No Rheum at the Inn? High Value Inpatient Rheumatology Pearls for Hospitalists-Slides

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This educational presentation by Dr. Vivek K. Murthy addresses key inpatient rheumatology topics relevant to hospitalists, focusing on acute monoarticular arthritis diagnosis, gout flare management, giant cell arteritis evaluation, and ANA testing interpretation.<br /><br />For acute monoarticular arthritis—often caused by gout, calcium pyrophosphate deposition disease (CPPD), septic arthritis, or trauma—joint inflammation must be distinguished from arthralgia. Septic arthritis should be presumed until ruled out; no history, physical exam, blood tests, or imaging alone reliably exclude it. Prompt knee x-ray and arthrocentesis are essential diagnostic steps, with synovial fluid analysis and cultures guiding management. Rheumatology consultation is advised early due to diagnostic complexity and infection risk.<br /><br />Regarding gout flare treatment, typical agents include colchicine, NSAIDs, and corticosteroids; however, interleukin-1 receptor antagonists like anakinra offer an effective alternative, especially when traditional therapies are contraindicated. Anakinra has demonstrated efficacy comparable to standard treatments and better safety versus steroids in some patients. It is important to dose and time colchicine appropriately and avoid anakinra in active infections due to immunosuppression risks.<br /><br />Giant cell arteritis (GCA) is a vasculitis primarily affecting adults over 50, characterized by cranial symptoms (headache, jaw claudication, scalp tenderness), polymyalgia rheumatica features, and large vessel involvement. Elevated ESR/CRP supports diagnosis but can be normal in rare cases. Temporal artery biopsy remains the diagnostic gold standard, unaffected significantly by steroid pre-treatment up to 2-4 weeks. Urgent treatment with high-dose steroids reduces risk of vision loss. Clinical algorithms guide biopsy and imaging decisions.<br /><br />Finally, antinuclear antibody (ANA) testing should be ordered only when suspicion for systemic lupus erythematosus (SLE) or related autoimmune diseases is moderate to high. Approximately one-third of healthy individuals have low-titer positive ANA without disease, making indiscriminate testing prone to false positives. Patterns of ANA fluorescence and specific subserologies help refine diagnosis but are imperfectly correlated with clinical syndromes. A negative ANA effectively excludes lupus and mixed connective tissue disease, although Sjogren’s syndrome requires additional SSA/SSB testing.<br /><br />In sum, clinicians should prioritize early invasive diagnostics in monoarthritis, consider IL-1 blockade for gout when conventional therapy is unsuitable, act promptly in suspected GCA, and apply ANA testing judiciously to avoid misinterpretation.

Keywords

inpatient rheumatology

acute monoarticular arthritis

gout flare management

giant cell arteritis

ANA testing interpretation

septic arthritis diagnosis

interleukin-1 receptor antagonists

colchicine dosing

temporal artery biopsy

systemic lupus erythematosus