HC MTC 7/1/21: Don’t just be reactive (arthritis), be proactive (about arthrocentesis)!

This morning, we discussed an interesting case of an older gentleman presenting with acute asymmetric polyarthritis and fever. Rheumatologist Dr. Paul Hsu gave his expert perspective and clinical pearls! We reviewed the differential diagnosis for acute polyarthritis and were most concerned about septic arthritis vs reactive arthritis vs gout in this particular patient. We agreed that an expedited arthrocentesis and empiric antibiotics were important parts of this patient’s initial management, given the suspicion for septic arthritis. Ultimately, the patient was diagnosed with reactive arthritis, likely related to his preceding UTI and diarrheal illnesses. His symptoms improved with steroids. 

Teaching Points: 

  1. When evaluating a patient with arthritis, it is important to characterize the time course and distribution of the joint involvement. This will really inform your differential diagnosis! 
  1. When you are concerned about a possible septic arthritis, urgent arthrocentesis and empiric antibiotics are imperative! Also get blood cultures and consider the possibility of underlying endocarditis, particularly when multiple joints are involved. 
  1. Remember to send synovial fluid for gram stain, culture, cell counts, and crystal analysis. If you have a limited amount of synovial fluid, prioritize the sample for: 

Culture > Crystal analysis > Cell counts 

Medical Spanish Word of the Day: joint = articulación 

Morning Report 11/10: IBD-Associated Arthritis

Today we had one of our amazing PGY3s and future gastroenterologists present a case on IBD-Associated Arthritis. The case started with a women transferred from an outside hospital for migratory polyarthritis and rash. We had Dr Chelsea Smith from our Rheumatology Department to walk show us her approach to polyarthritis. As a team, we used the patient demographics, history and rash to work through the different categories of seronegative arthritis and diagnose the patient with IBD-Associated Seronegative Arthritis!

Teaching Points

Polyarthritis can be broken down into seropositive (positive RF and CCP ab) or seronegative arthritis.

Seronegative Arthritis includes seronegative rheumatoid arthritis, infectious arthritis, systemic rheumatoid disease, crystal arthropathy, and spondyloarthropathy. History and physical exam will help with differentiating between different types of seronegative arthritis.

IBD is associated with various extra-intestinal manifestations including arthritis and dermatologic conditions, as seen in this patient.

Erythema nodosum and pyoderma gangrenosum are the most common cutaneous manifestations of IBD, however other manifestations include Sweet Syndrome and cutaneous vasculitis (like our patient had)!