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Septic arthritis in rheumatoid arthritis — SCE Acute Medicine MCQ

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EasyMusculoskeletal systemSeptic arthritis in rheumatoid arthritisSCE Acute Medicine

A 66-year-old man presents with acute painful swelling of the right knee and fever. He has rheumatoid arthritis treated with methotrexate. Temperature is 38.6°C, CRP is 186 mg/L and the knee is hot with reduced range of movement. Plain radiograph shows chronic erosive change but no fracture. What is the most appropriate next step in management?

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Correct answer: A — Urgent joint aspiration for Gram stain, culture and crystals before antibiotics if this does not delay treatment

Septic arthritis must be excluded in any hot swollen joint, especially with immunosuppression; aspiration should assess Gram stain, culture and crystals. Crystals do not exclude infection, and intra-articular steroid before excluding sepsis is unsafe. Antibiotics should follow cultures if the patient is stable, or be given immediately if septic.

Reference: BSR guideline for hot swollen joint; NICE CKS septic arthritis