Case Presentation by Dr. Heather Bowman

CC: “My legs and knees are swelling”

HPI: CG is a 93-year-old female with history of arthritis who comes to the to the emergency department stating that she is having leg and knee swelling.  She’s been unable to walk since last night.  She is unable to describe the quality or severity of the pain but she says “they’re killing her really bad”.  She says she’s had this before and they had put a needle in her knee last time.  Nothing makes the pain and swelling better or worse.  No trauma, fever or nausea or vomiting.

ROS: Negative except as per HPI

PMH:Patient is a poor historian and is only able to say she has had Shingles, review of EMR shows patient has arthritis and A. fib., CAD status post stent, hypertension, CHF, stroke, diverticulitis and breast cancer

PSH:Patient denies, per EMR had coronary catheter and stent placement 2007

MEDICATIONS: Patient is unsure.  Per EMS has pantoprazole, Klor-Con, acetaminophen, aspirin furosemide, & ranitidine

ALLERGIES:Penicillin

SOCIAL HISTORY: Patient lives in a senior citizen home.  Reports has lots of support from her neighbors and her granddaughter

Physical Exam:

Vitals: Blood pressure was 155/86, pulse 90, respirations 16, febrile 38.2, satting 100% on room air

General: No Acute Distress, lying comfortably on stretcher

HEENT: PERRL, EOMI, very hard of hearing, mucous membranes dry

Cardiovascular: +S1, S2, no murmers, Radial and DP pulses symmetric

Respiratory: Clear to auscultation bilaterally

Gastrointestinal:  NT/ND

Musculoskeletal: Strength 4/5 in upper extremities and right leg, strength 4/5 left leg limited due to pain, effusion over both knees left greater than right, right knee has good range of motion, not warm or indurated. Left knee is warm not indurated, left knee range of motion limited at 45° due to pain

Skin: Intact

Neurologic:  patient can’t ambulate due to pain.

Labs/Radiograph

Electrolytes: Na=140, K=3.8, Cl=103, HCO3=27, BUN=20, Createnine=0.9, Glucose=101, Ca=9.3, Mg=2.1

CBC: WBC=8.5, Hgb=10.4, Platelets=182

Others: CRP=75.30, ESR=53

UA: 2-5 squamous cells, Specific gravity=1.015, blood=2+, protein=1+, Nitraes: positive, Leukocyte esterase 2+, RBC=5-10, WBC=20-50, bacteria=4+, trichomonas=neg

Cell count and differential, gram stain and bacterial culture, and the answer to question#3: pending

Complete R knee:

1.  Generalized osteopenia without identification of an acutely displaced fracture.

2.  Development of a moderate joint effusion.

3.  Severe osteoarthritis of the right knee

Complete L knee:

1.  Generalized osteopenia without identification of an acutely displaced fracture.

2.  Moderate to large joint effusion and soft tissue swelling.

3.  Advanced osteoarthritis of the left knee with findings suggesting loose intraarticular bodies.

Questions:

1. Which of the following is an absolute contraindication to arthrocentesis?

A. Infection of soft tissues over joint

B. Prosthetic joints

C. Confirmed Bacteremia

D. Hereditary bleeding diatheses

E. Patient on oral anticoagulants

2. Which is the correct pairing of organism and at risk population for septic arthritis?

A. N. Gonorrhoeae is the most common cause of septic arthritis for teens and patients >65yo.

B. Staph, strep, H. Influenzae, and E. coli are the most common cause of septic arthritis for kids

C. Salmonella is the most common cause of septic arthritis in patients with sickle cell

D. Staph aureus, Strep epidermidis, enterobacteriaceae and pseudomonus are most common causes in patient with a prosthetic joint

E. Gonococcal septic arthritis is more common in young males

3.  Besides cell count with differential, gram stain and bacterial culture and sensitivity, which other test is high yield for working up most joint effusions?  

A. Uric acid

B. Synovial protein

C. Crystal analysis

D.Synovial glucose

E. Lactate dehydrogenase

F. Rheumatoid factor

Answers:

1)    A

2)    D

3)    C

Discussion

1. Which of the following is an absolute contraindication to arthrocentesis?

A. Infection of soft tissues over joint-YES, arthrocentesis is absolutely contraindicated if infection of soft tissues over the joint is present.  However, remember joint may be warm, swollen and tender with acute arthritis and it is appropriate to perform arthrocentesis once you have eliminated cellulitis as the cause of this finding.

 B. Prosthetic joints-NO, while prosthetic joints are high risk for infection and you should avoid arthrocentesis if possible, if you suspect an infected prosthesis, you should perform an arthrocentesis.

