Clinical Approach to Acute Arthritis

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Clinical Approach to Acute Arthritis

• Azam amini
• Rheumatologist
• Boushehr university of medical science

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Acute Arthritis

• The sudden onset of inflammation of the joint,
  causing severe pain, swelling, and redness.
• Structural changes in the joint itself may result
  from persistence of this condition.

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Signs of Inflammation

• Swelling
• Warmth
• Erythema
• Tenderness
• Loss of function

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Key Points

• Distinguish arthritis from soft tissue non
  articular syndromes
• If the problem is articular distinguish single
  joint from multiple joint involvement
• Inflammatory or non-inflammatory disease
• Always consider septic arthritis!

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Articular Vs. Periarticular
Clinical feature Articular Periarticular
Anatomic structure Painful site Pain on movement Swelling Synovium, cartilage, capsule Diffuse, deep Active/passive, all planes Common Tendon, bursa, ligament, muscle, bone Focal point Active, in few planes Uncommon
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Inflammatory Vs. Noninflammatory
Feature Inflammatory Noninflammatory
Pain (when?) Swelling Erythema Warmth AM stiffness Systemic features î ESR, CRP Synovial fluid WBC Examples Yes (AM) Soft tissue Sometimes Sometimes Prominent Sometimes Frequent WBC gt2000 Septic, RA, SLE, Gout Yes (PM) Bony Absent Absent Minor (lt 30 ) Absent Uncommon WBC lt 2000 OA, AVN
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Acute Monoarthritis

• Inflammation (swelling, tenderness, warmth) in
  one joint
• Occasionally polyarticular diseases can present
  with monoarticular onset
• (RA, JRA,Reactive and enteropathic arthritis,
  Sarcoid arthritis, Viral arthritis, Psoriatic
  arthritis)

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Acute Monoarthritis - Etiology

• THE MOST CRITICAL DIAGNOSIS TO CONSIDER
  INFECTION !
• Septic
• Crystal deposition (gout, pseudogout)
• Traumatic (fracture, internal derangement)
• Other (hemarthrosis, osteonecrosis, presentation
  of polyarticular disorders)

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Questions to Ask History Helps in DD

• Pain come suddenly, minutes? fracture.
• 0ver several hours or 1-2 days? infectious,
  crystals, inflammatory arthropathy.
• History of IV drug abuse or a recent infection?
  septic joint.
• Previous similar attacks? crystals or
  inflammatory arthritis.
• Prolonged courses of steroids? infection or
  osteonecrosis of the bone.

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Acute Monoarthritis
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Indications for Arthrocentesis

• The single most useful diagnostic study in
  initial evaluation of monoarthritis SYNOVIAL
  FLUID ANALYSIS
• 1. Suspicion of infection
• 2. Suspicion of crystal-induced arthritis
• 3. Suspicion of hemarthrosis
• 4. Differentiating inflammatory from
  noninflammatory arthritis

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Tests to Perform on Synovial Fluid

• Low threshold for doing Gram stain and cultures .
• Total leukocyte count/differential inflammatory
  vs. non-inflammatory.
• Polarized microscopy to look for crystals.
• Not necessary routinely Chemistry (glucose,
  total protein, LDH) unlikely to yield helpful
  information beyond the previous tests.

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Septic Joint

• Most articular infections a single joint
• 15-20 cases polyarticular
• Most common sites knee, hip, shoulder
• 20 patients afebrile
• Joint pain is moderate to severe
• Joints visibly swollen, warm, often red
• Comorbidities RA, DM, SLE, cancer,etc

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Septic Joint - Nongonococcal

• 80-90 monoarticular
• Most develop from hematogenous spread
• Most common
• Gram positive aerobes (80)
• Majority with Staph aureus (60)
• Gram negative 18

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Septic Joint - Gonococcal

• Most common cause of septic arthritis
• Often preceded by disseminated gonococcemia
• Sexually active individual, 5-7 days h/o fever,
  chills, skin lesions, migratory arthralgias and
  tenosynovitis ? persistent monoarthritis
• Women often menstruating or pregnant
• Genitourinary disease often asymptomatic

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Disseminated Gonococcemia Pustules
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Gout

• Caused by monosodium urate crystals
• Most common type of inflammatory monoarthritis
• Typically first MTP joint, ankle, midfoot, knee
• Pain very severe cannot stand bed sheet
• May be with fever and mimic infection
• The cutaneous erythema may extend beyond the
  joint and resemble bacterial cellulitis

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Acute Gouty Arthritis
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Risk Factors

• Primary gout Obesity, hyperlipidemia, diabetes
  mellitus, hypertension, and atherosclerosis.
• Secondary gout alcoholism, drug therapy
  (diuretics, cytotoxics), myeloproliferative
  disorders, chronic renal failure.

