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Real Doctors (Life Makers)  |  Clinical  |  Medicine & medical subspecialities  |  Question 2 [Arthritis] « previous next »
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dr_b.e.s.m
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Question 2 [Arthritis]
« on: /October/ 08, 2005, 08:18:56 PM »

2] A 57-year-old man comes to the emergency department because of excruciating pain in his right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no chronic medical conditions, does not take any medications, and denies any similar episodes in the past. He admits to a few "drinking binges" over the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes (PMNs). Laboratory studies show: Serum
Leukocytes........16,000/mm3
Uric acid...........15 mg/dL
Calcium.............9 mg/dL

Which of the following is the most appropriate pharmacotherapy?

A Allopurinol
B Ceftriaxone
C Indomethacin
D Probenecid
E eSulfinpyrazone



In order to manage a case of joint disease, we must answer the following 4 questions: (this case is a very typical one that can be diagnosed immediatly but we are talking about systematic approach to arthritis in general)

1-Is it mono/ oligo/ polyarthritis ?
2-Is it actute or chronic?
3-Is it inflamatory arthritis? [presence of red warm joint / morning stiffness>1 hr]
4-Is there any affection of other body systems? [skin / eye / lung / kindey /etc...]


well, another important question is to know if it's the joint affected or periarticular structure eg. tendon , bursa, etc.. [it'll be clear with examination]

try to apply this to our patient .......

.......... Undecided

......... Undecided

........... Undecided


What do you think??

A case of monoartritis [it's only the big toe] - Acute [no previous history] - Inflamatory [erythematous and warm] - No other systems affected.



Next question: what are the causes of acute mono arthritis?? 3 condition : trauma, infection, and crystalline arthritis.


What shall we do next to identify the exact cause (after history and examination of course) ?

A. Radiographs of the joint may be useful in documenting trauma or preexisting joint disease. Radiographs are usually normal in acute infectious or crystalline arthritis.? ? [we don't need it here as there is no history of trauma or preexisting disease, right? ]

B. Synovial fluid should be aspirated in all patients with a monarticular arthritis who do not have a preexisting diagnosis that is consistent with the clinical picture. [ so we need synovial fluid aspiration] ? Synovial fluid cell counts [not mentioned in our case] above 5000 nucleated cells/?l suggest an inflammatory etiology. Counts above 50,000 cells/?l may indicate infection, particularly if 75% or more of the cells are polymorphonuclear. Crystals occur in cases of crystal induced arthritis [our case here] ? which includes gout, pseudogout, and apatite disease. A
efinitive diagnosis of gout or pseudogout is made by finding intracellular crystals in joint fluid examined with a compensated polarized light microscope. Urate crystals, which are diagnostic of gout, are needle shaped and strongly negatively birefringent. The calcium pyrophosphate dihydrate crystals seen in pseudogout are pleomorphic and weakly positively birefringent. Hydroxyapatite complexes, diagnostic of apatite disease, and basic calcium phosphate complexes can be identified only by electron microscopy and mass spectroscopy.

What kind of crystals are found in this case? negatively birefringent, needle-shaped crystals so it's URATE.

So this is GOUT. Acute gout [as there is no previous history]

Another point in the diagnosis is that this is Acute Primary Gout ( as there is no identified cause for secondry gout)

Here is a hint about secondry gout :
Intrinsic renal disease, diuretic therapy, low-dose aspirin, nicotinic acid, cyclosporine, and ethanol all interfere with renal excretion of uric acid. Starvation, lactic acidosis, dehydration, preeclampsia, and diabetic ketoacidosis also can induce hyperuricemia. Overproduction of uric acid occurs in myeloproliferative and lymphoproliferative disorders, hemolytic anemia, polycythemia, and cyanotic congenital heart disease.



Now we have the diagnosis , these are guidelines for the treatment , read them and you'll know the correct answer:

1.NSAIDs are the treatment of choice for acute gout due to ease of administration and low toxicity. Clinical response may require 12?24 hours, and initial doses should be high, followed by rapid tapering over 2?8 days. One approach is to use indomethacin, 50 mg PO q6h for 2 days, followed by 50 mg PO q8h for 3 days and then 25 mg PO q8h for 2?3 days. The long-acting NSAIDs generally are not recommended for acute gout. Selective COX-2 inhibitors have not been critically evaluated for treatment of gout but should also be effective.

2.Glucocorticoids are useful when NSAIDs are contraindicated. An intra-articular injection of glucocorticoids produces rapid dramatic relief. Alternatively, prednisone, 40?60 mg PO qd, can be given until a response is obtained and then should be tapered rapidly.

3.Colchicine is most effective if given in the first 12?24 hours of an acute attack and usually brings relief in 6?12 hours. In view of the efficacy and tolerability of a short course of NSAIDs, colchicine is not commonly used to treat gout but is useful when NSAIDs or glucocorticoids are contraindicated or not tolerated.


which one will you choose for this patient?





« Last Edit: /October/ 08, 2005, 08:28:20 PM by dr_b.e.s.m » Logged


 
3abeer
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Re: Question 2 [Arthritis]
« Reply #1 on: /October/ 09, 2005, 05:28:57 AM »

NSAIDs are the 1st choice in acute gout with ahigh dose

when the big toe is involved we call it podagra

drinking can pricipitate an acut attack , so patient should be adviced about that  Cool
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dr_b.e.s.m
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Re: Question 2 [Arthritis]
« Reply #2 on: /October/ 10, 2005, 06:29:59 AM »

Exactly, that's the correct answer. NSAIDs (in this case Indomethacin).

Some people think that colchicine is the main treatment of acute gouty arthritis but this in not true of course , it's used only if NSAIDs and steroids can't be used.



-Another question, what about using drugs like probenicid and allopurinol during the acute attack? they are uric acid lowering drugs so what if we use them beside NSAID during acute gout? Will it be useful?

I read something, read that manipulating uric acid level may worsen the attack!! so they can't be used in acute attack. Even after resolving of the attack and we wanna use them as prophylactic medications ,we better give colchicine with the initiation of uric acid lowering drugs in order to prevent precipitation of an acute attack. (given till uric acid level is <5). Another fact is that serum uric acid isn't always elevate during actue gouty arthritis (ie. normal uric acid levels do not rule out gout ).

-Patients with acute monoarthritis needs prompot diagnosis and management , why?
Simply because one of the causes is septic arthritis which can cause severe joint destruction if delayed management.









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dr_b.e.s.m
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Another case of arthritis
« Reply #3 on: /October/ 10, 2005, 06:32:39 AM »

A 17-year-old girl presents to the emergency department with a 2-day history of a painful and swollen right big toe. She also has had a fever, with temperatures up to 38.9 C (102 F), at home for 2 days. On physical examination, her temperature is 101.8 F (38.8 C). Her first metatarsal joint of the right foot is markedly swollen and very painful to touch. An aspirated fluid from the joint reveals a white blood count of 35,000/ mm3. what is the most likely diagnosis?
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dr_b.e.s.m
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Re: Question 2 [Arthritis]
« Reply #4 on: /October/ 29, 2005, 07:48:17 AM »

This table is a summary for results of joint aspirate in different types of arthritis. Applying these facts to the last case and try to guess what's the diagnosis.

* table.JPG (20.98 KB - downloaded 21 times.)
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