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Orthopaedic Blunder: - Ward 5F - Edendale Hospital

1. A 24-year old black male presented with painful swollen joints for 12 months and inability to walk or use his left hand. Examination found oral candidiasis, lymphadenopathy, peripheral neuropathy, and symmetrical polyarthritis. 2. Investigations showed macrocytic anemia, low B12 and folate levels, and HIV positivity. He was diagnosed with B12 deficiency causing spinal cord degeneration and HIV-related symmetrical polyarthritis. 3. He was treated with supplements, NSAIDs, steroids, and occupational therapy, and showed improvement in hand function and ability to walk after 2 months.

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114 views

Orthopaedic Blunder: - Ward 5F - Edendale Hospital

1. A 24-year old black male presented with painful swollen joints for 12 months and inability to walk or use his left hand. Examination found oral candidiasis, lymphadenopathy, peripheral neuropathy, and symmetrical polyarthritis. 2. Investigations showed macrocytic anemia, low B12 and folate levels, and HIV positivity. He was diagnosed with B12 deficiency causing spinal cord degeneration and HIV-related symmetrical polyarthritis. 3. He was treated with supplements, NSAIDs, steroids, and occupational therapy, and showed improvement in hand function and ability to walk after 2 months.

Uploaded by

aya kafeel
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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ORTHOPAEDIC BLUNDER

• WARD 5F
• EDENDALE
HOSPITAL
HISTORY
• 24/02- N.M- 24 YEAR OLD BLACK
MALE
• ORTHOPAEDIC WARD-CONSULT-ON
SKIN TRACTION
X2/52…..??ARTHRITIS
• C/O- PAINFUL SWOLLEN JOINTS X2/12
• -UNABLE TO WALK
• - LOSS OF FUNCTION>> L HAND
• ON ENQUIRY
- EARLY MORNING STIFFNESS
-FIRST EPISODE
- LOW , NO LOA, NIGHTSWEATS
- NO HX TB/ TB CONTACTS
- NO HX OF CONJUNCTIVITIS;
VISUAL PROBLEMS
-NO PENILE D/C, INCONTINENCE
• PAST MEDICAL HX/ SURGICAL HX-
NAD
• SOCIAL HX- NO ROH, SMOKING,
TOXIC SUBSTANCES
ON EXAMINATION
• IN BED, UNABLE TO WALK;
PALLOR+;ORAL CANDIDIASIS; SHOTTY
CERVICAL L/N; NO JAUNDICE; NOT
EMACIATED; NO SKIN LESIONS.
• CHEST= CLEAR; NORMAL CHEST EXP
• C.V.S= NAD
• ABDOMEN= SNT; NO SPLENOMEGALY; NOI
PENILE D/C
• CNS= GCS- 15/15; PEARL; NO
CONJUNCTIVITIS
• SENSORY SYSTEM= DECREASED
VIBRATION SENSE; JOINT POSITION SENSE
LOWER LIMBS
• MOTOR SYSTEM- NO FASICULATIONS; NO
MUSCLE WASTING; TONE= NORMAL
POWER- L.L= 3/5; U.L= 4/5; DECREASED
REFLEXES- L.L NO CLONUS OR BABINSKI.
• MUSCULOSKELETAL SYSTEM
- SWOLLEN TENDER JOINTS- DIP, PIP,
WRIST,ELBOW, ANKLE
- SYMMETRICAL, NO EFFUSIONS
-DECREASED POWER ACTIVE +
PASSIVE .
- NO DEFORMITIES
ASSESSMENT
• R.V.D----ORAL CANDIDIASIS
---L/N’S
• POLYARTHRITIS—SYMMETRICAL
• PERIPHERAL NEUROPATHY
INVESTIGATIONS
• X-RAY– L HAND; KNEE;CXR
• FBC- HB= 10; MCV=101; WBC=5;
PLT=259;TLC=1100
• U+E= NAD
• LFT- TP=88; ALB= 14
• LDH= 680; CK= 140
• ESR=105MM/HR]
• COLLAGEN VASCULAR SCREEN =
NEGATIVE
• RHEMATOID FACTOR = NEGATIVE
• HIV=ELISA POSITIVE
• VIT B12<<100
• FOLATE=4.8
• U/S ABDOMEN = NAD
FINAL DIAGNOSIS
• HIV +
• VITAMIN B12 DEF-----SUBACUTE
DEGENERATION OF SPINAL CORD
• SERONEGATIVE SYMMETRICAL
POLYARTHRITIS?? HIV RELATED
TREATMENT
• FOLATE; VIT B12; DIFLUCAN
• NSAID- INDOCID 25MG TDS
• PRENISOLONE 40MG DAILY
• INH; VIT B6
• O.T
• ******IMPROVEMENT ----after 2/52
function of hand back; able to walk
DISCUSSION
• APPROACH TO ARTHRITIS
• MANAGEMENT OF ARTHRITIS
• HIV + ARTHRITIS
• HIV + MACROCYTIC ANAEMIA
MUSCULOSKELETAL COMPLAINT

