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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.
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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!
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.
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
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
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
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 Acute Polyarthritis
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.
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 Sarcoid Arthritis • Chronic inflammatory disorder – noncaseating granulomas at involved sites • 15-20% arthritis; symmetrical: wrists, PIPs, ankles, knees • Common with hilar adenopathy • Erythema nodosum • Löfgren’s syndrome: acute arthritis, erythema nodosum, bilateral hilar adenopathy
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
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
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.
