Clinical Case Database / Category: Patient Management

Polyarticular joint flare in an immunosuppressed patient with rheumatoid arthritis

Publication details

Dr Kirstin Laverick, Dr Lucy Grant, Dr Uma Karjigi, Dr Christina Page
Foundation Years Journal, volume 9, issue 10, p.55 (123Doc Education, London, November 2015)

Abstract

We describe the case of a 53 year old caucasian woman with longstanding rheumatoid arthritis, on immunosuppressive therapies presenting with polyarthritis and sepsis. Differential diagnoses including a rheumatoid flare secondary to sepsis and polyarticular septic arthritis needed to be considered. The diagnosis was initially clouded by respiratory symptoms and signs indicating a concurrent chest infection. The case was complicated by transfer out-of-hours between hospitals whilst the patient was acutely unwell. We learn that a Staphylococcus aureus joint infection is the most common in those with underlying rheumatoid arthritis and that the treatment is based on the supportive measures dictated by the 'sepsis six', especially intravenous flucloxacillin immediately after joint aspiration. Additionally, attention needs to be paid to increasing steroid doses and the cessation of methotrexate and biological therapy whilst unwell with an infection.
This case highlighted the importance of keeping a differential list in mind, challenging the diagnosis if something does not fit and the importance of communication between multidisciplinary teams, as well as other hospitals, when transferring a patient. The most crucial learning point is the importance of early joint aspiration prior to intravenous antibiotics, to help prevent joint destruction and the morbidity and mortality associated with sepsis.

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Authors

Dr Kirstin Laverick

Consultant Rheumatologist
Queen Elizabeth Hospital
Gateshead
NE9 6SX
kirstin.laverick@nhs.net

Dr Lucy Grant

FY1
Queen Elizabeth Hospital
Gateshead
NE9 6SX
lucy.grant@ghnt.nhs.uk

Dr Uma Karjigi

Rheumatology Specialty Trainee 7
Queen Elizabeth Hospital
Gateshead
NE9 6SX
u.karjigi@nhs.net

Dr Christina Page (Corresponding author)

CT1
Queen Elizabeth Hospital
Gateshead
NE9 6SX
christina.page@doctors.org.uk

References

1. Shirtliff, M.E. & Mader, J. T. Acute Septic Arthritis. Clinical Microbiology Review. October 2002. 15(4):527-44.
2. Coakley G, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology. August 2006 45 (8): 1039-1041
3. Ding T, et al. BSR and BHPR rheumatoid arthritis guidelines on safety of anti-TNF therapies. BSR guidelines. Rheumatology (Oxford). 2010 Nov;49(11):2217-9.
4. Chakravarty K et al. BSR and BHPR guidelines for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists. Rheumatology (Oxford). 2008 Jun;47(6):924-5.
5. Malaviya AP et al. BSR and BHPR guidelines for the use of intravenous tocilizumab in the treatment of adult patients with rheumatoid arthritis. Rheumatology (Oxford). 2014 Jul;53(7):1344-6
6. Lohse, A. et al. Pneumococcal polyarticular septic arthritis in a patient with rheumatoid arthritis. Rev Rhum Engl Ed. 1999 Jun;66(6):344-6.
Acknowledgement to the patient who kindly consented for us to publish this article. We also acknowledge the support of Dr. Clive Kelly and the rest of the rheumatology department at Queen Elizabeth Hospital, Gateshead, in the production of this article.

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About the Clinical Cases Database

T​he Foundation Years Clinical Cases Database is​ a selection of 600 peer-reviewed clinical cases in the field of patient safety and clinical practice, specifically focused on the clinical information needs of junior doctors, based around the Foundation Year Curriculum programme (MMC). The cases have been chosen to align with the Foundation Year Curriculum.

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