Polymyalgia Rheumatica/Temporal arthritis: Symptoms and Treatment

Polymyalgia rheumatica/temporal arthritis is a condition that can cause a variety of symptoms. It may present with predominantly polymyalgia symptoms such as muscle pain and stiffness, or arthritis symptoms such as headaches, scalp tenderness, and jaw claudication. Systemic features like fever, malaise, and weight loss may also be present. Weakness is not a typical feature, but it may be apparent due to pain or stiffness with weight loss. The ESR (erythrocyte sedimentation rate) is usually very high in this condition.

Temporal arthritis is a serious complication of this condition that can result in blindness. It is important to note that temporal arthritis is a vasculitis that affects medium and large-sized arteries throughout the body, not just the temporal artery. The superficial temporal artery supplies the orbit of the eye and is a branch of the external carotid artery, while the ophthalmic artery supplies the majority of the blood to the eye itself and is a branch of the internal carotid artery. Inflammation and narrowing of the temporal artery can cause blindness.

If temporal arthritis is suspected, it must be treated with high-dose steroids. This condition is a reminder that prompt diagnosis and treatment are crucial to prevent serious complications.

Treatment Options for Severe Rheumatoid Arthritis

Severe rheumatoid arthritis can be a challenging condition to manage, especially when conventional disease-modifying anti-rheumatic drugs (DMARDs) fail to provide relief. In such cases, biological therapies may be recommended. Here are some treatment options for severe rheumatoid arthritis:

Enrol in Biological Therapy Programme
Patients with highly active disease despite trying three previous agents for a therapeutic treatment duration may be candidates for biological treatments. TNF-alpha inhibitors and anti-CD20 are examples of biological treatments that are routinely used in the UK.

Maintain on Steroids and Add a Bisphosphonate
Short-term treatment with glucocorticoids may be offered to manage flares in people with recent-onset or established disease. However, long-term treatment with glucocorticoids should only be continued when the long-term complications of glucocorticoid therapy have been fully discussed and all other treatment options have been offered.

Commence Leflunomide
Severe disease that has not responded to intensive therapy with a combination of conventional DMARDs should be treated with biological agents. Leflunomide is one of the DMARDs that can be used in combination therapy.

Use Methotrexate/Leflunomide Combination
Patients who have not responded to intensive DMARD therapy may be prescribed a biological agent, as per NICE guidelines. Methotrexate and leflunomide are two DMARDs that can be used in combination therapy.

Avoid Commencing Penicillamine
DMARD monotherapy is only recommended if combination DMARD therapy is not appropriate. Patients without contraindications to combination therapy should not be prescribed penicillamine.

Reactive Arthritis

Reactive arthritis is a medical condition that is typically characterized by a combination of three symptoms: urethritis, conjunctivitis, and seronegative arthritis. This type of arthritis usually affects the large weight-bearing joints, such as the knee and ankle, but not all three symptoms are always present in a patient. Reactive arthritis can be triggered by either a sexually transmitted infection or a dysenteric infection. One of the most notable signs of this condition is the appearance of a brown macular rash known as keratoderma blennorrhagica, which is usually seen on the palms and soles.

The main treatment for reactive arthritis involves the use of non-steroidal anti-inflammatory drugs (NSAIDs). These medications can help to alleviate the pain and inflammation associated with the condition. Additionally, antibiotics may be prescribed to individuals who have recently experienced a non-gonococcal venereal infection. This can help to reduce the likelihood of that person developing reactive arthritis. Overall, the symptoms and treatment options for reactive arthritis can help individuals to manage this condition and improve their quality of life.

Management of Suspected Infected Olecranon Bursitis

Suspected infected olecranon bursitis requires prompt management to prevent complications. The following options are available:

Option 1: Oral flucloxacillin and refer for urgent aspiration
Empirical antibiotics, such as oral flucloxacillin, should be started immediately to cover for staphylococci and streptococci. However, urgent same-day aspiration should also be arranged to confirm the diagnosis and obtain antibiotic susceptibility.

Option 2: Arrange for corticosteroid injection
If there are no signs of infection, corticosteroid injection may be considered after conservative measures have failed in aseptic olecranon bursitis. However, in suspected septic olecranon bursitis, urgent antibiotics and aspiration are required.

Option 3: Oral flucloxacillin only
Empirical oral flucloxacillin should be started as soon as possible in suspected infected olecranon bursitis. However, referral for urgent aspiration is also necessary to confirm the diagnosis and obtain antibiotic susceptibility.

Option 4: Oral amoxicillin and refer for urgent aspiration
Flucloxacillin, not amoxicillin, should be given for suspected septic olecranon bursitis to cover the most common organisms. Urgent aspiration should also be arranged to confirm the diagnosis and obtain antibiotic susceptibility.

Option 5: Refer for urgent aspiration
Urgent aspiration is necessary to confirm the diagnosis and obtain antibiotic susceptibility. Empirical antibiotics should be started first while awaiting culture results. If the patient is seen in the Emergency Department, aspiration may be done first before starting antibiotics.

Common Organisms in Septic Arthritis

Septic arthritis is a serious condition that occurs when a joint becomes infected. The most common organism causing septic arthritis is Staphylococcus aureus. Pseudomonas spp can also cause septic arthritis, but it is less likely than S. aureus, especially in intravenous drug users. Escherichia coli is another pathogen that can cause septic arthritis, but it is less common than S. aureus. In children under the age of two, Haemophilus influenzae is the most common organism causing septic arthritis. Neisseria gonorrhoeae is a common cause of arthritis in the United States, but it is uncommon in Western Europe. It is important to identify the causative organism in order to provide appropriate treatment for septic arthritis.

