FKT Mono 2014
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Transcript of FKT Mono 2014
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Monoartrita AcutaDR. SIMON SIAO-PINCLINICA REUMATOLOGIE
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Artrita Acuta
Infamatie acuta (instaata !rusc" a unei articuatii #urere se$era% tume&ere si
roseata
Durata ' -) sa*tamani
Le+iuni structurae articuare *ersistenta infamatiei
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Semne #e Infamatie
Tume&ere
Ca#ura
Eritem,roseata
Sensi!iitate (#ureroasa"
unctiei articuare
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Puncte-c/eie
Dierentiem artrita #e sin#roamee (non"*eriarticuare
Dierentiem aectarea monorticuara #e cea *oi(oi0o"-articuara
Dierentiem o !oaa infamatorie #e una non-infamatorie
A$em in $e#ere intot#eauna artrita septica !
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Articuar $s Periarticuar
Trasatura clinica Articular Periarticular
Structura anatomica sino$ie% cartia1% ca*sua%(os"
ten#on% !ursa% i0amentmusc/i% (os"
Localizarea durerii #iu+a,*roun#a ocaa,*unctiorma
Durerea lamiscare/mobilizare
acti$a,*asi$a% in toate*anurie
acti$a,in cate$a *anuri
Tumeferea comuna rara
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Infamatorie $s Noninfamatorie
Caracteristica Inamatorie Noninamatorie
Durere (cand #a (AM" #a (PM"
Tumefere tesuturi moi osoasa
"ritem cateo#ata a!sent
Caldura *re+enta a!senta
#edoare matinala accentuata,#e #urata minora (2 34 5"
$enomene sistemice cateo#ata a!sente
% &S'/C#P rec$ent a!senta (rareori 6"
Leucocite in LS L 7 444 L 2 444
") se*tica% 0uta% PR% LES% etc. artro+a% osteonecro+a (Oetc.
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Monoartrita Acuta - Etioo0ie
Cea mai 0ra$a situatie #e uat in consi#erare8 IN$"CTIA !
Se*tica
Microcristaina (0uta% *seu#o0uta"
Ate8 /emartro+a% ON% traumatisme (ractura% #eran1ament intern" etc.
Oca+iona% bolile poliarticulare *ot a$ea un #e!ut monoarticuar
PR ($e+i cursu8 *oiartrita reumatoi#a"
S*A8 AR% AE% APs ($e+i cursu8 s*on#iartrite"
Artrita #in sarcoi#o+a% $irae etc.
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Anamne+a - intre!ari utie(*entru #ia0nosticu etioo0ic,#ierentia"
Durerea a a*arut !rusc% in minute 9 ractura
In #ecurs #e ore sau :- +ie 9 artrita se*tica,cristaina,infamatorie
Istoric8 a!u+ #ro0uri i.$.% inectie recentaartrita se*tica
Atacuri,e*isoa#e anterioare simiare (recurente"artrita cristaina
Cura *reun0ita corticosteroi+i inectie,ON etc.
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istoric ; eLG%
ractura
infamatie,re$arsat = re$ar
A#T#*C"NT"+A US% CT s
orto*e#ie
AL,*#IT- DIA,N*STIC
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Ce mai im*ortant #emers #ia0nostic in e$auarea initiaa a unei monoartrite acute8
ANALI+A LIC'ID.L.I SIN*&IAL !
:.in sus*iciunea #e inectie,artrita se*tica
.in sus*iciunea #e artrita microcristaina
3.*entru #ierentierea artro*atiei infamatorii #e cea non-infamatorie
).in sus*iciunea #e /ematro+a
@.sco* tera*eutic (e$acuare coectii mari,/ematro+a% instiare
corticosteroi+i,aneste+ice ocae"
Artrocente+a - In#icatii
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Te/nica
:. A!or# me#ia sau atera
. G in e
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Contrain#icatii
:. Ceuita (a ocu *unctiei"
. Sus*iciunea #e !acteriemie B CI reati$a (#acasus*icionam artrita se*tica acem artrocente+a "
3. Si0uranta artrocente+ei a *acientii cucoa0uo*atii,tratatment anticoa0uant B incerta
a*reciere #e a ca+ a ca+ a$em a in#emana8 *asma *roas*ata con0eata%
concentrate *ac/etare etc.
