Clinical Approach to Acute Arthritis

Yolanda Farhey, MD Assistant Professor Division of Immunology

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 (discrepancy between active and passive ROM suggests periarticular/soft tissue) 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 Synovium, structure cartilage, capsule Diffuse, deep Painful site Active/passive, Pain on all planes movement Common Swelling Periarticular Tendon, bursa, ligament, muscle, bone Focal point Active, in few planes Uncommon

Inflammatory Vs. Noninflammatory

Feature
Pain (when?) Swelling Erythema Warmth AM stiffness Systemic features 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 rhomboidshaped Weakly positive birefringent

Other Tests Indicated for Acute Arthritis

1. Almost always indicated:

Radiograph, bilateral CBC Cultures PT/PTT ESR Serologic: ANA, RF Serum Uric acid level

2. Indicated in certain patients:

3. Rarely indicated:

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

Inflammatory Vs. Noninflammatory

Feature
Morning stiffness Fatigue Activity Rest Systemic Corticosteroid

Inflammatory
>1 h Profound Improves Worsens Yes Yes

Mechanical
< 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 Lfgrens 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

Circinate Balanitis 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 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

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 Stills Erythema marginatum (Rheumatic Fever) Vesicopustular lesions (gonococcal arthritis) Erythema nodosum (acute sarcoid, enteropathic arthritis)

Disseminated Gonococcemia Pustules

Keratoderma Blenorrhagica Reactive Arthritis

Circinate Balanitis Reactive Arthritis

Erythema Marginatum Rheumatic Fever

Circinate Evanenscent Nonpruritic rash

Adult Stills 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