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T284. Joint and bursae

A. Clinical approach to acute joint pain

โ€ข
Septic arthritis๋Š” ๋ถ“๊ณ  ์—ด๊ฐ์ด ๋™๋ฐ˜๋œ ๊ด€์ ˆํ†ต์—์„œ ๊ฐ€์žฅ ์ค‘์š”ํ•˜๊ฒŒ ๊ณ ๋ ค๋˜์–ด์•ผ ํ•จ.
โ€ข
์ง„๋‹จ๊ฒ€์‚ฌ๋ฅผ ์ด์šฉํ•˜์—ฌ ์ž„์ƒ์  ์ง„๋‹จ์ด๋ฉฐ screening ํ•  ์ˆ˜ ์žˆ๋Š” sensitive single diagnostic parameter๋Š” ์—†์Œ. (Synovial WBC count๋„ ํฌํ•จ)

A1. Clinical features and risk factors

1.
Nongonococcal septic arthritis์˜ 85%๋Š” ํ•˜๋‚˜์˜ ๊ด€์ ˆ์„ ์นจ๋ฒ”ํ•œ๋‹ค.
2.
S.aureus, S.pneumoniae : ๋‘˜ ์ด์ƒ์˜ ๊ด€์ ˆ์„ ์นจ๋ฒ”ํ•œ๋‹ค.
3.
ํ•˜๋‚˜ ์ด์ƒ์˜ ๊ด€์ ˆ์„ ์นจ๋ฒ”ํ•˜๋Š” ๊ฒฝ์šฐ Rheumatoid arthritis(50%) Immunocompromise Goute Diabetes Renal disease
4.
Polyarticular septic arthritis๊ฐ€ ๋‹จ์ผ๊ด€์ ˆ๋ณด๋‹ค ์‚ฌ๋ง๋ฅ ์ด ๋†’๋‹ค (11% vs 30%)
5.
์ตœ๊ทผ์˜ ๊ด€์ ˆ ์ˆ˜์ˆ ๋ ฅ, ๊ณ ๊ด€์ ˆ์ด๋‚˜ ๋ฌด๋ฆŽ์˜ ์ธ๊ณต๊ด€์ ˆ์„ ํฌํ•จํ•˜๋Š” cellulitis๋Š” nongonoccocal septic arthritis๋ฅผ ์‹œ์‚ฌํ•  ์ˆ˜ ์žˆ๋‹ค.

A2. Synovial fluid analysis

โ€ข
Septic arthritis๊ฐ€ ์˜์‹ฌ๋˜๋ฉด ์ง์ ‘ ์น˜๋ฃŒ๋ฅผ ์œ„ํ•ด joint fluid๋ฅผ ์–ป์–ด์•ผ ํ•œ๋‹ค
โ€ข
Synovial lactate๋‚˜ Novel biomarker presepsin ์ƒ์Šน์€ septic arthritis๋ฅผ ์‹œ์‚ฌํ•œ๋‹ค.
โ€ข
Gram stain, leukocyte with differential, crystal์„ ๋ถ„์„ํ•˜๊ณ  glucose, protein, LDH๋Š” ์น˜๋ฃŒ๊ฒฐ์ •๊ณผ ์ƒ๊ด€ ์—†๋‹ค,

A3. Serum laboratory study

โ€ข
Inflammatory and reactive arthritis์—์„œ ESR์ด๋‚˜ CRP๊ฐ€ ์ฆ๊ฐ€ํ•  ์ˆ˜ ์žˆ์ง€๋งŒ ํŠน์ด์ ์ด์ง€๋Š” ์•Š๋‹ค. ํ•˜์ง€๋งŒ ์น˜๋ฃŒ์— ๋Œ€ํ•œ ๋ฐ˜์‘์„ ๋ชจ๋‹ˆํ„ฐ๋งํ•˜๋Š” ๋ชฉ์ ์œผ๋กœ ์‚ฌ์šฉํ•  ์ˆ˜ ์žˆ๋‹ค.
โ€ข
Serum WBC์˜ nongonococcal bacterial septic arthritis์— ๋Œ€ํ•œ sensitivity๋Š” 60%์ด๋‹ค.
โ€ข
Procalcitonin์ด ์ƒ์Šนํ–ˆ์„ ๊ฒฝ์šฐ septic arthritis๋ฅผ rule in ํ•˜๋Š”๋ฐ 90%์˜ specificity๋ฅผ ๋ณด์ด์ง€๋งŒ sensitivity๋Š” 67%๋กœ ๋‚ฎ๋‹ค.