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Anai+a Lic/i#uui Sino$ia (LS"
Coloratie ,ram culturi
Inectii non0onococice - sensi!iitate @4-@ cooratie% @-F4 cuturi
Inectii 0onococice - sensi!iitate 2 :4 cooratie% :4-@4 cuturi
6 /emocuturi% secretie uretraa,rectaa,oroarin0iana
riscuui #e contaminare8 LS trimis a a!orator in serin0a #e artrocente+a
Numar total de leucocite/proportie P-N8 #ierentia+a LS infamator #e ce
noninfamator
?aoare *ra08 444 L,mm3% @ PMN (orientati$ "
-icroscopie in lumina polarizata8 i#enti&ca cristaee (MSU% CPPD"
Pre+enta cristaeor nu e
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Artrita Se*tica
Ma1oritatea inectiior B monoarticuare
:@-4 - *oiarticuare
Ce mai a#esea8 0enunc/i% so#% umar
Durerea articuara B mo#erata,se$era
O!iecti$ B tume&ere % ca#ura % roseata B a#eseori
Comor!i#itati8 DH% PR% LES% cancer etc.
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Artrita Se*tica:. inectii non0onococice
4-F4 monoarticuare
Ma1oritatea /emato0ene
Ce mai rec$ent
Aero!i Gram 6
Ma1oritatea Stap0 aureus
Gram B% :
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Artrita Se*tica. inectii 0onococice
Cea mai rec$enta cau+a #e artrita se*tica
Prece#ata a#esea #e 0onococemie sistemica,#iseminata
Scenariu8 in#i$i+i se
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S.SPICI.N" CLINICAA#T#ITA S"PTICA
artrocente+a,LS
nr. eucocite
cooratie Gram
cuturi
Procacitonina
cristae
!io*sie sino$iaa
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Guta B De&nitie
K Maniestari cinice /etero0ene
K De*unere tisuara a cristaeor #e urat monoso#ic (MSU"
K >i*eruricemie (su*rasaturare a ic/i#eor e
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Maniestari Cinice
*steoarticulare Artrita 1utoasa K atacuri infamatorii
recurente
Articuare
Periarticuare
Tof K acumuare tisuara #e cristae MSU
Articuara
Osoasa
In tesuturie moi
Cartia0inoasa
To& 6 artrita,artrite acute
Renae Neroitia+a urica K cacui #e aci#
uric in tractu urinar
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>i*eruricemia
Dere0area meta!oica ce re*re+inta su!stratu !oii
De&nitie8 ni$eu aci#uui uric DS $aoarea me#ie
.4 m0,# *entru !ar!ati
.4 m0,# *entru emei
"cretie renala defcitara a acidului uric B ma1oritatea ca+urior
>i*er*ro#uctie #e aci# uric B minoritate
'iperuricemia asimptomatica
N.re*re+inta o !oaa
Pre+enta a @ #in *o*uatie
Mai *utin #e : #in ) $or #e+$ota #e*o+ite tisuare #e urat
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actori #e Risc
Guta *rimara B asociata cu8 O!e+itate
>i*eri*emie
Dia!et +a/arat
>i*ertensiune arteriaa
Ateroscero+a
Guta secun#ara8
Acooism
Me#icamente (#iuretice% citoto
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Eta*e #e E$outie
>i*eruricemie asim*tomatica (7 . m0,#"
ara8 artrita% to& sau neroitia+a
,uta acuta intermitenta
Guta intercritica
Inter$a asim*tomatic intre atacurie acute
Cristae MSU i#enti&ca!ie in LS
Lic/i#u cu cristae MSU8 ceuaritate
Refecta infamatia *ersistenta% su!cinica
,uta cronica to2acee
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. Guta Acuta Intermitenta
E*iso#u initia *rece#at #e ani (#eca#a" #e /i*eruricemie asim*tomatica
De!ut !rusc (noa*tea sau #imineata #e$reme"% cu a*aritia,#e+$otarea ra*i#a a
semneor #e infamatie (ca#ura% tume&ere% roseate% #urere"
Durerea atin0e *aro
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In mo# caracteristic B #urere oarte se$era (/i*ereste+ie cutanata"
Sim*tome sistemice8 e!ra% rison
Eritemu *oate & conun#at cu ceuita
Atacu se re+o$a in cate$a ore :- sa*tamani
In a+ee initiae8
Atacuri rare (inter$ae i!ere #e ani"
In e$outie8
Atacuri mai rec$ente
Cu #urata mai mare
Cu aectarea mai mutor articuatii
Atacurile sunt precipitate de orice % sau 3 rapida a ni4elului de urat sdestabilizarea microtoflor si 54arsarea6 in lic0idul sino4ial
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Guta Cronica Toacee
A*are #u*a :4 ani #e 0uta intermitenta acuta
Perioa#e intercritice8 =
Articuatia aectata - #urere,tume&ere *ersistenta
6 atacuri acute rec$ente (a cate$a sa*tamani"
Aectare poliarticulara
Ce mai a#esea
Uneori simetrica
Ten#inta #e aectare a mem!reor su*erioare
Conun#ata cu P#(0uta reumatoi#aQ"
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Locai+area To&or
$rec4ent De0ete maini,*icioare
Gatu mainii
Urec/e (antehelix"
Genunc/i
Jursa oecraniana
Hone #e *resiune - ante!rat% ataunara
Ten#on A/ie
Sinovie
Os subcondral
Rar No#ui >e!er#en
Pirami#e renae
?a$e car#iace
Scerotica
Tofi ulcerati material alb cretos cumare de cristale -S.
