Transcript Clinical Approach to Acute Arthritis
Clinical Approach to Acute Arthritis
Azam amini Rheumatologist Boushehr university of medical science
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.
Signs of Inflammation
Swelling Warmth Erythema Tenderness Loss of function
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!
Articular Vs. Periarticular
Clinical feature Articular Anatomic structure Painful site Pain on movement Swelling Synovium, cartilage, capsule Periarticular Tendon, bursa, ligament, muscle, bone Focal “point” Diffuse, deep Active/passive, all planes Active, in few planes Common Uncommon
Inflammatory Vs. Noninflammatory
Feature Pain (when?) Swelling Erythema Warmth AM stiffness Systemic features î ESR, CRP Synovial fluid WBC Examples Inflammatory Yes (AM) Soft tissue Sometimes Sometimes Prominent Sometimes Frequent WBC >2000 Septic, RA, SLE, Gout Noninflammatory Yes (PM) Bony Absent Absent Minor (< 30 ‘) Absent Uncommon WBC < 2000 OA, AVN
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)
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)
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.
Acute Monoarthritis
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
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.
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
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%
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
Disseminated Gonococcemia – Pustules
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
Acute Gouty Arthritis
Risk Factors
Primary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis.
Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure.
Urate Crystals
Needle-shaped Strongly negative birefringent
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).
Associated Conditions
Hyperparathyroidism Hypercalcemia Hypocalciuria Hemochromatosis Hypothyroidism Gout Aging
CPPD Crystals
Rod or rhomboid shaped Weakly positive birefringent
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
Polyarthritis
Definite inflammation (swelling, tenderness, warmth of > 5 joints A patient with 2-4 joints is said to have pauci- or oligoarticular arthritis
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
Feature
Inflammatory Vs. Noninflammatory
Inflammatory Mechanical Morning stiffness Fatigue Activity Rest Systemic Corticosteroid >1 h Profound Improves Worsens Yes Yes < 30 min Minimal Worsens Improves No No
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
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.
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
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/polyarthritis with stiffness in young women exposed to kids with E.I.
May persist for a few weeks to months.
Viral Arthritides Parvovirus
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).
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!
Acute Polyarthritis - RA
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 L öfgren’s syndrome: acute arthritis, erythema nodosum, bilateral hilar adenopathy
Acute Polyarthritis in Sarcoidosis
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
Asymmetric, Inflammatory Oligoarthritis
Enthesitis in Reactive Arthritis
Keratoderma Blenorrhagica – Reactive Arthritis
Reactive Arthritis Conjunctivitis
Reactive Arthritis – Palate Erosions
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
Acute Polyarthritis Psoriatic
Dactylitis “Sausage Toes” – Psoriasis
Psoriasis
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.
Butterfly Rash – SLE
Photosensitivity
Alopecia - SLE
Arthritis of Rheumatic Fever
Etiology: Streptococcus pyogenes (group A); there is damaging immune response to antecedent infection mimicry”.
– molecular cross reaction with target organs “molecular Migratory polyarthritis, large joints: knees, ankles, elbows, wrists.
Major manifestations: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules.
Erythema Marginatum – Rheumatic Fever
Circinate Evanenscent Nonpruritic rash
Rheumatic Fever – Subcutaneous Nodes
Gouty Arthritis
Skin Lesions Useful in Diagnosis
Psoriatic plaques Keratoderma Blenorrhagicum (reactive arthritis) Butterfly rash (SLE) Salmon colored rash of JRA, adult Still’s Erythema marginatum (Rheumatic Fever) Vesicopustular lesions (gonococcal arthritis) Erythema nodosum (acute sarcoid, enteropathic arthritis)
Disseminated Gonococcemia – Pustules
Keratoderma Blenorrhagica – Reactive Arthritis
Erythema Marginatum – Rheumatic Fever
Circinate Evanenscent Nonpruritic rash
Adult Still’s Disease and JRA Rash
Salmon or pale-pink Blanching Macules or maculopapules Transient (minutes or hours) Most common on trunk Fever related
SLE – Face Rash
SLE – Interarticular Rash Hands
Keratoderma Blenorrhagicum
Erythema Nodosum
Sarcoidosis Inflammatory Bowel Disease – related arthritis
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.
Tenosynovitis in JRA
Dactylitis “Sausage Toes” – Psoriasis, Reactive, Enteropathic
Enthesitis
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)
Reactive Arthritis Conjunctivitis
Episcleritis
Reactive Arthritis – Palate Erosions
Alopecia - SLE
Nail Pitting - Psoriasis
Nail Changes in Reactive Arthritis