Rheumatologic Disease in the Intensive Care Unit

Chapter 58 Rheumatologic Disease in the Intensive Care Unit



Lynda S. Tilluckdharry, MB, BCh, BAO, LRCP&SI , Christine Haas Jones, MD




1 A critically ill patient is seen with an acute hot, swollen joint. What is the next step in management? What are the most common organisms found in a septic joint?


Aspiration of the joint should be performed immediately to rule out a septic joint, crystalline disease, or other inflammatory forms of arthritis. The synovial fluid should be sent for cell count and differential, Gram stain, culture, and crystalline analysis. High fevers and elevated inflammatory markers: erythrocyte sedimentation rate (ESR), C-reactive protein, and white cell counts, may be found in both infection and crystalline arthropathy. It is important to remember that septic arthritis and crystal-induced arthropathy can occur concurrently in a joint.


In all age and risk groups, the most common causative organisms of septic arthritis are Staphylococcus aureus and Streptococci strains. In nursing home patients, intravenous abusers, elderly people, and patients with recent orthopedic procedures, consider methicillin-resistant S. aureus. These populations are also susceptible to mixed bacterial infections, gram-negative organisms, fungal infections, and unusual organisms. In young adults, consider Neisseria gonorrhoeae as a cause of septic arthritis. Treatment includes prompt removal of purulent material from the joint space and initiation of appropriate intravenous antibiotics targeting suspected organisms. Serial arthrocentesis or open surgical drainage may be necessary.



2 List the risk factors for the development of septic arthritis




image Diabetes


image Alcoholism


image Joint prosthesis


image Intravenous drug abuse


image Skin infections or cutaneous ulcers


image Recent joint surgery or intraarticular corticosteroid injection


image Age: elderly or young


image Previous joint pathologic condition, for example, rheumatoid arthritis (RA), osteoarthritis, or crystal-induced arthropathy



3 Name the common risk factors for gout




image Surgery


image Dehydration


image Drugs such as diuretics


image High purine intake in diet


image Trauma


image Infections


image Renal insufficiency


image Excess alcohol intake



4 How do you interpret synovial fluid analysis?


See Table 58-1.



Table 58-1 Synovial fluid analysis

image


5 What specific precautions should be taken when performing intubation in a patient with RA?


Cervical spine disorders occur in 30% to 50% of patients with RA. The most common presentation of cervical spine arthritis is C1-C2 subluxation or atlantoaxial subluxation (AAS). Vertical and subaxial subluxation occurs less commonly. It is prudent for providers to use caution when performing any manipulations of the cervical spine, particularly endotracheal intubation in patients with RA. Spinal cord compression due to C1 and C2 instability may lead to neurologic deficits or death. Lateral and flexion cervical spine radiographs or magnetic resonance imaging should be obtained before intubation in the following situations:



image RA duration >3 years


image Long-term use of corticosteroid


image Severe peripheral joint deformities from RA


image Male sex


image Neck pain


image Risk factors for osteoporosis


image Prior cervical spine subluxation


image Clinical evidence of cervical myelopathy


If clinical or radiographic evidence of subluxation exists and intubation is required, an anesthesiologist should be present during the procedure. In patients with AAS, subluxation is worsened with cervical flexion and reduced by cervical extension. Cricoarytenoid arthritis may also complicate endotracheal intubation. These patients may present with symptoms of tracheal pain, stridor, dysphonia, and shortness of breath (see Fig. 58-1).


image

Figure 58-1 Rheumatoid arthritis of the cervical spine.


(From Firestein GS, Budd RC, Harris ED, et al: Kelley’s Textbook of Rheumatology, 8th ed, vol 1. Philadelphia, Saunders, 2008, p 810.)



6 What is scleroderma renal crisis (SRC)? When should this diagnosis be considered, and how is it confirmed?


SRC will occur in 15% of patients with systemic sclerosis (SSc). SRC is a medical emergency and presents with an abrupt onset of hypertension (>150/85 mm Hg) and acute renal failure (>30% reduction of glomerular filtration rate). SRC can precede the diagnosis of SSc, and patients can initially be seen with normal blood pressures.



image Clinical symptoms include headaches, visual disturbances from hypertensive retinopathy, seizures, encephalopathy, fever, general malaise, pulmonary edema. Less commonly, patients may have arrhythmias, myocarditis, and pericarditis.


image Laboratory tests typically show an elevated creatinine level, microangiopathic hemolytic anemia, and thrombocytopenia. Urinalysis may show mild proteinuria, hematuria, and granular casts.