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Guta B co-mor!i#itati
Joi meta!oice si c$ >i*ertensiune arteriaa
Pre+enta a @-@4 #in *acienti
-:) #intre /i*ertensi$i au 0ut
O!e+itate
Se coreea+a *uternic cu /i*erur
Atat a J cat si
Pacientii cu 0uta sunt in#eo!ste
>i*eri*emie
4 #intre cei cu 0uta au tri0ic
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As*ecte Ra#ioo0ice
,uta In sta#iie initiae
Necaracteristic (tume&ere #e *arti moi"
Ero+iuni
a #istantaQ
o$er/an0in0 e#0eQ
*unc/e# outQ
Pre+er$area in#eun0ata a s*atiuuiarticuar
Osteo*enie 1u
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Date #e a!orator
>i*eruricemie
Consi#erata mut tim* ca *iatra #e temeie a #ia0nosticuui cu toate ca8
?asta ma1oritatea a *ersoaneor cu /i*eruricemie nu $or #e+$ota
nicio#ata 0uta
Ni4elul uricemiei poate f normal in cursul atacului de 1uta !
?S>% eucocito+a (neutro&ie" usoasa% trom!ocito+a reacti$a
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Dia0nostic #e Certitu#ine
E$i#entierea cristaeor #e MSU in LS (sau inmateriau to&or"
orma acicuara
Jirerin0enta ne0ati$a intensa (0a!en straucitorcan# sunt *araee cu a
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Tratament:. Guta acuta
Controu sim*tomeor,#urerii
AINS
Do+a ma
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. Tera*ia >i*ouricemianta
Mentinerea uratuui seric 2 4. m0,# K OT
Acoo =% tia+i#e =% aimente cu continut crescut in *urine =
In/i!itori #e
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3. Guta Cronica Toacee
Re#ucerea ni$euui #e aci# uric *ermite #isoutia to&or (ao*urino" Mentinem ni$eu cu ce *utin :.4 m0,# su! *ra0u #e su*raraturatie #e .4
m0,#
Ao*urino (#o+e u+uae :44-344 m0,+i"
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Joaa *rin #e*unere #e cristae #e *iroosat#i/i#rat #e caciu CPPD
Terminoo0ie
:. Pseo#o0uta K atacuri infamatorii acute 0uta-like
. Con#rocacino+a K termen ra#ioo0ic8 o*acitati in cartia1u /iain si,sau
&!rocartia1
3. Artro*atia *rin *iroosat K aterari structurae articuare asociate #e*o+iteor #e
CPPD (cu sau ara con#rocacino+a"
8) 9oala prin depunere de cristale de CPPD : ;
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Cau+e
Pre4alenta inalta I#io*atica in asociere cu im!atranirea
(cea mai rec$enta"
Com*icatie a artro+ei
Pre$aenta 1oasa amiiaa
Asociata cu !oi meta!oice
sistemice8
>i*er*aratiroi#ism
>emocromato+a
>i*oma0ne+iemie
>i*otiroi#ism (mi
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orme #e maniestare cinica
Pattern #e *seu#o0uta
Pattern *seu#oreumatoi# ($e+i cursu8 *oiartrita reumatoi#a"
orma *seu#oartro+ica ($e+i cursu8 artro+a"
# #
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:. Pattern #e *seu#o0uta
@
Infamatie in una sau mai mute articuatii
De!ut !rusc
Cinic 1uta
Distri!utie anatomica
ocai+ate a 1enunc0i
De o!icei monoarticuare
S*ontan sau traumatism% c/iru0ie% IMA etc.
