Rosen & Barkin's 5-Minute Emergency Medicine Consult (76 page)

• Malaise, fatigue
  
• Generalized musculoskeletal pain
  
• After weeks to months, patients develop swollen, warm, painful joints.
  
• Often worse in morning
  
• Joint involvement usually symmetric and polyarticular
  
• Starting in small joints of hands and feet:
  
  • Later wrists, elbow, and knees
    
• Distal interphalangeal (DIP) joints of hand generally not involved:
  
  • Presence of swelling in these joints should suggest another type of arthritis.
    
• Synovitis is typically gradual.
  
• Classic joint findings in long-standing disease:
  
  • Metacarpophalangeal (MCP) swelling with ulnar deviation
    
  • Swan neck and boutonniere deformities
    
• Extra-articular complications:
  
  • SC nodules
    
  • Vasculitis
    
  • Pericarditis or myocarditis
    
  • Pulmonary fibrosis
    
  • Pneumonitis
    
  • Sjögren syndrome
    
  • Mononeuritis multiplex
    
• Evidence of mild pericarditis on echocardiogram is found in up to 1/3 of patients.
  
• Consider ECG evaluation in these patients
  
• Patients usually present to ED owing to exacerbations of the disease or complication in other organ systems:
  
  • Airway obstruction from cricoarytenoid arthritis or laryngeal nodules
    
  • Heart block, constrictive pericarditis, pericardial effusion with possible tamponade or myocarditis
    
  • Pulmonary fibrosis, pleuritis, intrapulmonary nodules, or pneumonitis
    
  • Hepatitis
    
• Neurologic findings may result from cervical spine subluxation or ocular manifestations such as scleritis and episcleritis.
  
  • Can also have retinal vasculitis in periphery, and recurrent iritis—consider in patients with photophobia, red eye, and decreased vision. These patients need ophthalmologic evaluation
    
• Complications of chronic steroid use:
  
  • Infections
    
  • Steroid-induced osteopenia and fractures
    
  • Insulin resistance
    
  • Glaucoma or IOP elevation, accelerated cataracts
    
• Patients may present with side effects related to chronic salicylate or NSAID use such as GI bleeding.
  
• Drugs such as methotrexate, gold, or d-penicillamine also have toxic side effects, most commonly GI but also neuropathic.
  

• Primary diagnosis of rheumatoid arthritis (RA) is rarely made in the ED.
  
• Synovitis should be present for at least 6 wk; a minimum of 4 of the following 7 criteria as established by the American Rheumatism Association must be met to make the diagnosis:
  
  • Stiffness of the involved joints in the morning for at least 1 hr
    
  • Arthritis in 3 or more joints with effusion or soft tissue swelling
    
  • Arthritis of joint in hand (wrist, MCP, or proximal interphalangeal [PIP] joint)
    
  • Symmetric arthritis
    
  • Rheumatoid nodules on extensor surfaces or juxta-articular surfaces
    
  • Significantly elevated rheumatoid factor
    
  • Characteristic radiographic changes include erosions and decalcification (not attributable to osteoarthritis).
    
• Other pertinent history: Malaise, weakness, weight loss, myalgias, bursitis, tendonitis, fever of unknown cause
  
• Initial workup should focus on demonstrating that other causes of arthritis are not present, especially septic arthritis, reactive arthritis, or gout.
  
• Arthrocentesis of a joint effusion may be required.
  

ECG, chest radiograph, C-spine or extremity radiograph, and hemoglobin testing are helpful if patient presents with complications of RA.

• CBC: Mild anemia with leukocytosis and thrombocytosis
  
• Erythrocyte sedimentation rate (ESR): Often >30. Guide for elevation is age/2 in men, (age + 10)/2 in women. Consider GCA in patients with elevated markers and RA with vision loss that is acute.
  
• C-reactive protein correlates with erosive disease
  
• Antinuclear antibodies (ANA) 30–40% positive screening tool
  
• Rheumatoid factor: Elevated in ∼70% of cases
  
• Joint fluid analysis:
  
  • Typically between 4,000 and 50,000 white cells
    
  • Neutrophil predominance
    
  • Microscopic Gram stain of fluid should show no organisms and no crystals.
    
• ECG: Conduction defects are rare, but heart block may be seen. May see evidence of pericarditis.
  

