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7/29/2019 Acute Arthritisbk

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Clinical Approach to

Acute Arthritis

Yolanda Farhey, MDAssistant Professor

Division of Immunology


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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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Articular Vs.

PeriarticularClinical feature Articular Periarticular

Anatomic

structure

Painful site

Pain onmovement

Swelling

Synovium,

cartilage,capsule

Diffuse, deep

Active/passive,all planes

Common

Tendon, bursa,

ligament,muscle, bone

Focal point

Active, in fewplanes

Uncommon


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Inflammatory Vs.

NoninflammatoryFeature Inflammatory Noninflammatory

Pain (when?)

SwellingErythema

Warmth

AM stiffness

Systemic features

ESR, CRP

Synovial fluid WBC

Examples

Yes (AM)

Soft tissueSometimes

Sometimes

Prominent

Sometimes

Frequent

WBC >2000

Septic, RA, SLE,

Gout

Yes (PM)

BonyAbsent

Absent

Minor (< 30 )

Absent

Uncommon

WBC < 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 -

EtiologyTHE MOST CRITICAL DIAGNOSIS TOCONSIDER: INFECTION !

SepticCrystal deposition (gout, pseudogout)

Traumatic (fracture, internal

derangement)Other (hemarthrosis, osteonecrosis,presentation of polyarticular disorders)


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Questions to Ask

History Helps in DDPain 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 orosteonecrosis of the bone.


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Acute Monoarthritis


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Indications for

ArthrocentesisThe single most useful diagnostic studyin initial evaluation of monoarthritis:

SYNOVIAL FLUID ANALYSIS1. Suspicion of infection

2. Suspicion of crystal-induced arthritis

3. Suspicion of hemarthrosis4. Differentiating inflammatory fromnoninflammatory arthritis


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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 severeJoints visibly swollen, warm, often red

Comorbidities: RA, DM, SLE, cancer,etc


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Septic Joint -

Nongonococcal80-90% 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 -

GonococcalMost common cause of septic arthritis

Often preceded by disseminated

gonococcemiaSexually 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

monoarthritisTypically: first MTP joint, ankle, midfoot, knee

Pain very severe; cannot stand bed sheet

May be with fever and mimic infectionThe 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, chronicrenal failure.


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Urate Crystals

Needle-shaped

Strongly negativebirefringent


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CPPD Crystals

Deposition DiseaseCan 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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Polyarthritis

Definite inflammation(swelling, tenderness,warmth of > 5 joints

A patient with 2-4 joints is

said to have pauci- oroligoarticular arthritis


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Acute Polyarthritis

Infection

Gonococcal

MeningococcalLyme disease

Rheumatic fever

Bacterial

endocarditisViral (rubella,parvovirus, Hep. B)

Inflammatory

RA

JRASLE

Reactive arthritis

Psoriatic arthritisPolyarticular gout

Sarcoid arthritis


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Inflammatory Vs.

NoninflammatoryFeature Inflammatory Mechanical

Morning

stiffness

Fatigue

Activity

RestSystemic

Corticosteroid

>1 h

Profound

Improves

Worsens

Yes

Yes

< 30 min

Minimal

Worsens

Improves

No

No


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Temporal Patterns in

PolyarthritisMigratory pattern: Rheumatic fever,

gonococcal (disseminated

gonococcemia), early phase of Lymedisease

Additive pattern: RA, SLE, psoriasis

Intermittent: Gout, reactive arthritis


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Patterns of Joint

InvolvementSymmetric 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 contactPolyarthritis 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, erythemainfectiosum (EI).

Children slapped cheek; adults flu-likeillness, maculopapular rash on extremities.

Joints involved more in adults (20% of cases).

Abrupt onset symmetric

polyarthralgia/polyarthritis with stiffness inyoung women exposed to kids with E.I.

May persist for a few weeks to months.


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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 involvedAcute hand deformity: fusiform swelling offingers 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 isdiagnostic, 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

Lfgrens 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 withinflammatory synovitis from which viableorganisms cannot be cultured

Association with HLA B 27

Asymmetric, oligoarticular, knees, ankles, feet

40% have axial disease (spondylarthropathy)

Enthesitis: inflammation of tendon-bonejunction (Achilles tendon, dactylitis)

Extraarticular: rashes, nails, eye involvement


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Enthesitis in Reactive

Arthritis

K t d


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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 involvementspondylitis 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 synovitisRA-like.

Do not develop erosions.

Other clinical features help with DD:malar rash, photosensitivity, rashes,alopecia, oral ulceration.


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Alopecia - SLE


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Arthritis of Rheumatic

FeverEtiology: Streptococcus pyogenes (group A);there is damaging immune response toantecedent infection molecular cross

reaction with target organs molecularmimicry.

Migratory polyarthritis, large joints: knees,ankles, elbows, wrists.

Major manifestations: carditis, polyarthritis,chorea, erythema marginatum, subcutaneousnodules.


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Erythema Marginatum

Rheumatic FeverCircinate

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

DiagnosisPsoriatic plaques

Keratoderma Blenorrhagicum (reactivearthritis)

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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Keratoderma


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Keratoderma

Blenorrhagica

Reactive Arthritis


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Circinate Balanitis

Reactive Arthritis


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Adult Stills Disease and

JRA RashSalmon or pale-pink

Blanching

Macules ormaculopapules

Transient (minutesor hours)

Most common ontrunk

Fever related


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SLEFace Rash


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SLEInterarticular

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 DDInflammation of the synovial-lined

sheaths surrounding tendons.

Exam: tenderness and swelling alongthe 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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Extraarticular Features

Helpful in DDEye 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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Episcleritis


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Reactive Arthritis

Palate Erosions


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Alopecia - SLE


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