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Cure Arthritis Naturally

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2000-75,000

Often >100.000

Polymorphonuclear cells

<25%

<25%

Often >50%

>85%

Culture results

Negative

Negative

Negative

Often positive

Glucose

Nearly equal to blood

Nearly equal to blood

<50 mg/dL lower than blood

<50 mg/dL lower than blood

Source: Koch AE. Approach to the patient with pain in one or a few joints. In: Kelly's textbook of internal medicine. New York: Williams and Wilkins, 2000:1322.

Source: Koch AE. Approach to the patient with pain in one or a few joints. In: Kelly's textbook of internal medicine. New York: Williams and Wilkins, 2000:1322.

intravenous ceftriaxone is the usual initial therapy, usually with rapid improvement in symptoms. Nongonococcal septic arthritis usually is caused by Gram-positive organisms, most often S. aureus, so treatment would involve an antistaphylococcal penicillin such as nafcillin. or vancomycin when methicillin resistance is suspected. It is essential to drain the purulent joint fluid, usually by repeated percutaneous aspiration. Open surgical drainage or arthroscopy is required when joint fluid is loculated, or when shoulders, hips, or sacroiliac joints are involved.

Gout classically is progresses through four stages.

Stage I is asymptomatic hyperuricemia. Patients have elevated uric acid levels without arthritis or kidney stones. The majority of patients with hyperuricemia never develop any symptoms, but the higher the uric acid level and the longer the duration of hyperuricemia, the greater the likelihood of the patient developing gouty arthritis.

Stage 2 is acute gouty arthritis, which most often involves the acute onset of severe monoarticular pain, often occurring at night, in the first MTP joint, ankle, or knee, with rapid development of joint swelling and erythema and sometimes associated with systemic symptoms such as fever and chills. This usually follows decades of asymptomatic hyperuricemia. Attacks may last hours or up to 2 weeks.

Stage 3 is intercritical gout, or the period between acute attacks. Patients are generally completely asymptomatic. The vast majority of patients will have another acute attack within 1-2 years. The presence of these completely asymptomatic periods between monoarthritic attacks is so uncommon, except in crystalline arthritis, (hat it is often used as a diagnostic criterion for gout.

Stage 4 is chronic tophaceous gout, which usually occurs after 10 or more years of acute intermittent gout. In this stage, the intercritical periods are no longer asymptomatic; the involved joints now have chronic swelling and discomfort. which worsens over time. Patients also develop subcutaneous tophaceous deposits of monosodium urate.

In general, asymptomatic hyperuricemia requires no specific treatment. Lowering the urate level does not necessarily prevent the development of gout, and most of these patients will never develop any symptoms. Acute gouty arthritis is treated with therapies to reduce the inflammatory reaction to the presence of the crystals, all of which arc most effective if started early in the attack. Potent NSAIDs, such as indomethacin, are the mainstay of therapy. Alternatively, oral colchicine can be taken every hour until the joint symptoms abate, but dosing is limited by gastrointestinal side effects such as nausea and diarrhea. Individuals affected by acute joint pain with renal insufficiency, for which NSAIDs or colchicine is relatively contraindicated, usually benefit from intraarticular glucocorticoid injection or oral steroid therapy. Steroids should be used only if infection has been excluded. Treatment to lower uric acid levels is inappropriate during an acute episode because any sudden increase or decrease in urate levels may precipitate further attacks.

During intercritical gout, the focus shifts to preventing further attacks by lowering uric acid levels. Dietary restriction is mainly aimed at avoiding organ-rich foods, such as liver, and avoiding alcohol. Patients taking thiazide diuretics should be switched to another antihypertensive if possible. Urate lowering can be accomplished by therapy to increase uric acid excretion by the kidney, such as with probenecid. Uricosuric agents such as this are ineffective in patients with renal failure, however, and are contraindicated in patients with a history of uric acid kidney stones. In these patients, allopurinol can be used to diminish uric acid production. In either case, urate lowering can precipitate acute attacks, so initial prophylaxis with daily low-dose colchicine usually is necessary.

Patients with tophaceous gout are managed as previously described during acute attacks and treated with allopurinol to help tophaceous deposits resolve. Surgery may be indicated if the mass effect of tophi causes nerve compression, joint deformity, or chronic skin ulceration with resultant infection.

Patients with pseudogout are treated similarly for acute attacks (NSAIDs, colchicine, systemic or intraarticular steroids). Prophylaxis with colchicine may be helpful in patients with chronic recurrent attacks, but there is no effective therapy for preventing CPPD crystal formation or deposition.

Comprehension Questions

[21.1] A previously healthy 18-year-old college freshman presents to the student health clinic complaining of pain on the dorsum of her left wrist and in her right ankle, fever, and a pustular rash on the extensor surfaces of both her forearms. She has mild swelling and erythema of her ankle, and pain on passive flexion of her wrist. Less than 1 mL of joint fluid is aspirated from her ankle, which shows 8000 polymorphonuclear (PMN) cells per high-power field (hpf) but no organisms on Gram stain. Which of the following is the best initial treatment?

A. Indomethacin orally

B. Intravenous ampicillin

C. Colchicine orally

D. Intraarticular prednisone

E. Intravenous ceftriaxone

[21.2] What diagnostic test is most likely to give the diagnosis for the case in Question [21.1]?

A. Crystal analysis of the joint fluid

B. Culture of joint fluid

C. Blood culture

D. Cervical culture

121.3) A 30-year-old man is noted to have an acutely swollen and red knee. Joint aspirate reveals numerous leukocytes and polymorphonuclear leukocytes, hut no organisms on Gram stain. Analysis shows few negatively birefrin-gent crystals. Which of the following is the best initial treatment?

A. Oral corticosteroids

B. Intraarticular corticosteroids

C. Intravenous antibiotic therapy

D. Oral colchicine

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