clinical approach to acute arthritis
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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. - PowerPoint PPT PresentationTRANSCRIPT
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