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Urate Crystals

• Needle-shaped
• Strongly negative birefringent

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CPPD Crystals Deposition Disease

• Can cause monoarthritis clinically
  indistinguishable from gout Pseudogout.
• Often precipitated by illness or surgery.
• Pseudogout is most common in the knee (50) and
  wrist.
• Reported in any joint (Including MTP).
• CPPD disease may be asymptomatic (deposition of
  CPP in cartilage).

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Associated Conditions

• Hyperparathyroidism
• Hypercalcemia
• Hypocalciuria
• Hemochromatosis
• Hypothyroidism
• Gout
• Aging

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CPPD Crystals

• Rod or rhomboid-shaped
• Weakly positive birefringent

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Other Tests Indicated for Acute Arthritis

• 1. Almost always indicated
• Radiograph, bilateral
• CBC
• 2. Indicated in certain patients
• Cultures
• PT/PTT
• ESR
• 3. Rarely indicated
• Serologic ANA, RF
• Serum Uric acid level

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Polyarthritis

• Definite inflammation (swelling, tenderness,
  warmth of gt 5 joints
• A patient with 2-4 joints is said to have pauci-
  or oligoarticular arthritis

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Acute Polyarthritis

• Infection
• Gonococcal
• Meningococcal
• Lyme disease
• Rheumatic fever
• Bacterial endocarditis
• Viral (rubella, parvovirus, Hep. B)

• Inflammatory
• RA
• JRA
• SLE
• Reactive arthritis
• Psoriatic arthritis
• Polyarticular gout
• Sarcoid arthritis

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Inflammatory Vs. Noninflammatory
Feature Inflammatory Mechanical
Morning stiffness Fatigue Activity Rest Systemic Corticosteroid gt1 h Profound Improves Worsens Yes Yes lt 30 min Minimal Worsens Improves No No
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Temporal Patterns in Polyarthritis

• Migratory pattern Rheumatic fever, gonococcal
  (disseminated gonococcemia), early phase of Lyme
  disease
• Additive pattern RA, SLE, psoriasis
• Intermittent Gout, reactive arthritis

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Patterns of Joint Involvement

• Symmetric polyarthritis involving small and large
  joints viral, RA, SLE, one type of psoriatic
  (the RA-like).
• Asymmetric, oligo- and polyarthritis involving
  mainly large joints, preferably lower
  extremities, especially knee and ankle reactive
  arthritis, one type of psoriatic, enteropathic
  arthritis.
• DIP joints Psoriatic.

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Viral Arthritis

• Younger patients
• Usually presents with prodrome, rash
• History of sick contact
• Polyarthritis similar to acute RA
• Prognosis good self-limited
• Examples Parvovirus B-19, Rubella, Hepatitis B
  and C, Acute HIV infection, Epstein-Barr virus,
  mumps

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Parvovirus B-19

• The virus of fifth disease, erythema
  infectiosum (EI).
• Children slapped cheek adults flu-like
  illness, maculopapular rash on extremities.
• Joints involved more in adults (20 of cases).
• Abrupt onset symmetric polyarthralgia/polyarthriti
  s with stiffness in young women exposed to kids
  with E.I.
• May persist for a few weeks to months.

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Viral Arthritides - Parvovirus
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Rubella Arthritis

• German measles.
• Young women exposed to school-aged children.
• Arthritis in 1/3 of natural infections also
  following vaccination.
• Morbilliform rash, constitutional symptoms.
• Symmetric inflammatory arthritis (small and large
  joints).

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Rheumatoid Arthritis

• Symmetric, inflammatory polyarthritis, involving
  large and small joints
• Acute, severe onset 10-15 subacute 20
• Hand characteristically involved
• Acute hand deformity fusiform swelling of
  fingers due to synovitis of PIPs
• RF may be negative at onset and may remain
  negative in 15-20!
• RA is a clinical diagnosis, no laboratory test is
  diagnostic, just supportive!