A4. Imaging

โ€ข
์ดˆ์ŒํŒŒ๊ฐ€ ๊ด€์ ˆ์•ก ๋ฐ ๊ด€์ ˆ ์ฒœ์ž์— ์œ ์šฉํ•˜๋‹ค.
โ€ข
๋‹จ์ˆœ x-ray๋ฅผ ํ†ตํ•ด ์ข…์–‘, AVN, osteomyelitis ๋“ฑ์„ ํ™•์ธํ•  ์ˆ˜ ์žˆ๋‹ค.
โ€ข
MRI๋Š” septic arthritis๋ฅผ ํ‰๊ฐ€ํ•˜๋Š”๋ฐ ๊ถŒ์žฅ๋˜์ง„ ์•Š์ง€๋งŒ ์–ด๋ ค์šด ์ผ€์ด์Šค์—์„œ ๋„์›€๋  ์ˆ˜ ์žˆ๋‹ค.

B. Septic arthritis

โ€ข
๊ธ‰์„ฑ์˜ ์—ด๊ฐ๊ณผ ๋ถ€์ข…, ์••ํ†ต์„ ๋™๋ฐ˜ํ•œ ๊ด€์ ˆ์˜ ์šด๋™ ์ œํ•œ์€ ๋‹ค๋ฅธ ์ง„๋‹จ์ด ๋ฐํ˜€์ง€๊ธฐ ์ „๊นŒ์ง€๋Š” bacterial nongonococcal septic arthritis์ด๋‹ค.

B1. Bacterial nongonococcal septic arthritis

(1) ์ง„๋‹จ

โ€ข
์ž„์ƒ ์ฆ์ƒ์ด ์ง„๋‹จ์ ์ด์ง€ ์•Š์ง€๋งŒ, ์ผ๋ฐ˜์ ์ธ ์–‘์ƒ์ด ์ง„๋‹จ์— ๋„์›€์ด ๋œ๋‹ค Joint pain Hx. of joint swelling Fever โ†’ ๋‹จ, ์ด๋“ค ์—ญ์‹œ ํ™˜์ž์˜ 50%์ด์ƒ์—์„œ๋งŒ ๊ด€์ฐฐ.
โ€ข
Joint aspiration and analysis๊ฐ€ ์ง„๋‹จ์— ํ•„์ˆ˜์ ์ด์ง€๋งŒ sensitivity๋Š” ๋†’์ง€ ์•Š๋‹ค.

(2) ์น˜๋ฃŒ

โ€ข
Septic arthritis๊ฐ€ ์ž„์ƒ์ ์ธ ํ‰๊ฐ€์™€ ๊ด€์ ˆ ์ฒœ์ž ํ›„์—๋„ ์ถฉ๋ถ„ํžˆ ๋ฐฐ์ œํ•  ์ˆ˜ ์—†๋‹ค๋ฉด, Parenteral antibiotics๋ฅผ ์‚ฌ์šฉ / ํ†ต์ฆ ์กฐ์ ˆ / Synovial fluid culture๊ฐ€ ๋‚˜์˜ฌ ๋•Œ๊นŒ์ง€ ํ™˜์ž ์ž…์›
โ€ข
MRSA๋ฅผ ํฌํ•จํ•œ staphylococcal, streptococcal species๋ฅผ ์ปค๋ฒ„ํ•  ์ˆ˜ ์žˆ๋Š” ํ•ญ์ƒ์ œ๋ฅผ ์‚ฌ์šฉ. : Vancomycin + ๊ด‘๋ฒ”์œ„ Cephalosporin์ด๋‚˜ Carbapenem์ด ์„ ํ˜ธ

