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CDHB

Acute Swelling of a Single Joint - Septic Arthritis, Gout etc.

The cause of the acute swelling must be established before any rational form of treatment can be given.

Possible Causes

• Trauma ± haemorrhage.
• Infection (septic arthritis signs may be modified if on steroids or in the presence of chronic arthritis e.g., rheumatoid arthritis).
• Crystal deposition (gout and pseudogout).
• Reactive to infections elsewhere - urethritis, colitis, rheumatic fever.
• Rheumatoid disease.
• Other conditions e.g., palindromic rheumatism, psoriasis, osteoarthritis, inflammatory bowel disease.

Investigations

• CBC + diff, platelets and ESR or CRP.
• Aspirate joint fluid and send to Microbiology for:
  • Gram stain and culture (Send aspirate in sterile tube, capped syringe or inoculate into blood culture bottle).
  • Cell counts and differential (put fluid into EDTA tube and mix).
  • Compensated polarized light examination for crystals (capped syringe).
• Blood culture - 2 sets. Aim for 10 mL per bottle of each set. Consider possibility of gonococcal infection. Inform laboratory as special culture techniques will be needed.
• Serum urate level.
• Coagulation profile if bleeding disorder suspected.
• X-ray joint.

When indicated from history:

• Tissue type - HLA-B27.
• Swab throat, cervix, urethra, anus (should be cultured at bedside to grow N. gonorrhoeae). Do chlamydia trachomatis nucleic acid testing on cervical and urethral swabs in women and first-catch urine in men.
• Culture faeces (Yersinia, Salmonella, Campylobacter).
• Ferritin if haemochromatosis suspected.

Treatment

Septic Arthritis:

• Splint joint and give analgesia.
• Use appropriate antibiotic.
  If Gram positive cocci seen or staphylococci suspected (S. aureus is the most common organism), give flucloxacillin 2 g IV q4-6h.
  If allergic to penicillin give cephazolin 2 g IV q8h if allergy mild or vancomycin if allergy severe. Refer to Penicillin Allergy.
• Repeat aspiration of synovial fluid daily when effusion is recurrent.
• Consult Orthopaedic and Infectious Diseases Services. Most non-prosthetic infected large joints will be considered for arthroscopic washout. All suspected prosthetic joint infections should be referred to/discussed with the Orthopaedic Service.

Acute gout or pseudogout:

Initial therapeutic options include NSAIDs, steroids, or colchicine:

• NSAIDs: may be used in the absence of contraindications such as previous peptic ulceration or renal disease. Caution is advised in the elderly. Naproxen 750 mg stat then 500 mg BD until the inflammation has settled.
• Steroids: if the joint is easily accessible to injection and you are competent to carry out this procedure, intra-articular steroids should be given. Otherwise give oral steroids which are the first choice in the elderly, in patients with renal impairment, or those with any other contraindication to NSAIDs. Prednisone 20-40 mg PO daily until the acute attack has resolved followed by a slow reduction over 14 days to avoid rebound attacks.
• Colchicine: should not be used in the elderly or those with renal impairment (eGFR <50 mL/min), due to the high risk of toxicity. Colchicine is generally only effective when prescribed within 24 hours of the onset of attack. Large doses of colchicine are inappropriate. The recommended dose is 1 mg followed by 0.5 mg 6 hourly to a maximum of 2 mg per 24 hours. Many patients will not tolerate even this dose - remember - diarrhoea is a sign of toxicity not a side effect.

  Note: A lower dose regimen has also been shown to be effective (colchicine 1 mg stat, then 0.5 mg 1 hour later and no further doses for 3 days).

  Note: A cumulative oral dose of 6 mg over four days should not be exceeded. Additional colchicine should not be administered for at least three days after a course of oral treatment.

  Fatal and non-fatal cases of colchicine toxicity have been reported with concomitant use of P-glycoprotein and CYP3A4 inhibitors such as cyclosporin, clarithromycin, erythromycin, verapamil, diltiazem, ketaconazole, HIV protease inhibitors etc. Toxicity can also be increased by daily consumption of grapefruit juice, hepatic and renal impairment, statins, fibrates and digoxin.

Prevention of recurrent gout

After an acute attack of gout has subsided, consideration must be given to the cause of the hyperuricaemia. When urate-lowering drugs such as allopurinol are commenced the initiation period should be covered by NSAIDs, prednisone or rarely colchicine for 12 weeks or longer as urate-lowering drugs can precipitate acute attacks of gout.

Allopurinol dose should initially be adjusted according to renal function (see table below). Dose should be started low and increased 2-4 weekly to the recommended dose according to creatinine clearance. Only sustained reduction of serum urate to <0.36 mmol/L will prevent gout. If recommended dose of allopurinol fails to achieve this target urate, consideration should be given to a gradual increase in allopurinol dose. Review closely for possible side effects including allopurinol hypersensitivity syndrome.

Allopurinol Dosage

Haemarthrosis:

• Immobilize joint.
• If bleeding disorder suspected do not aspirate joint before seeking advice. If however blood is found unexpectedly on a diagnostic tap, aspirate as much as possible. Remember to ask about family history of bleeding disorders.
• Unless trauma is clearly the cause refer to Haematologist as a bleeding disorder likely. Following consultation appropriate coagulation factor replacement may be indicated. A normal coagulation profile does not necessarily rule out a coagulopathy. Significant trauma requires referral to an Orthopaedic Surgeon.
• X-ray if history of trauma.

Topic Code: 1690