7 Who is at risk for SRC, and what are risk factors indicating poor prognosis? What treatment should be initiated in SRC?


The major risk factors for the development of SRC are early diffuse cutaneous systemic sclerosis, positive antinuclear antibody (ANA) with a diffuse speckled pattern, rapidly progressive skin disease, and recent corticosteroid use. Patients with positive anti-fibrillarin, anti-U1RNP, and RNA polymerase I and II antibodies are at a higher risk for SRC.


Poor prognosis for recovery from SRC is associated with the following:



image Male sex


image Age > 50 years


image Persistent renal failure


image Initial presentation with normal blood pressure


Treatment should include early therapy with angiotensin-converting enzyme inhibitors (ACEi) such as captopril and lisinopril. To avoid hypoperfusion, ensure gradual decrease in blood pressure with other antihypertensives such as calcium channel blockers, nitrates, and β-blockers. Transient mild increases in creatinine level are common and are not an indication to stop the ACEi. Many patients will require supportive care with dialysis, and kidney function may take up to 3 years to improve. Plasma exchange can be considered in patients with microscopic angiopathy.



8 What conditions can be associated with a positive ANA test in a critical care patient?




image Systemic lupus erythematosus (SLE) or drug-induced lupus


image Mixed connective tissue disease


image Autoimmune liver disease


image Systemic sclerosis


image Sjögren syndrome


image RA


image Polymyositis (PM)


image Malignancy


image Thyroid disease


image Miscellaneous: normal population (5%-10%), elderly (20%), medications



9 How do you interpret a positive ANA test? What additional investigations should be ordered if there is a positive ANA test?


In isolation, a positive ANA test should not be used to make a specific diagnosis, and a negative ANA does not exclude an autoimmune condition. In most laboratories an ANA titer of >1:40 is considered positive, and clinically significant titers are usually >1:160.


Additional investigations that should be obtained include double-stranded DNA (dsDNA), SS-A (Ro) and SS-B (La) antibodies, Smith antigen (Sm), ribonuclear protein (RNP), centromere antibody, urinalysis, complement levels (C3 and C4), and a complete blood cell count with differential, which may show leucopenia and lymphopenia.



10 What clinical findings in a patient whose condition is deteriorating would prompt the consideration of SLE?




image Unexplained fevers


image Unexplained neurologic symptoms such as altered mental status, seizures, psychosis (lupus cerebritis)


image Renal abnormalities with proteinuria and cellular casts (lupus nephritis)


image Hematologic disorders such as hemolytic anemia


image Serositis such as pericardial effusion and pleural effusion


image Multiorgan failure


MD SOAP’N HAIR: Malar rash, Discoid rash, Serositis, Oral ulcer, Arthritis, Photosensitivity, Neurologic abnormality, Hematologic abnormality, ANA (positive), Immunologic abnormality, Renal involvement.



11 Describe antiphospholipid syndrome (APS)


APS is an acquired cause of hypercoagulability. Fifty percent of patients with APS have SLE. Recurrent venous and arterial thromboses and embolism are the hallmark of this syndrome. See Table 58-2.


Table 58-2 Clinical features and investigations of antiphospholipid syndrome








Clinical features Investigations


Hematologic: recurrent venous or arterial thromboses, thrombocytopenia, hemolytic anemia, renal thrombotic microangiopathy


Neurologic: stroke, transient ischemic attacks, seizures, transverse myelitis, migraines, chorea, multiinfarct dementia


Cutaneous: livedo reticularis, distal gangrene, thrombophlebitis


Pulmonary: embolism, intraalveolar hemorrhage, hypertension


Cardiac: valvular disease (vegetations), myocardial infarction


Musculoskeletal: osteonecrosis


Obstetric: recurrent miscarriages, placental insufficiency, preeclampsia, or severe eclampsia

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Rheumatologic Disease in the Intensive Care Unit

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