clinical approach to acute arthritis

1. Clinical Approach to Acute Arthritis Yolanda Farhey, MD Assistant Professor Division of Immunology

3. Signs of Inflammation Swelling Warmth Erythema Tenderness Loss of function

4. 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!

5. Articular Vs. Periarticular

6. Inflammatory Vs. Noninflammatory

7. 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)

8. 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)

9. 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.

10. Acute Monoarthritis

11. 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

12. 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.

13. 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

14. 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%

15. 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

16. Disseminated Gonococcemia – Pustules

17. 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

18. Acute Gouty Arthritis

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

20. Urate Crystals Needle-shaped Strongly negative birefringent

21. 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).

22. Associated Conditions Hyperparathyroidism Hypercalcemia Hypocalciuria Hemochromatosis Hypothyroidism Gout Aging

23. CPPD Crystals Rod or rhomboid-shaped Weakly positive birefringent

24. 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

25. Polyarthritis Definite inflammation (swelling, tenderness, warmth of > 5 joints A patient with 2-4 joints is said to have pauci- or oligoarticular arthritis

26. 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

27. Inflammatory Vs. Noninflammatory

28. 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

29. 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.

30. 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

31. 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.

32. Viral Arthritides - Parvovirus

33. 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).

34. 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!

35. Acute Polyarthritis - RA

36. 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

37. Acute Polyarthritis in Sarcoidosis

38. 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

39. Asymmetric, Inflammatory Oligoarthritis

40. Enthesitis in Reactive Arthritis

41. Keratoderma Blenorrhagica – Reactive Arthritis

42. Circinate Balanitis – Reactive Arthritis

43. Reactive Arthritis - Conjunctivitis

44. Reactive Arthritis – Palate Erosions

45. 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

46. Acute Polyarthritis - Psoriatic

47. Dactylitis “Sausage Toes” – Psoriasis

48. Psoriasis

49. 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.

50. Butterfly Rash – SLE

51. Photosensitivity

52. Alopecia - SLE

53. 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.

54. Erythema Marginatum – Rheumatic Fever Circinate Evanenscent Nonpruritic rash

55. Rheumatic Fever – Subcutaneous Nodes

56. Gouty Arthritis

57. Skin Lesions Useful in Diagnosis Psoriatic plaques Keratoderma Blenorrhagicum (reactive arthritis) Butterfly rash (SLE) Salmon-colored rash of JRA, adult Still’s Erythema marginatum (Rheumatic Fever) Vesicopustular lesions (gonococcal arthritis) Erythema nodosum (acute sarcoid, enteropathic arthritis)

58. Disseminated Gonococcemia – Pustules

59. Keratoderma Blenorrhagica – Reactive Arthritis

60. Circinate Balanitis – Reactive Arthritis

61. Erythema Marginatum – Rheumatic Fever Circinate Evanenscent Nonpruritic rash

62. Adult Still’s Disease and JRA Rash Salmon or pale-pink Blanching Macules or maculopapules Transient (minutes or hours) Most common on trunk Fever related

63. SLE – Face Rash

64. SLE – Interarticular Rash Hands

65. Keratoderma Blenorrhagicum

66. Erythema Nodosum Sarcoidosis Inflammatory Bowel Disease – related arthritis

67. 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.

68. Tenosynovitis in JRA

69. Dactylitis “Sausage Toes” – Psoriasis, Reactive, Enteropathic

70. Enthesitis

71. 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)

72. Reactive Arthritis - Conjunctivitis

73. Episcleritis

74. Reactive Arthritis – Palate Erosions

75. Alopecia - SLE

76. Nail Pitting - Psoriasis

77. Nail Changes in Reactive Arthritis