Clinical Approach to Acute Arthritis

Azam aminiRheumatologist

Boushehr university of medical science

Acute ArthritisThe 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 InflammationSwellingWarmthErythemaTendernessLoss of function

Key PointsDistinguish arthritis from soft tissue non articular syndromes If the problem is articular distinguish single joint from multiple joint involvementInflammatory or non-inflammatory diseaseAlways consider septic arthritis!

Articular Vs. PeriarticularClinical feature Articular PeriarticularAnatomic structure

Painful site Pain on movementSwelling

Synovium, cartilage, capsuleDiffuse, deepActive/passive, all planesCommon

Tendon, bursa, ligament, muscle, boneFocal “point”Active, in few planesUncommon

Inflammatory Vs. Noninflammatory

Feature Inflammatory NoninflammatoryPain (when?)SwellingErythemaWarmthAM stiffnessSystemic featuresî ESR, CRPSynovial fluid WBCExamples

Yes (AM)Soft tissue SometimesSometimesProminent SometimesFrequentWBC >2000Septic, RA, SLE, Gout

Yes (PM)BonyAbsentAbsentMinor (< 30 ‘)AbsentUncommonWBC < 2000OA, AVN

Acute MonoarthritisInflammation (swelling, tenderness, warmth) in one jointOccasionally 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 !SepticCrystal 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 ANALYSIS1. Suspicion of infection2. Suspicion of crystal-induced arthritis3. Suspicion of hemarthrosis4. 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 JointMost articular infections – a single joint15-20% cases polyarticularMost common sites: knee, hip, shoulder20% patients afebrileJoint pain is moderate to severeJoints visibly swollen, warm, often redComorbidities: RA, DM, SLE, cancer,etc

Septic Joint - Nongonococcal

80-90% monoarticularMost develop from hematogenous spreadMost common:Gram positive aerobes (80%)Majority with Staph aureus (60%)Gram negative 18%

Septic Joint - GonococcalMost common cause of septic arthritisOften preceded by disseminated gonococcemiaSexually active individual, 5-7 days h/o fever, chills, skin lesions, migratory arthralgias and tenosynovitis persistent monoarthritisWomen often menstruating or pregnantGenitourinary disease often asymptomatic

Disseminated Gonococcemia – Pustules

GoutCaused by monosodium urate crystalsMost common type of inflammatory monoarthritisTypically: first MTP joint, ankle, midfoot, kneePain very severe; cannot stand bed sheetMay be with fever and mimic infectionThe cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis

Acute Gouty Arthritis

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

Urate CrystalsNeedle-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 ConditionsHyperparathyroidismHypercalcemiaHypocalciuriaHemochromatosisHypothyroidismGoutAging

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

PolyarthritisDefinite inflammation (swelling, tenderness, warmth of > 5 jointsA patient with 2-4 joints is said to have pauci- or oligoarticular arthritis

Acute PolyarthritisInfectionGonococcalMeningococcalLyme diseaseRheumatic feverBacterial endocarditisViral (rubella, parvovirus, Hep. B)

InflammatoryRAJRASLEReactive arthritisPsoriatic arthritisPolyarticular goutSarcoid arthritis

Inflammatory Vs. Noninflammatory

Feature Inflammatory Mechanical

Morning stiffnessFatigueActivityRestSystemicCorticosteroid

>1 h

Profound ImprovesWorsensYesYes

< 30 min

MinimalWorsensImprovesNoNo

Temporal Patterns in Polyarthritis

Migratory pattern: Rheumatic fever, gonococcal (disseminated gonococcemia), early phase of Lyme diseaseAdditive pattern: RA, SLE, psoriasisIntermittent: 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 ArthritisYounger patientsUsually presents with prodrome, rashHistory of sick contactPolyarthritis similar to acute RAPrognosis good; self-limitedExamples: Parvovirus B-19, Rubella, Hepatitis B and C, Acute HIV infection, Epstein-Barr virus, mumps

Parvovirus B-19The 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 ArthritisGerman 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 ArthritisSymmetric, inflammatory polyarthritis, involving large and small jointsAcute, severe onset 10-15 %; subacute 20%Hand characteristically involvedAcute hand deformity: fusiform swelling of fingers due to synovitis of PIPsRF 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 ArthritisChronic inflammatory disorder – noncaseating granulomas at involved sites15-20% arthritis; symmetrical: wrists, PIPs, ankles, kneesCommon with hilar adenopathyErythema nodosumLöfgren’s syndrome: acute arthritis, erythema nodosum, bilateral hilar adenopathy

Acute Polyarthritis in Sarcoidosis

Reactive ArthritisInfection-induced systemic disease with inflammatory synovitis from which viable organisms cannot be cultured Association with HLA B 27 Asymmetric, oligoarticular, knees, ankles, feet40% 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 ArthritisPrevalence of arthritis in Psoriasis 5-7%Dactilytis (“sausage fingers”), nail changesSubtypes: 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 SLEMusculoskeletal 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 – 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.

Erythema Marginatum – Rheumatic Fever

CircinateEvanenscentNonpruritic rash

Rheumatic Fever – Subcutaneous Nodes

Gouty Arthritis

Skin Lesions Useful in Diagnosis

Psoriatic plaquesKeratoderma Blenorrhagicum (reactive arthritis)Butterfly rash (SLE)Salmon-colored rash of JRA, adult Still’sErythema marginatum (Rheumatic Fever)Vesicopustular lesions (gonococcal arthritis)Erythema nodosum (acute sarcoid, enteropathic arthritis)

Disseminated Gonococcemia – Pustules

Keratoderma Blenorrhagica – Reactive

Arthritis

Erythema Marginatum – Rheumatic Fever

CircinateEvanenscentNonpruritic rash

Adult Still’s Disease and JRA Rash

Salmon or pale-pink BlanchingMacules or maculopapulesTransient (minutes or hours)Most common on trunkFever 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 RAOral ulcerations: painful in reactive arthritis and enteropathic, not painful in SLENail 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