ACUTE ARTHRITIS

BY Dr. Mehrunnisa Umar

MBBS,FCPS.

ASSISTANT PROFESSOR
HAMDARD COLLEGE OF MEDICINE & DENTISTRY @ KARACHI

CLINICAL APPROACH TO ACUTE ARTHRITIS

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
IF THE PROBLEM IS ARTICULAR

TISSUE NON ARTICULAR SYNDROMES

DISTINGUISH SINGLE JOINT FROM MULTIPLE JOINT INVOLVEMENT DISEASE

INFLAMMATORY OR NON-INFLAMMATORY DONT FORGET SEPTIC ARTHRITIS!

ARTICULAR VS PERIARTICULAR
CLINICAL FEATURE ARTICULAR PERIARTICULAR

ANATOMIC STRUCTURE PAINFUL SITE PAIN ON MOVEMENT SWELLING

SYNOVIUM, CARTILAGE, CAPSULE DIFFUSE, DEEP ACTIVE/PASSIVE, ALL PLANES COMMON

TENDON, BURSA, LIGAMENT, MUSCLE, 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

NON INFLAMMATORY
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
SEPTIC CRYSTAL DEPOSITION (GOUT, PSEUDOGOUT) TRAUMATIC (FRACTURE, INTERNAL

DERANGEMENT)

OTHER HEMARTHROSIS OSTEONECROSIS

QUESTIONS TO ASK THAT HELPS IN DD

PAIN COME SUDDENLY, PREVIOUS SIMILAR

MINUTES? FRACTURE

ATTACKS?

0VER SEVERAL HOURS

OR 1-2 DAYS? INFECTIOUS CRYSTALS INFLAMMATORY ARTHROPATHY

CRYSTALS OR INFLAMMATORY

ARTHRITIS

PROLONGED COURSES

OF STEROIDS?

HISTORY OF IV DRUG

ABUSE OR A RECENT INFECTION? septic

INFECTION OSTEONECROSIS OF

THE BONE

Cause Avascular necrosis

Suggestive Findings Joint pain in a patient with history of corticosteroid use or sickle cell disease Acute onset, severe pain, redness, swelling, great toe or knee

Diagnostic approach X-ray plus CT or MRI

Crystal-induced arthritis (uric acid, Ca pyrophosphate, Ca hydroxyapetite)

Arthrocentesis with cell counts, Gram stain, cultures, and crystal examination

Haemarthrosis

Acute onset Trauma, Typically, a known bleeding disorder, hemoglobinopathy, or coagulopathy

Arthrocentesis plus CT or MRI

Osteoarthritis

Slowly progressive older, obese or patients who frequently use the affected joint (eg, in manual labor or high-impact sports)
Fever and poorly localized pain without joint swelling or erythema

X-ray

Osteomyelitis

X-ray plus bone scan, CT, or MRI Sometimes CT-guided bone biopsy

ACUTE MONOARTHRITIS

INDICATIONS FOR ARTHROCENTESIS

MOST USEFUL DIAGNOSTIC TEST FOR

MONOARTHRITIS IS

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

Inflammatory Vs infecftious changes of synovial fluid

OTHER TESTS INDICATED FOR ACUTE ARTHRITIS

RADIOGRAPH, BILATERAL CBC CULTURES

PT/APTT
ESR SEROLOGIC

ANA RF SERUM URIC ACID LEVEL

SEPTIC JOINT

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

GOUT
CAUSED BY MONOSODIUM URATE CRYSTALS MOST COMMON TYPE OF INFLAMMATORY

MONOARTHRITIS

TYPICALLY:

FIRST MTP JOINT, ANKLE, MIDFOOT, KNEE

PAIN VERY SEVERE MAY BE WITH FEVER AND MIMIC INFECTION THE CUTANEOUS ERYTHEMA MAY EXTEND BEYOND THE

JOINT AND RESEMBLE BACTERIAL CELLULITIS

ACUTE GOUTY ARTHRITIS

RISK FACTORS
OBESITY

HYPERLIPIDEMIA
DIABETES MELLITUS HYPERTENSION ATHEROSCLEROSIS ALCOHOLISM DRUG THERAPY (DIURETICS,

CYTOTOXICS) MYELOPROLIFERATIVE DISORDERS CHRONIC RENAL FAILURE

URATE CRYSTALS
NEEDLE-SHAPED
STRONGLY

NEGATIVE BIREFRINGENT

PSEUDOGOUT

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 CPPD IN CARTILAGE)

ASSOCIATED CONDITIONS
HYPERPARATHYROIDISM HYPERCALCEMIA HYPOCALCIURIA HEMOCHROMATOSIS HYPOTHYROIDISM

GOUT
AGING

CPPD CRYSTALS

ROD OR

RHOMBOIDSHAPED

WEAKLY

POSITIVE BIREFRINGENT

GOUTY ARTHRITIS

POLYARTHRITIS

POLYARTHRITIS
DEFINITE INFLAMMATION

(SWELLING, TENDERNESS, WARMTH) OF > 5 JOINTS OLIGOARTHRITS

A PATIENT WITH 2-4 JOINTS IS

SAID TO HAVE PAUCI- OR OLIGOARTICULAR ARTHRITIS

CAUSES OF ACUTE POLYARTHRITIS

INFECTION
GONOCOCCAL MENINGOCOCCAL LYME DISEASE RHEUMATIC FEVER BACTERIAL ENDOCARDITIS VIRAL (RUBELLA,

INFLAMMATORY
RA JRA

SLE
REACTIVE ARTHRITIS PSORIATIC ARTHRITIS POLYARTICULAR GOUT SARCOID ARTHRITIS

PARVOVIRUS, HBV)

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

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 SYMPTOMS

MORBILLIFORM RASH, CONSTITUTIONAL SYMMETRIC INFLAMMATORY ARTHRITIS (SMALL

AND LARGE JOINTS)

RHEUMATOID ARTHRITIS

RHEUMATOID ARTHRITIS

SYMMETRIC, INFLAMMATORY POLYARTHRITIS, INVOLVING LARGE AND SMALL JOINTS

ACUTE 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

ANKLES, KNEES

15-20% ARTHRITIS; SYMMETRICAL: WRISTS, PIPS,

COMMON WITH HILAR ADENOPATHY

ERYTHEMA NODOSUM LFGRENS SYNDROME

ACUTE ARTHRITIS, ERYTHEMA NODOSUM, BILATERAL HILAR ADENOPATHY

ACUTE POLYARTHRITIS IN SARCOIDOSIS

ERYTHEMA NODOSUM

SARCOIDOSIS INFLAMMATORY

BOWEL DISEASE RELATED ARTHRITIS

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

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% HLA B27 (+) HIV-ASSOCIATED MORE SEVERE

ACUTE POLYARTHRITIS - PSORIATIC

NAIL PITTING - PSORIASIS

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

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

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

THANKS

ANY QUESTIONS ???????