Understanding HLA and Autoimmune Diseases

HLA-B27 is a genetic marker associated with ankylosing spondylitis, an autoimmune disease that primarily affects the spine. This disease is more common in males and typically presents in the 20s and 30s. Other autoimmune manifestations, such as anterior uveitis, can also occur in individuals with HLA-B27. Additionally, young men with this genetic marker may be prone to reactive arthritis after chlamydia or gonorrhoeal urethritis.

Rheumatoid factor, on the other hand, is not associated with HLA-B27 or ankylosing spondylitis. While stiffness that improves with exercise may be seen in rheumatoid arthritis, this disease typically affects peripheral joints and does not lead to calcification of the anterior spinal ligament.

Other HLA markers are associated with different autoimmune diseases. HLA-DR3 is linked to type 1 diabetes mellitus, HLA-DR5 is associated with pernicious anaemia and Hashimoto’s thyroiditis, and HLA-B8 is linked to Graves’ disease. Understanding these genetic markers can aid in the diagnosis and management of autoimmune diseases.

Differential Diagnosis for Knee Aspirate: Pseudogout, Gout, prepatellar Bursitis, Septic Arthritis, Osteoarthritis

A knee aspirate was performed on a patient who presented with knee pain. The aspirate revealed positively birefringent calcium pyrophosphate crystals, indicating pseudogout. This condition is associated with haemochromatosis and can be treated with non-steroidal anti-inflammatory agents, corticosteroid injections, or short courses of oral corticosteroids. Colchicine may also be an option for some patients. Familial pyrophosphate arthropathy, a rare form of the condition, may be linked to mutations in genes related to inorganic phosphate transport.

Gout is a differential diagnosis for this case, but the knee aspirate would reveal negatively birefringent crystals. prepatellar bursitis, a sterile condition not associated with crystals or raised white cell counts, can be ruled out. Septic arthritis would present with a systemic inflammatory response and rhomboid-shaped birefringent crystals would not be present. Osteoarthritis is a chronic condition and would not present acutely, and joint aspirate would not show rhomboid-shaped birefringent crystals.

Differentiating Types of Arthritis

Degenerative osteoarthritis is a condition that becomes more prevalent and symptomatic as one ages. It is characterized by the erosion and loss of articular cartilage. On the other hand, rheumatoid arthritis typically affects the small joints of the hands and feet, leading to marked joint deformity due to a destructive pannus. Gouty arthritis, on the other hand, is more likely to cause swelling and deformity with joint destruction, and the pain is not related to usage. Osteomyelitis, meanwhile, is an ongoing infection that produces marked bone deformity, not just joint narrowing. Lastly, Lyme disease produces a chronic arthritis, but it is typically preceded by a deer tick bite with a skin lesion. It is much less common than osteoarthritis. By the differences between these types of arthritis, proper diagnosis and treatment can be given to patients.

Understanding Autoimmune Disorders: Differentiating Between Ankylosing Spondylitis, SLE, and Rheumatoid Arthritis

Autoimmune disorders can be difficult to diagnose due to their overlapping symptoms. However, certain laboratory tests can help differentiate between them.

One such test is the human leukocyte antigen (HLA)-B27, which is associated with ankylosing spondylitis. This autoimmune disorder primarily affects men and is characterized by back stiffness that improves throughout the day, sacroiliitis, and a bamboo spine on radiography.

On the other hand, positive antinuclear antibodies and anti-double-stranded DNA antibodies are associated with systemic lupus erythematosus (SLE). Patients with SLE may experience joint pain, skin rashes, and organ involvement.

Lastly, positive anti-cyclic citrullinated peptide (CCP) antibodies are associated with rheumatoid arthritis. This autoimmune disorder is characterized by joint pain, swelling, and stiffness, and can lead to joint deformities if left untreated.

In summary, understanding the specific laboratory tests associated with different autoimmune disorders can aid in their diagnosis and treatment.

Types of Arthritis and Infections that can Cause Tenosynovitis

Tenosynovitis is a condition where the tendon sheath becomes inflamed, causing pain and swelling. It can be caused by various types of arthritis and infections. Here are some of the most common causes:

Systemic Sclerosis: This autoimmune disease causes fibrosis of connective tissue, resulting in hard and thickened skin, swollen digits, and Raynaud’s phenomenon. Tenosynovitis in systemic sclerosis is non-tender and without swelling of the tendons.

Rheumatoid Arthritis: Tenosynovitis due to rheumatoid arthritis causes pain and swelling of tendons. It usually involves the interphalangeal, metacarpophalangeal, and wrist joints, and can cause deformities such as swan neck and Boutonnière’s deformity.

Gout: Gout can cause tenosynovitis, which is very painful and presents with redness and swollen tendons. It typically affects the metatarsophalangeal joints.

Disseminated Gonococcal Infection: This infection can cause acute migratory tenosynovitis, especially in younger adults. Women may be asymptomatic, while men may present with urethral discharge or dysuria.

Reactive Arthritis: This type of arthritis causes pain and swelling of tendons, commonly affecting the knees or sacrum. It is an acutely inflammatory process and would therefore be swollen and tender.

In conclusion, tenosynovitis can be caused by various types of arthritis and infections, and it is important to identify the underlying cause in order to provide appropriate treatment.