Septic arthritis is rare (incidence roughly 7 per 100,000) but should always be considered in patients presenting with an acutely swollen joint. It can be life-threatening (case fatality rate 11%) and needs to be assessed and treated as an emergency.
History and examination
Patients with a short history of hot, swollen painful joint should be investigated to exclude septic arthritis
Uncommon cause of acute arthritis. Infective precipitant can be difficult to identify.
Common cause of acute monoarthritis. Like gout, it is episodic and can be severe. Generally affects the older population in joints with pre-existing osteoarthritis. Due to calcium pyrophosphate dihydrate (CPPD) crystals deposited in the joint, hence it is sometimes called CPPD disease or CPPD arthropathy
Bleeding into the joint is rare without a contributing cause such as haemophilia (or other genetic bleeding predisposition) or anticoagulation use.
New inflammatory arthritis
Rutherford AI, Subesinghe S, Bharucha T, Ibrahim F, Kleymann A, Galloway JB. A population study of the reported incidence of native joint septic arthritis in the United Kingdom between 1998 and 2013. Rheumatology (Oxford). 2016 Dec;55(12):2176-2180. doi: 10.1093/rheumatology/kew323. Epub 2016 Sep 16. PMID: 27638811.
Carter JD. Treating reactive arthritis: insights for the clinician. Ther Adv Musculoskelet Dis. 2010;2(1):45-54. doi:10.1177/1759720X09357508
Macmullan P, McCarthy G. Treatment and management of pseudogout: insights for the clinician. Ther Adv Musculoskelet Dis. 2012;4(2):121-131. doi:10.1177/1759720X11432559
Early introduction of DMARDs in rheumatoid arthritis prevents joint damage and improves long-term outcomes. As such, NICE states that all adults with persistent synovitis of undetermined cause should be referred urgently if any of the following apply:
The small joints of the hands or feet are affected
More the one joint is affected
There has been a delay of ≥3 months between symptom onset and seeking medical advice
Referral pathways vary nationally but often Rheumatology departments will have an Early Arthritis Clinic service to see patients fulfilling these criteria urgently.
FBC, U&Es, LFTs (this is not only helpful in diagnosis and ruling out other causes, but is also useful to have when starting new medication in clinic)
Inflammatory markers – CRP and ESR
Autoantibodies – rheumatoid factor and anti CCP antibody (ACPA)
Others – consider urate if gout is possible
Imaging – often not needed in primary care and should not delay referral - patients with suspected inflammatory arthritis will get XRs of hands and feet as a baseline investigation and most will get a musculoskeletal ultrasound
Treatment (while awaiting rheumatology review)
Rest and ice
NSAIDs if not contraindicated (e.g. naproxen 250-500mg BD with PPI cover)
Discuss with local rheumatologist if this is not sufficient while waiting for review. Corticosteroids can be helpful but it is often better for rheumatology to assess the patient first
NICE (2018a) Rheumatoid arthritis in adults: management. National Institute for Health and Care Excellence. http://nice.org.uk [https://www.nice.org.uk/guidance/ng100]
GCA should be considered in older patients (>50 years, peak incidence 70-79 years) with a new headache and (in most cases) scalp tenderness. Ischaemic sequelae including visual loss can occur rapidly but can be prevented with prompt treatment so a high index of suspicion is important. If suspected it may be appropriate to start treatment with corticosteroids before assessment in secondary care, particularly out-of-hours, but it is important to check bloods including inflammatory markers first.
Liaise with rheumatology as soon as possible. Temporal artery ultrasound can avoid the need for biopsy but becomes less sensitive with steroid treatment.
Referral pathways vary nationally but BSR guidelines suggest patients ideally should be assessed by rheumatology next working day. Many local services have ‘fast-track’ pathways in place.
If there are visual symptoms (transient or permanent visual loss or diplopia) patients should be reviewed urgently by ophthalmology before rheumatology.
History and examination
GCA is vanishingly rare under 50 years of age. Consider alternative diagnoses in this group.
Ongoing management after diagnosis
British Society for Rheumatology guideline on diagnosis and treatment of Giant cell arteritis
Oxford Desk Reference Rheumatology
Gout is the commonest inflammatory arthritis, with a prevalence in the UK of 2.49% in 2012. Although the gold standard for diagnosis remains joint aspiration and identification of monosodium urate crystals, this is often not needed when the clinical picture is clear.
History and examination
Allopurinol starting dosage
50mg twice weekly
50mg every two days
50mg/100mg alternate days
There is still widespread belief that gout only affects older, overweight men and that it is a self-inflicted disease. Although lifestyle factors can impact on the risk of developing gout and having attacks, these beliefs can prevent patients seeking help early. The course of the disease should be explained to the patient, including the likelihood of flares during initiation of ULT
Gout in renal failure
When to refer to rheumatology
Stamp LK, Chapman PT, Barclay ML, et al. A randomised controlled trial of the efficacy and safety of allopurinol dose escalation to achieve target serum urate in people with gout. Annals of the Rheumatic Diseases 2017;76:1522-1528. Accessed at http://dx.doi.org/10.1136/annrheumdis-2016-210872 on 7/6/21.
Michelle Hui, Alison Carr, Stewart Cameron, Graham Davenport, Michael Doherty, Harry Forrester, Wendy Jenkins, Kelsey M. Jordan, Christian D. Mallen, Thomas M. McDonald, George Nuki, Anthony Pywell, Weiya Zhang, Edward Roddy, for the British Society for Rheumatology Standards, Audit and Guidelines Working Group, The British Society for Rheumatology Guideline for the Management of Gout, Rheumatology, Volume 56, Issue 7, July 2017, Pages e1–e20, https://doi.org/10.1093/rheumatology/kex156
Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Annals of the Rheumatic Diseases 2017;76:29-42.
American College of Rheumatology Guidelines May 2020: https://www.rheumatology.org/Portals/0/Files/Gout-Guideline-Early-View-2020.pdf
Quick tip; Provide education to patients about long-term steroid therapy such as ‘sick days’ and the need to adhere to strict compliance to therapy
History and examination
The following should be ruled out in the presence of raised inflammatory markers and malaise:
Common alternative diagnoses are:
Patients with a typical history and prompt (1 week) and sustained response to initiating corticosteroids can be managed in primary care. Consider referral to secondary care if the following atypical clinical features are present:
GCA should always be managed in secondary care so refer these patients urgently (see separate section)
Similarly consider referral if the following are present with treatment.
DMARDs such as methotrexate have been used in PMR as steroid sparing agents
Relapses (not just unexplained rises in CRP/ ESR)
Bhaskar Dasgupta, Frances A. Borg, Nada Hassan, Kevin Barraclough, Brian Bourke, Joan Fulcher, Jane Hollywood, Andrew Hutchings, Valerie Kyle, Jennifer Nott, Michael Power, Ash Samanta, on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guidelines for the management of polymyalgia rheumatica, Rheumatology, Volume 49, Issue 1, January 2010, Pages 186–190, https://doi.org/10.1093/rheumatology/kep303a
Rheumatology Secrets, chapter 20, Idiopathic Inflammatory Myopathies. Sterling G.West