C. Confirmed Bacteremia-NO, confirmed bacteremia is considered a relative contraindication because infection can spread to the joint, but it is not an absolute contraindication.

D. Hereditary bleeding diatheses -NO, hereditary bleeding tendency is also a relative contraindication.  However it is acceptable to do arthrocentesis to relieve a tense hemarthrosis in bleeding disorder such as hemophilia after infuse appropriate clotting factors

E. Patient on oral anticoagulants-NO, There is little data regarding arthrocentesis of patients on oral anticoagulants, however studies have demonstrated risk iatrogenic hemarthrosis is quite low, even with INR as high as 4.5.  Therefore when necessary is appropriate to perform arthrocentesis in patient on oral anticoagulants.

2. Which is the correct pairing of organism and at risk population for septic arthritis?

A. N. Gonorrhoeae is the most common cause of septic arthritis for teens and patients >65yo.  NO, While N. Gonorrhoeae is the most common cause of septic arthritis for teens and young adults, staphylococcus is more likely once a patient is >40yo.

B. Staph, strep, H. Influenzae, and E. coli are the most common cause of septic arthritis for kids.  NO, Staph, strep and E. coli are true but the incidence of H. flu has decreased to almost zero since the vaccine was developed.

C. Salmonella is the most common cause of septic arthritis in patients with sickle cell-NO, while salmonella is more prevalent in patients with sickle cell compared to the general population, the more common causes still predominate.

D. Staph aureus, Strep epidermidis, enterobacteriaceae and pseudomonus are most common causes in patient with a prosthetic joint-YES, true

E. Gonococcal septic arthritis is more common in young males-NO, while gonorrhea is more common in males, disseminated gonococcal infection is actually more common in women (4:1 prevalence), especially during pregnancy or after menstruation when the alkaline vaginal environment makes the organisms more resistant to the host defenses in the bloodstream and therefore more likely to disseminated and because infected women more likely to be asymptomatic.

3. Besides cell count with differential, gram stain & bacterial culture and sensitivity, which other test is high yield for working up most joint effusions?  

A. Uric acid-NO, Uric acid is not helpful for diagnosing acute gouty arthritis because it actually can normalize during acute phase

B. Synovial protein-NO, Synovial protein is unreliable in distinguishing inflammatory and infectious from noninfectious and therefore is no longer recommended.  Synovial protein had a sensitivity of 0.52 in one study, and ordering it is discouraged because it is likely to provide misleading or redundant information.

C. Crystal analysis-YES, Of the answers listed, crystal analysis is the best.  Remember to use a green top (liquid sodium heparin) to prevent clotting.  Calcium oxalate and lithium heparin anticoagulatns can introduce artificial crystals into the fluid.  Under a polarizing microscope, calcium pyrophosphate (gout) is a positively birefringent crystal (long axis is blue when parallel to the Z-axis and yellow when perpendicular to it).  Calcium pyrophosphate crystals are smaller than 10 micrometers and can be rods, rhomboids, plates or needle like.  Monosodium urate (pseudogout) is a negatively birefringent crystal (long axis is yellow when parallel to Z-axis and blue when perpendicular).  Urate crystals are needle shaped, and between 2-10 micrometers.   You can also see cholesterol crystals which are large, very bright, square or rectangular with broken corners.  As always, use the entire clinical picture and your clinical judgment when ruling out septic arthritis.  Patients with underlying joint disease are more likely to develop a septic arthritis and finding crystals does not eliminate an infectious cause.

D.Synovial glucose, -NO, Glucose is unreliable in distinguishing inflammatory and infectious from noninfectious and therefore is no longer recommended.  Glucose had a sensitivity of 0.2 in one study, and ordering it is discouraged because it is likely to provide misleading or redundant information.

E. Lactate dehydrogenase-NO, Lactate dehydrogenase is also unreliable in distinguishing inflammatory and infectious from noninfectious and therefore is no longer recommended

F. Rheumatoid factor-NO, Rheumatoid factor is less frequently obtained than crystal analysis and has little diagnostic value in the ED, though it can be useful to the clinician providing follow up care.

