今日の臨床サポート

単関節痛・単関節炎

著者: 綿貫聡 東京都立多摩総合医療センター 救急総合診療センター

監修: 野口善令 豊田地域医療センター 総合診療科

著者校正/監修レビュー済:2021/06/02
患者向け説明資料

概要・推奨   

  1. 単関節痛の頻度のい原因疾患は、変形性関節症、外傷、結晶性関節炎、化膿性関節炎である。
  1. 化膿性関節炎評価のためには、関節穿刺での関節液培養提出とともに血液培養提出を同時に行うことが望ましい。また、関節液中の白血球増多、多核球割合の増多の評価とともに、化膿性関節炎の診断に有用である
  1. 結晶性関節炎のリスクとしては、肥満、体重増加、高血圧、利尿薬使用、アルコールなどが挙げられる。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
綿貫聡 : 特に申告事項無し[2021年]
監修:野口善令 : 特に申告事項無し[2021年]

改訂のポイント
  1. 定期レビューを行った(変更なし)。
 

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 関節腫脹が認められる場合には、炎症性関節炎を考慮すべきである。
  1. 炎症性関節炎の中で見逃してはいけないのは化膿性関節炎で、除外のためには穿刺が必須であり、疑われた時点で整形外科へのコンサルトが望ましい。
  1. 結晶性関節炎の診断のためには、関節液についての偏光顕微鏡での結晶の確認が必要である。
  1. その他、関節リウマチを含めて自己免疫疾患による関節腫脹が単関節炎というプレゼンテーションで始まる可能性もある。
問診・診察のポイント  
  1. general impressionの評価が最優先で、状態が悪い場合には積極的に菌血症を背景とした関節症、特に化膿性関節炎を考慮する。

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文献 

著者: M J Ryan, R Kavanagh, P G Wall, B L Hazleman
雑誌名: Br J Rheumatol. 1997 Mar;36(3):370-3.
Abstract/Text Data from 1158 cases of septic arthritis reported to the Public Health Laboratory Service (PHLS) Communicable Disease Control Centre (CDSC) from England and Wales over a 4 yr period (January 1990 December 1993) are presented. Reports where a bacterial organism was isolated from synovial fluid, or where an organism was isolated from blood cultures where a diagnosis of septic arthritis was reported, were examined. Reports of infection were more common in children (12.7% of infections were in the under 10 age group) and the elderly (54.7% aged 60 or over), and were higher in males in all age groups except in the elderly. The most common causative organisms remain staphylococcal and streptococcal species, comprising 40.6% (470) and 28% (324) of cases, respectively. The most common streptococci seen were Streptococcus pneumoniae and Lancefield group A beta-haemolytic Streptococcus organisms, 60.8% (197/324), although group B, C and G organisms accounted for 33.6% of streptococcal isolates (109/324). Haemophilus influenzae septic arthritis is not exclusive to children as 23.2% (16-69) of cases occurred over the age of 15. A total of 48% (635) of isolates were identified from both synovial fluid and blood cultures, 32.6% (378) from joint fluid alone and 12.5% (146) from blood cultures. Although this study excludes cases of septic arthritis where no organism was isolated, it presents important bacteriological information from a large number of isolates from England and Wales over a 4 yr period. Risk factors identified include a joint prosthesis, joint disease/connective tissue disorder. immunosuppression and diabetes.

PMID 9133971  Br J Rheumatol. 1997 Mar;36(3):370-3.
著者: Mary E Margaretten, Jeffrey Kohlwes, Dan Moore, Stephen Bent
雑誌名: JAMA. 2007 Apr 4;297(13):1478-88. doi: 10.1001/jama.297.13.1478.
Abstract/Text CONTEXT: In patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality.
OBJECTIVE: To review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis.
DATA SOURCES: Structured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity.
STUDY SELECTION: Studies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis.
DATA EXTRACTION: Three authors independently abstracted data from the included studies.
DATA SYNTHESIS: Fourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts <25,000/microL: LR, 0.32; 95% CI, 0.23-0.43; for counts > or =25,000/microL: LR, 2.9; 95% CI, 2.5-3.4; for counts >50,000/microL: LR, 7.7; 95% CI, 5.7-11.0; and for counts >100,000/microL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47).
CONCLUSIONS: Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.