B2. Gonococcal septic arthritis

โ€ข
์ Š๊ณ  ์„ฑ์  ํ™œ๋™์ด ์™•์„ฑํ•œ ์„ฑ์ธ์—์„œ septic arthritis์˜ ๊ฐ€์žฅ ํ”ํ•œ ์›์ธ์ด๋‹ค.
โ€ข
Synovial fluid culture์—์„œ ์ข…์ข… ์Œ์„ฑ์ด๋‹ค.
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์ด์™ธ์—๋„ pharynx. urethra, cervix, rectal culture๊ฐ€ ํ•„์š”ํ•˜๋ฉฐ ์ดˆ๊ธฐ ๋ฐฐ์–‘์ด ์Œ์„ฑ์ด๋ผ๋„ ํ•ญ์ƒ์ œ๋ฅผ ์‚ฌ์šฉํ•˜๋ฉด์„œ ๋‹ค๋ฅธ ๋ฐฐ์–‘๊ฒฐ๊ณผ๋ฅผ ํ™•์ธํ•˜์—ฌ์•ผ ํ•œ๋‹ค.
โ€ข
์ˆ˜์ˆ ์ ์ธ ์ฒ˜์น˜๋Š” ๋Œ€๋ถ€๋ถ„ ํ•„์š”ํ•˜์ง€ ์•Š์œผ๋ฉฐ (joint destruction์„ ์œ ๋ฐœํ•˜์ง€ ์•Š๊ธฐ ๋•Œ๋ฌธ), ์ž„์ƒ์  ๊ฐœ์„ ์ด ์žˆ์„ ๋•Œ๊นŒ์ง€ ๋งค์ผ joint aspiration ์‹œํ–‰
โ€ข
N. gonorrhoeae์˜ ๊ฒฝ์šฐ 3rd cephalosporin๋กœ ์ž˜ ์น˜๋ฃŒ๋œ๋‹ค.

C. Crystal-induced synovitis (gout and pseudogaout)

Gout
Pseudogout

D. Viral arthritis

* m/c cause of viral arthritis in US : parvovirus B19, rubella, hepatitis B

E. Lyme disease

โ€ข
Mono- or ologoarticular assymetric joint involvement.
โ€ข
๋Œ€๊ด€์ ˆ, ํŠนํžˆ ๋ฌด๋ฆŽ๊ด€์ ˆ ์นจ๋ฒ”
โ€ข
์ตœ๊ทผ์— endemic area์— ๋ฐฉ๋ฌธํ•œ ๊ธฐ์™•๋ ฅ์ด ์žˆ์œผ๋ฉด ์˜์‹ฌํ•ด ๋ณผ ์ˆ˜ ์žˆ์œผ๋ฉฐ, ์ง„๋“œ๊ธฐ์— ๋ฌผ๋ฆฐ ๊ธฐ์™•๋ ฅ์ด ์žˆ์„ ๊ฒฝ์šฐ ๋„์›€์ด ๋œ๋‹ค.
โ€ข
์น˜๋ฃŒ : Doxycycline, Amoxicillin or Cefuroxime์œผ๋กœ 4์ฃผ๊ฐ„ ์น˜๋ฃŒ

F. Hemarthrosis

F1. Traumatic hemarthrosis

โ€ข
Ligament injury๋‚˜ intro-articular fracture์™€ ์—ฐ๊ด€
โ€ข
๋Œ€๋Ÿ‰์˜ traumatic effusion์„ aspiration ํ•ด ์ฃผ๋Š” ๊ฒƒ์€ ํ†ต์ฆ์„ ๊ฒฝ๊ฐ, ํ™œ๋™๋ฒ”์œ„๋ฅผ ๋„“ํ˜€์ฃผ๋Š” ํšจ๊ณผ๋Š” ์žˆ์ง€๋งŒ ์žฅ๊ธฐ์  outcome์— ์ฐจ์ด๊ฐ€ ์—†๋‹ค.
โ€ข
์น˜๋ฃŒ : Immobilization, Ice, Elevation

