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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"