Asim*tomatic intre cri+e
Simuea+a inectia8 eritem su*ra1acent 6 maniestari sistemice (e!ra% eucocito+a% *roteineor
acuta"
P tt # t i#
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. Pattern *seu#oreumatoi#
CPPD @
Aectea+a mai mute articuatii
(0enunc/i% 0atu mainii% coate"
Distri!utie simetrica
Infamatie mai *utin e$i#enta (low-
grade"8 in0rosare sino$iaa% 6contracturi in fe
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3. orma *seu#oartro+ica
CPPD:, asocia+a un *roces #e0enerati$ *ro0resi$
articuar artro+a secun#ara
Genunc/iu ce mai #es aectat
Com*artiment atera ($a0us"
Artro+a i+oata emuro*ateara
N.sunt aectate8 ID% IP% CMC I
Pana a @4 6 atacuri recurente #e
*seu#o0uta acuta
R
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Caracteristici ra#ioo0ice
O*acitati *unctiorme,iniare in cartia1u /iain si,sau &!rocartia1
Se#ii caracteristice8
Cartia1 /iain 0enunc/i si so#
Menisc me#ia,atera
i!rocartia1u sim&+ei *u!iene
Li0amentu triun0/iuar a car*uui (&!rocartia1"
Screening radiolo1ic? 1enunc0i pel4is (simfza pubiana
mana/1atul mainii
C it ii # #i ti
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Criterii #e #ia0nostic
Paracinic Demonstrarea *re+entei cristaeor CPPD (rom!oi#ae% !irerin0enta *o+iti$a
sa!a" in LS
Demonstrarea ra#ioo0ica a caci&erior ti*ice
T t t
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Tratament
Atac acut,: articuatie mare8
Artrocente+a (in#e*artarea LS *oate intreru*e un atac in#e*artarea
cristaeor" In1ectarea ocaa #e corticosteroi+i cu #urata un0a #e actiune
Coc/icina
AINS
Atac *oiarticuar
AINS
Corticotera*ie sistemica
Coc/icina
Atacuri rec$ente
Coc/icina
Nu eista modalitati terapeutice pentru indepartarea cristalelor CPPD d
sau pentru pre4enirea depozitarii lor
Ten#inita caci&ca
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Ten#inita caci&ca
De&nitie
Joaa autoimitata
Aectea+a in mo# caracteristic *acienti #e $arsta mi1ocie (34 B 4 ani"% *re#ominant
Datorata #e*unerii cristaeor #e 0idroiapatita ('A a ni$eu ten#oaneor (in#eose!caotei rotatorior"
) sta#ii
a+a *re-caci&ca
Asim*tomatica (/i*oA in tesuturie #in
Durata sa*tamani
a+a *ost-caci&ca
Sim*tome ,restrictie a miscarior (#urata8 uni"
Ten#inita caci&ca
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Ten#inita caci&ca
Locai+are
Supraspinos @B
Inras*inos :@
Su!sca*uar @
6 tesuturi moi *eriarticuare% i0amente% ca*sua%
!ursa,SASD
Ten#inita caci&ca
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Ten#inita caci&ca
Ra#ioo0ic
O*acitati /i*er#ense% orma,#imensiuni$aria!ie
US
>i*ereco0enitati (arcuate% *unctate%no#u etc."% con *osterior #e um!ra
RM
Semna /i*o#ens% intens% omo0en (T:"
Tratament
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Tratament
Antia0ice,AINS
In1ectii ocae B aneste+ic oca,corticosteroi# oca
(in#eose!i in !ursa SASD"
As*iratie,a$a1 (contro eco0ra&c"
C/irur0ie
S.SPICI.N" CLINICAA#T#ITA IN$LA-AT*#I"
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artrita reacti$a
artrita *soria+ica
s*on#iita anc/io+anta
sarcoi#o+a
LES
uretrita,!aanita %con1uncti$ita% #iaree% J
*soria+is cutanat,un0/ia
om!a0ie infamatorie%u$eita
EN% a#eno*atie /iara
ras/ maar% sero+ita% uceratii!ucae
A#T#ITA IN$LA-AT*#I"