PMID 17405973  JAMA. 2007 Apr 4;297(13):1478-88. doi: 10.1001/jama.297・・・
著者: Hyon K Choi, Karen Atkinson, Elizabeth W Karlson, Gary Curhan
雑誌名: Arch Intern Med. 2005 Apr 11;165(7):742-8. doi: 10.1001/archinte.165.7.742.
Abstract/Text BACKGROUND: Limited prospective information exists on the relation between obesity and weight change and the risk of gout. Similarly, both hypertension and diuretic use have been considered risk factors for gout; however, their independent contributions have not been established prospectively.
METHODS: We prospectively examined over a 12-year period (1986-1998) the relation between adiposity, weight change, hypertension, and diuretic use and incident gout in 47,150 male participants with no history of gout at baseline. We used a supplementary questionnaire to ascertain the American College of Rheumatology criteria for gout.
RESULTS: During 12 years we documented 730 confirmed incident cases of gout. Compared with men with a body mass index (BMI) of 21 to 22.9, the multivariate relative risks (RRs) of gout were 1.95 (95% confidence interval [CI], 1.44-2.65) for men with a BMI of 25 to 29.9, 2.33 (95% CI, 1.62-3.36) for men with a BMI of 30 to 34.9, and 2.97 (95% CI, 1.73-5.10) for men with a BMI of 35 or greater (P for trend <.001). Compared with men who had maintained their weight (+/-4 lb) since age 21 years, the multivariate RR of gout for men who had gained 30 lb or more since age 21 years was 1.99 (95% CI, 1.49-2.66). In contrast, the multivariate RR for men who had lost 10 lb or more since the study baseline was 0.61 (95% CI, 0.40-0.92). The multivariate RRs of gout were 2.31 (95% CI, 1.96-2.72) for the presence of hypertension and 1.77 (95% CI, 1.42-2.20) for diuretic use.
CONCLUSIONS: Higher adiposity and weight gain are strong risk factors for gout in men, while weight loss is protective. Hypertension and diuretic use are also important independent risk factors for gout.

PMID 15824292  Arch Intern Med. 2005 Apr 11;165(7):742-8. doi: 10.1001・・・
著者: Hyon K Choi, Karen Atkinson, Elizabeth W Karlson, Walter Willett, Gary Curhan
雑誌名: Lancet. 2004 Apr 17;363(9417):1277-81. doi: 10.1016/S0140-6736(04)16000-5.
Abstract/Text BACKGROUND: The association between alcohol consumption and risk of gout has been suspected since ancient times, but has not been prospectively confirmed. Additionally, potential differences in risk of gout posed by different alcoholic beverages have not been assessed.
METHODS: Over 12 years (1986-98) we used biennial questionnaires to investigate the relation between alcohol consumption and risk of incident gout in 47?150 male participants with no history of gout at baseline. We used a supplementary questionnaire to ascertain whether reported cases of gout met the American College of Rheumatology survey gout criteria.
FINDINGS: We documented 730 confirmed incident cases of gout. Compared with men who did not drink alcohol, the multivariate relative risk (RR) of gout was 1.32 (95% CI 0.99-1.75) for alcohol consumption 10.0-14.9 g/day, 1.49 (1.14-1.94) for 15.0-29.9 g/day, 1.96 (1.48-2.60) for 30.0-49.9 g/day, and 2.53 (1.73-3.70) for > or =50 g/day (p for trend <0.0001). Beer consumption showed the strongest independent association with the risk of gout (multivariate RR per 12-oz serving per day 1.49; 95% CI 1.32-1.70). Consumption of spirits was also significantly associated with gout (multivariate RR per drink or shot per day 1.15; 95% CI 1.04-1.28); however, wine consumption was not (multivariate RR per 4-oz serving per day 1.04; 95% CI 0.88-1.22).
INTERPRETATION: Alcohol intake is strongly associated with an increased risk of gout. This risk varies substantially according to type of alcoholic beverage: beer confers a larger risk than spirits, whereas moderate wine drinking does not increase the risk.

PMID 15094272  Lancet. 2004 Apr 17;363(9417):1277-81. doi: 10.1016/S01・・・
著者: D L Goldenberg
雑誌名: Lancet. 1998 Jan 17;351(9097):197-202. doi: 10.1016/S0140-6736(97)09522-6.
Abstract/Text
PMID 9449882  Lancet. 1998 Jan 17;351(9097):197-202. doi: 10.1016/S01・・・
著者: David J Hunter, David T Felson
雑誌名: BMJ. 2006 Mar 18;332(7542):639-42. doi: 10.1136/bmj.332.7542.639.
Abstract/Text
PMID 16543327  BMJ. 2006 Mar 18;332(7542):639-42. doi: 10.1136/bmj.332・・・

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