Clinical Course and analysis:

We elected to drain the left knee since it had a larger fluid collection, was warm, and was limiting her range of motion.  Approximately 40ccs of fluid were aspirated from GC’s left knee.  Her fluid gram stain showed numerous PMNs but no organisms.  Elevation of PMNs is consistent with an inflammatory or septic arthritis.  Culture was negative x 4 days.  Gram stain or culture of an organism would confirm septic arthritis but lack of an organism does not rule out septic arthritis as organism is not always cultured.  Cell count with differential and fluid crystals were ordered, but never done.  ID saw the patient and thought she had an inflammatory arthritis and recommended continuation of ceftriaxone for UTI with discontinuation of vanco.  The primary team continued ceftriaxone and vanco and their discharge diagnosis was septic arthritis.

WBC, ESR and CRP are sensitive but non-specific screening tests.  ESR is elevated in 90% of septic arthritis and along with CRP can be used to track response to infection, although the admitting team did not re-order these tests.  WBC greater than 10,000 can suggest a systemic illness but is only elevated in 50% of septic arthritis cases and sterile inflammatory processes create a similar leukocytosis.  Her WBC was not elevated throughout her hospital stay.  Cultures from infectious foci can often demonstrate the bacteria responsible for septic arthritis.  Her urine culture did show >100,000 CFU of E. coli and if she did have septic arthritis this is a likely source.

References:

Marx, J. A., R. S. Hockberger, et al. (2010). Rosen’s emergency medicine: concepts and clinical practice, Mosby/Elsevier.

Roberts, J. R. and J. R. Hedges (2009). Clinical Procedures in Emergency Medicine E-Book, Elsevier Health Sciences

This morning was an extremely difficult time, but I was closer to getting things more under control and was finally receiving the right care.

They woke me at 8.00am to take me down for an MRI (Magnetic Resonance Imaging) scan of my hips and spine; unfortunately, the porter collected me before the pain medications were dispensed and by the time we got down to Radiography, I was distressed and shouting out with the excruciating pain once again, especially after being ‘patslided’ numerous times (this is undoubtedly a useful way of manouvering immobile patients, but does not protect you from the pain of such movement). They had to call up to the ward to bring some relief down, since I needed to be still for the 40 minute scan and at this point it wasn’t looking likely. Even the Morphine didn’t really settle things down; I was realising that by the time it got to such extremes, it took repeated doses to get back on top of it. They asked me if I wanted to postpone the scan but I felt that it was needed to get to the bottom of what was causing the pain. The sooner we found that out, the sooner we could treat it properly.

So I told them I wanted to go ahead, grit my teeth and attempted to take my mind elsewhere.

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The MRI Scanner

I’ve had many MRI scans in the past and usually find them quite relaxing, despite the noise. They lie (sometimes strap) you on a stretcher that moves into a tunnel, where the scan takes place. In the above picture it looks like the patient has gone in headfirst, but in my experience my head has been at the entrance – much less claustrophobic. Usually, they give you headphones (often with music), both to protect your ears from the noise and to communicate with you from outside of the room; they also place a buzzer in your hand, which you can press at any time you feel distressed or want to stop. The scan is not painful. It basically consists of rotating magnetic signals being blasted at your body as you lie very still - you cannot feel these but they are expressed as noise patterns that change with different frequencies etc. So for five minutes it might sound like you’re surrounded by knocking, the next five by drilling, the next five by clicking, tapping, zapping and so on… A lady I met even described one of the noises as reminding her of frogs croaking first thing on a wet morning in Borneo!

I tend to just shut my eyes and relax, as if going to sleep; but this particular scan wasn’t that easy though. It was torture just making myself lie still, as my body kept trying to tense up to protect itself from the pain; I had to consciously relax every muscle and breathe. I think I cried through a good ten minutes or so of it but knew that wasn’t helping, despite it being an automatic response. The pain was still severe but eventually I managed to distance myself from it; I can’t exactly explain how – I’ve read a few books on meditative practices, so maybe they came in handy? I knew that each change in the sound pattern meant a certain amount of time passing and soon enough it went silent and a voice in my ear was telling me it was finished. To say I felt relieved would be an understatement!

Obviously, it takes time for someone to analyse the MRI scan pictures and give a full report, but sometimes things are apparent straight away. For me, they noticed that I had a lot of fluid surrounding my left femoral head (ie. Left Hip joint) and a smaller amount around the Right. I was taken straight to another part of the department to have this removed by aspiration and ultrasound. By that point, I was allowed further pain relief and this dose worked enough for me to feel a lot calmer. It’s embarrassing to look back on now, but I caused quite a scene that morning howling like a banshee and such. Thank goodness the worst was now over.