F2. Spontaneous hemarthrosis

โ€ข
์ผ๋ฐ˜์ ์œผ๋กœ coagulopathy๋ฅผ ๊ณ ๋ คํ•ด์•ผ ํ•œ๋‹ค.
โ€ข
ํ˜ˆ์šฐ๋ณ‘ ํ™˜์ž์—์„œ joint aspiration์€ ๋…ผ๋ž€์ด ์žˆ์œผ๋ฉฐ, ์‹œ์ˆ  ์‹œ ๋ฐ˜๋“œ์‹œ factor replacement ํ›„ ์‹œํ–‰

G. Rheumatoid arthritis

โ€ข
Progressive, polyaticular of symmetrric, sparing of distal interphalangeal joint.
โ€ข
์—ฌ์ž>๋‚จ์ž
โ€ข
Mornig stiffness

G1. ์น˜๋ฃŒ

(1) Salicylate or NSAIDs : ๊ธ‰์„ฑ์•…ํ™”

(2) Corticosteroid : ์งง์€ ๊ธฐ๊ฐ„

(3) MTX, Leflunomide, Sulfasalazine : ์žฅ๊ธฐ์ 

H. Reactive arthritis (Reiterโ€™s syndrome)

H1. Classic triad

โ€ข
Arthritis, Urethritis, Conjunctivitis. โ€“ ์ง„๋‹จ์— ํ•„์š”ํ•˜์ง€๋Š” ์•Š๋‹ค.
โ€ข
๊ฐ์—ผ์งˆํ™˜ 2~6์ฃผ ํ›„ acute, asymmetric oligoarthritics

H2. ์น˜๋ฃŒ

โ€ข
Rifampin + Doxicycline or Rifampin + Azithromycin

I. Bursitis

* m/c in elbow or knee

I1. Nonseptic bursitis

โ€ข
๋ฐ˜๋ณต์ ์ธ ์™ธ์ƒ์— ์˜ํ•ด ์ƒ๊ธฐ๊ฑฐ๋‚˜, gout ๋˜๋Š” pseudogout์™€ ์—ฐ๊ด€์ด ์žˆ๋‹ค๊ณ  ์•Œ๋ ค์ ธ ์žˆ๋‹ค.
โ€ข
๊ธ‰์„ฑ์ด๋ฉด septic bursitis ๊ณ ๋ ค
โ€ข
์น˜๋ฃŒ : NSAID + ์œ ๋ฐœ ํ™œ๋™ ์ค‘์ง€
โ€ข
Bursa fluid aspiration์€ ๋…ผ๋ž€์˜ ์—ฌ์ง€๊ฐ€ ์žˆ๋‹ค.

I2. Septic bursitis

โ€ข
Skin lesion์ด๋‚˜ local cellulitis์—์„œ ์ด์ฐจ์ ์œผ๋กœ bacrial spread์— ์˜ํ•ด ๋ฐœ์ƒํ•˜๋Š” ๊ฒฝ์šฐ๊ฐ€ ๋งŽ๋‹ค.
โ€ข
M/C site : prepatellar bursa and olecranon bursa
โ€ข
M/C pathogen : S. aureus
โ€ข
Septic bursitis๊ฐ€ ์˜์‹ฌ๋  ๊ฒฝ์šฐ์—๋Š” bursa fluid๋ฅผ aspiration ํ•ด ์ฃผ๋Š” ๊ฒƒ์ด ์ถ”์ฒœ๋œ๋‹ค.

I3. Olecranon bursitis

โ€ข
๊ตญ์†Œ์ ์ผ ๋•Œ : Clindamycin or Dicloxacillin
โ€ข
ํŒจํ˜ˆ์„ฑ์ผ ๋•Œ : Vancomycin + Piperacillin/Tazobactam or Meropenem

I4. Prepatellar bursitis

โ€ข
ํŒจํ˜ˆ์„ฑ์ผ ๋•Œ aspiration
septic arthritis ์ •์˜
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