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Acute Polyarthritis - RA
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Acute Sarcoid Arthritis

• Chronic inflammatory disorder noncaseating
  granulomas at involved sites
• 15-20 arthritis symmetrical wrists, PIPs,
  ankles, knees
• Common with hilar adenopathy
• Erythema nodosum
• Löfgrens syndrome acute arthritis, erythema
  nodosum, bilateral hilar adenopathy

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Acute Polyarthritis in Sarcoidosis
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Reactive Arthritis

• Infection-induced systemic disease with
  inflammatory synovitis from which viable
  organisms cannot be cultured
• Association with HLA B 27
• Asymmetric, oligoarticular, knees, ankles, feet
• 40 have axial disease (spondylarthropathy)
• Enthesitis inflammation of tendon-bone junction
  (Achilles tendon, dactylitis)
• Extraarticular rashes, nails, eye involvement

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Asymmetric, Inflammatory Oligoarthritis
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Enthesitis in Reactive Arthritis
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Keratoderma Blenorrhagica Reactive Arthritis
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Reactive Arthritis - Conjunctivitis
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Reactive Arthritis Palate Erosions
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Psoriatic Arthritis

• Prevalence of arthritis in Psoriasis 5-7
• Dactilytis (sausage fingers), nail changes
• Subtypes
• Asymmetric, oligoarticular- associated dactylitis
• Predominant DIP involvement nail changes
• Polyarthritis RA-like lacks RF or nodules
• Arthritis mutilans destructive erosive
  hands/feet
• Axial involvement spondylitis 50 HLAB27 ()
• HIV-associated more severe

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Acute Polyarthritis - Psoriatic
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Dactylitis Sausage Toes Psoriasis
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Psoriasis
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Arthritis Of SLE

• Musculoskeletal manifestation 90.
• Most have arthralgia.
• May have acute inflammatory synovitis RA-like.
• Do not develop erosions.
• Other clinical features help with DD malar rash,
  photosensitivity, rashes, alopecia, oral
  ulceration.

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Butterfly Rash SLE
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Photosensitivity
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Alopecia - SLE
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Arthritis of Rheumatic Fever

• Etiology Streptococcus pyogenes (group A) there
  is damaging immune response to antecedent
  infection molecular cross reaction with target
  organs molecular mimicry.
• Migratory polyarthritis, large joints knees,
  ankles, elbows, wrists.
• Major manifestations carditis, polyarthritis,
  chorea, erythema marginatum, subcutaneous nodules.

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Erythema Marginatum Rheumatic Fever

• Circinate
• Evanenscent
• Nonpruritic rash

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Rheumatic Fever Subcutaneous Nodes
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Gouty Arthritis
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Skin Lesions Useful in Diagnosis

• Psoriatic plaques
• Keratoderma Blenorrhagicum (reactive arthritis)
• Butterfly rash (SLE)
• Salmon-colored rash of JRA, adult Stills
• Erythema marginatum (Rheumatic Fever)
• Vesicopustular lesions (gonococcal arthritis)
• Erythema nodosum (acute sarcoid, enteropathic
  arthritis)

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Disseminated Gonococcemia Pustules
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Keratoderma Blenorrhagica Reactive Arthritis
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Erythema Marginatum Rheumatic Fever

• Circinate
• Evanenscent
• Nonpruritic rash

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Adult Stills Disease and JRA Rash

• Salmon or pale-pink
• Blanching
• Macules or maculopapules
• Transient (minutes or hours)
• Most common on trunk
• Fever related

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SLE Face Rash
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SLE Interarticular Rash Hands
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Keratoderma Blenorrhagicum
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Erythema Nodosum

• Sarcoidosis
• Inflammatory Bowel Disease related arthritis

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Tenosynovitis and Usefulness in DD

• Inflammation of the synovial-lined sheaths
  surrounding tendons.
• Exam tenderness and swelling along the track of
  the involved tendon between the joints.
• Characteristic of Reactive arthritis, Gout, RA,
  gonococcal arthritis, psoriatic.

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Tenosynovitis in JRA
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Dactylitis Sausage Toes Psoriasis, Reactive,
Enteropathic
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Enthesitis
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Extraarticular Features Helpful in DD

• Eye involvement conjunctivitis in reactive
  arthritis, uveitis in enteropathic and
  sarcoidosis, episcleritis in RA
• Oral ulcerations painful in reactive arthritis
  and enteropathic, not painful in SLE
• Nail lesions pitting (psoriasis), onycholysis
  (reactive arthritis)
• Alopecia (SLE)

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Reactive Arthritis - Conjunctivitis
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Episcleritis
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Reactive Arthritis Palate Erosions
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Alopecia - SLE
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Nail Pitting - Psoriasis
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Nail Changes in Reactive Arthritis