• Joint radiograph:
  
  • Joint effusion
    
  • Juxta-articular erosions and decalcification
    
  • Narrowing of joint space
    
  • Loss of cartilage
    
• MRI of joints can detect early inflammation before plain radiograph
  
• CXR reveal pulmonary fibrosis, pleural changes, nodular lung disease, or pneumonitis:
  
  • Cardiac silhouette may show changes related to myocarditis.
    
• Cervical spine radiograph:
  
  • Atlantoaxial joint subluxation may occur.
    

• Osteoarthritis
  
• Septic arthritis
  
• Reactive arthritis
  
• Gonococcal arthritis
  
• Lyme disease
  
• Gout
  
• Connective tissue disorders
  
• Systemic lupus erythematosus (SLE), dermatomyositis, polymyositis, vasculitis, Reiter syndrome, and sarcoid
  
• Rheumatic fever
  
• Malignancy
  

TREATMENT

Cervical spine immobilization and airway support as indicated

• ABCs:
  
  • Manage airway with attention to C-spine immobilization during intubation.
    
• Treat complications of RA as appropriate.
  

• Salicylates or NSAIDs are 1st-line treatment for RA:
  
  • If 1 NSAID fails, another NSAID from a different chemical class may work better.
    
• Early treatment of RA is important as joint changes may be most progressive during the 1st 18 mo.
  

• Glucocorticoids, methotrexate, and other 2nd-line therapies should be initiated by a rheumatologist.
  
• Aspirin (ECASA): Adult: 900 mg PO QID (2.6–5.4 g/d); peds: 60–90 mg/kg/d QID up to 3.6 g
  

Note: Enteric coated aspirin has delayed absorption and its analgesic effects will be delayed compared to regular aspirin. Doses of aspirin needed for anti-inflammatory effect approach toxic doses. Patients should be closely monitored and dose carefully titrated to avoid toxicity.

• Auranofin: 3–9 mg/d (peds: 0.15 mg/kg/d up to 9 mg) divided BID
  
• Celecoxib (Celebrex): 100–200 mg PO BID; peds: N/A
  
• Hydroxychloroquine: Adult: 200–600 mg/d divided BID
  
• Ibuprofen (Ibuprin, Advil, Motrin): 200–800 mg (peds: 10 mg/kg) PO q6h
  
• Leflunomide: 100 mg PO daily for 3 d, then maintenance dose of 10–20 mg PO daily; peds: N/A
  
• Methotrexate: 7.5 mg once/wk
  
• Prednisone: Maintenance: 5–10 mg PO daily; acute exacerbations: 20–50 mg PO daily; peds: Maintenance: 0.1 mg/kg/d PO, acute exacerbations: 2–5 mg/kg/d PO
  
• Sulfasalazine: Adult: 500–1,000 mg PO BID; peds: 30–60 mg/kg/d BID. up to 2 g
  
  • Not recommended in children <6 yr
    
• NSAIDs and Tramadol for breakthrough pain.
  
• Newer DMARDs and monoclonals need to be dosed by a rheumatologist and should likely not be prescribed in the ED: Abatacept, Adalimumab, Anakinra, Etanercept, Infliximab, Rituximab, Tocilizumab.
  

FOLLOW-UP

• Patients with severe or life-threatening presentations of RA and its complications should be admitted to hospital.
  
• Admission is warranted when diagnosis is unclear and serious illnesses such as septic joint or systemic vasculitis may be present or cannot be ruled out.
  
• Admission may be required for pain control.
  
• Admission may be required if patient has inadequate social support and is unable to maintain activities of daily living.
  
• Pediatric patients with fever and arthritis should be strongly considered for admission.
  

Patients without serious complications may be managed as outpatients with appropriate medications and follow-up.

All patients should have primary physician for further therapy and care as well as appropriate specialty care referral such as rheumatologists, cardiologists, and orthopedics.

• Recognize that symmetric arthritis is more consistent with RA.
  
• Even patients with RA can get septic arthritis.
  
• Consult rheumatologist rather than initiate steroids or TNF antagonists from ED.
  

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• Smedslund G, Byfuglien MG, Olsen SU, et al. Effectiveness and safety of dietary interventions for rheumatoid arthritis: A systematic review of randomized controlled trials.
  J Am Diet Assoc.
  2010;110(5):727–735.
  
• Smith JB, Haynes MK. Rheumatoid arthritis: A molecular understanding.
  Ann Intern Med.
  2002;136(12):908–922.
  
• The American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update.
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  2002;46:328–346.
  

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