5 joints
PSORIATIC ASSOCIATED JIA
-arthritis + psoriasis in patient < 16 years old
- only 10% of patients has the onset of psoriatic rash and arthritis
at the same time
-nail finding is evident (pitting, onycholysis& dactilitis)
-uveitis risk is 20%
ENTHESITIS RELATED ARTHRITIS
-arthritis
-enthesitis
-sacroiliac j involvement
-+ve HLA-B27
-uveitis up to 25%
-enthesitis is inflammation of tendon insertion,ligaments or fascia
insertion into the bone
-aortic involvement may
A MULTIDISCIPLINARY APPROACH IS RECOMMENDED .which
involve;
rheumatologist , paediatricians,
ophthalmologist,dentist,psychologists, physiotherapist,
occupational therapist, nurses, social workers and teachers
Physiotherapy will reduce deformity.
Rest is indicated when the joints are acuetly inflammed.
splints to prevent flexion deformity
Hydrotherapy in warm pool is particularly useful.
The child should be kept active and ambulant.
NSAID are used at higher doses than in adults
Intra articular steroid injections are used to treat resistant joints.
Methotrixate is added for at least 2 years .
-MTX& sulphasalazine are helpful for polyarticular JIA
biologic agents
like (TNF-ALPHA inhibitors) ETANERCEPT,Infliximab,Adalimumab are
more useful for polyarticular than systemic type.
they are now used with excellent response in severe JIA and in
uveitis and vasculitis.
Poor prognosis
1-polyarticular disease.
2-systemic arthritis that evolve into polyarthritis
3-extended oligiarticular disease.
- 4- polyarticular disease attributable to psoriatic arthritis