-

I was quite nervous about the hip aspiration. I’d had it done as a child but they put you under with gas at that age; this time it would be an injection of local anaesthetic. The team of people with me were lovely and great at making me feel at ease; the Radiographer in particular had a very calming effect and I felt in very safe hands.  He used the ultrasound scanner to examine my left hip first and to pinpoint just where the fluid had accumulated around it. This is similar to the scanners you see unborn babies with – a cold gel is placed on the surface of the skin and onto a ‘probe’, which the radiographer slides over the area in question, sending ultrasonic waves through the skin. These waves bounce off things inside at different levels (according to density I think), to create the pictures you see on the screen – the main thing I learnt is that fluid bounces back as black, so when he was looking for the fluid around my hip joint, it appeared as a large black shadow around/within the hip, which appears a greyish-white as that is denser.

Once he found the fluid, he needed to find a straight path to it from the skin surface without passing through any major blood vessels – there is actuallly a lot more time spent preparing the procedure than the procedure itself. Happy that he’d found a route, the radiographer then slowly began to administer the local anaesthetic by long needle; he did this in stages to ensure that I was as numb as possible, but as he came closer to the joint itself, he began to warn me that I’d feel quite a bit of pain but it would be shortlived. The pain didn’t come. He kept asking me “are you sure you can’t feel anything?”, while jabbing the needle further in, and I kept shaking my head. It was a bit like the movie ‘Death Becomes Her’ where the doctor can’t understand how her very broken wrist isn’t troubling her!

I asked him if this was something to worry about and he pulled that confused, thinking look that doctors do sometimes, as he explained that most patients find it at least uncomfortable to have a needle in the joint capsule. He said if I really wasn’t feeling anything, then he’d be concerned that I had some nerve damage to the hip itself and that this should be investigated too. For now though, we concentrated on the aspiration. With the needle in place, he was able to aspirate 5ml of fluid from the hip capsule; this didn’t look an awful lot to me – one small syringe, whereas my knees used to drain 2-3 much larger syringe-fulls as a child – but apparently it is a lot, as there is very little ‘spare room’ within hip joints. I was told that this explained the level of pain I was in and the lack of response to pain relief. He told me that they could have given me all the pain relief in the world, but as long as that fluid was stretching the joint out of place as it was, I’d have had excruciating pain. Hopefully, with it now gone, things would settle to a more bearable level.

I was confident that they would; in fact, I was pretty sure that I noticed an improvement as soon as the fluid was gone. I was by no means cured – the fluid needed to be sent for testing to rule out septic arthritis and we needed to find out if anything other than the Still’s Disease was causing the hip to produce so much fluid / get the full report on the MRI scan etc…  I have had very fluidy joints in the past, but I can’t remember where it fits in with things. Since this has become a major issue this past week, I will look into it myself at some point. After the hip aspiration, I was also given an abdominal ultrasound; something I was due to have that day anyway. It showed that my liver and spleen were enlarged, but since this is common with my flares, it didn’t cause him too much concern.

The rest of the day blurs in with the rest; I was to remain slightly propped up on my back in bed to take the pressure off my hips until the full MRI report was back, but with no turning timetable; instead I had to be checked for pressure sores and, when developing the starts of them on my heels, had to rest them on an inflatable. The auxillaries had to do everything for me – wash me, dress me, toilet me, help feed me… but when you feel so poorly those things don’t bother you, you’re grateful for the help and they were brilliant at providing it. I slept a lot but my Kindle came in handy as I managed to hold it above me to read for short periods but then my friend downloaded some audiobooks onto my blackberry, which was even more perfect! People were always popping into my room to see if I was okay and I had plenty of visitors, so strangely, I never felt bored!

It was decided that we would go ahead with my fifth Tocilizumab infusion that afternoon; the initial feeling on examining the fluid from my hip was that it was ‘viscous and stringy’, a good sign that there was no infection present. If it turned out there was, I’d be hooked up to IV antibiotics straight away anyway… it was one of those ‘risk-weighing’ decisions and I guess there was more risk in leaving the Still’s untreated by this point.  My infusion ward was only next door and my regular nurses took it in turns to pop round and check on the infusion and to see what ‘trouble’ I’d got myself into. They all have a way of making you feel that they care about you as an individual and they have a lot of patients going through their ward each week/month/year.  I guess this is an example of how good care can be in hospital too – from one extreme to the other.

My consultant visited that afternoon but I don’t remember much about the conversation now. All I know is that I was pleased he took the time to see me and it again reassured me that I was on the right track. One thing that we both agreed though, is that I’ve had some nasty flares and some severe joint involvement over the years; but this hip pain was totally out of proportion to anything I’d ever experienced and we needed to get to the bottom of it fast.

L