• 1. ARTICULAR ?
• 2.ACUTE / CHRONIC
• 3. INFLAMMATION
• 4.HOW MANY JOINTS
• 5. SYMMETRICAL ??
ARTICULAR
-complaint >>6/52
• ACUTE • CHRONIC
• Acute arthritis • Is there inflammation
• Infectious arthritis no yes
• Gout
• Pseudogout
• Reiters syndrome
• Initial presentation
HOW MANY JOINTS??
• <3 • >3
• INDOLENT INFXN • CHRONIC
• PSORIATIC INFLAMMATION
• REITERS • ASYMMETRICAL
• PAUCIARTICULAR --PSORIATIC
J.A --REITERS
SYMMETRICAL
--R.A
• ESTABLISH DIAGNOSIS OF R.A
• DOCUMENT BASELINE DX
ACTIVITY + DAMAGE
• ESTIMATE PROGNOSIS
INITIATE THERAPY
• EDUCATE
• START DMARD WITHIN 3/12
• CONSIDER NSAID
• CONSIDER LOCAL/ SYSTEMIC
STEROIDS
• OT
PERIODICALLY ASSESS DX
ACTIVITY
• ADEQUATE • INADEQUATE
RESPONSE WITH RESPONSE—ONGOING
ACTIVE DX AFTER
DECREASING DX
3/12 RX
ACTIVITY
• CHANGE / ADD
DMARD
• MULTIPLE DMARD
FAILURE/
STRUCTURAL JT
DAMAGE =SURGERY
MUSCULOSKELETAL
MANIFESTATIONS OF HIV
• MYOPATHIES- PYOMYOSITIS
- POLYMYOSITIS
- RX S/E
INFLAMMATORY ARTHROPATHIES
# ARTHRALGIA
- 45% OF PTS
- ?? CYTOKINES/ TRANSIENT BONE
ISCHAEMIA
• -ANY STAGE OF HIV
• 50 TO 70% OF ACUTE HIV
• ACUTE ONSET , SEVERE PAIN
• 4 OR FEWER JOINTS
• << 24 HRS; SELF-LIMITING
• LATE STAGES OF HIV- 10% OF AIDS
• RX= NSAID
ACUTE SYMMETRICAL
POLYARTHRITIS
• RESEMBLES POLYARTHRITIS
• SMALL JTS OF HAND ACUTE ONSET;
R.F= NEGATIVE
• X- RAY MIMICS R.A
• GOLD THERAPY
HYPERTROPHIC
OSTEOARTHROPATHY
• SYSTEMIC D/O AFFECTING BONES,
JTS, SOFT TISSUES WITH PCP
• SEVERE PAIN LOWER EXTREMITIES;
DIGITAL CLUBBING; ARTHRALGIAS;
NON PITTING OEDEMA;
PERIARTICULAR SOFT TISSUE
INVOLVEMENT OF ANKLE, KNEE,
ELBOW
• REITERS SYNDROME
• PSORIATIC ARTHRITIS
• AVASCULAR NECROSIS
HIV ASSOCIATED
ARTHRITIS
• 1ST DESCRIBED 1988
• 2 THEORIES-RXN TO IMMUNE
COMPLEXES WITHIN SYNOVIUM;
DIRECT HIV INFXN OF SYNOVIUM–
HIV + ASSAY SYNOVIAL FLUID
• >> MALES
• ACUTE ONSET; SEVERE PAIN,
DISABILITY >>KNEES + ANKLES
• X RAY= OSTEOPAENIA, NO
ERROSIONS
• HLA B27, R.F = NEGATIVE
• SYNOVIAL BIOPSY= CHRONIC
MONONUCLEAR INFILTRATES
• RX = NSAID
HIV + MACROCYTIC
ANAEMIA
• MALABSORPTION
• ACHLORYDIA
THE END
• RHEMATIC DX AND
AIDS- JOSEPH GOLBUS
1994
• GUIDELINES MX R.A-
2002 UPDATE-
AMERICAN COLLEGE
• HARRISONS-15TH
• MUSCULOSKELETAL
MANIFESTSTIONS OF
HIV- AIDS READER
2003

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