168 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 12, No.4, 1999 Everyday Practice

POLYARTHRITIS Approach to a patient with polyarthritis Inflammatory I Non-inflammatory R. HANDA I I Asymmetric Symmetric Osteoarthritis

Acute L Chronic Acute L Chronic I I I I Rheumatic Psoriatic. INTRODUCTION • Post viral • Rheumatoid fever arthropathy • Hepatitis B arthritis The term 'polyarthritis' refers to the involvement of more than and C • Systemic lupus four joints. The important causes of polyarthritis are inflamma- • Infective erythematosus tory [such as rheumatoid arthritis (RA), systemic lupus erythema- endocarditis • Juvenile chronic tosus (S~E), psoriasis, scleroderma, juvenile rheumatoid arthritis arthritis (of the polyarticular type), rheumatic fever, and adult -onset Still's • Systemic sclerosis disease] and non-inflammatory (such as osteoarthritis). The key • Psoriatic points to be considered in every patient with polyarthritis are arthropathy listed in the box below. FIG1. Algorithmic approach to polyarthritis

Key points in dealing with polyarthritis point is that a clinician should hesitate to diagnose RA if the • Inflammatory or non-inflammatory disease is asymmetrical.

• Distribution ARE THE UPPER OR THE LOWER LIMB JOINTS -Symmetrical or asymmetrical -Upper limbs, lower limbs or both INVOLVED? Both upper and lower limbs are involved in RA, SLE and psoria- • Pattern -Additive sis. Predominant involvement of either upper or lower limbs can -Migratory help in narrowing the diagnostic possibilities (Table II). The -Intermittent fusiform swelling typical of RA is shown in Fig. 2. • Extra-articular features TABLE II. Limb involvement in arthritis -Fever -Nodules Both upper and lower limbs -Mucocutaneous lesions • Rheumatoid arthritis • Specific joints involved • Systemic lupus erythematosus • Psoriasis • Erosive or non-erosive arthritis Mainly lower limbs • Seronegative spondyloarthropathy IS THE ARTHRITIS SYMMETRIC OR ASYMMETRIC? • Erythema nodosum • Gout Rheumatoid arthritis, SLE and nodular osteoarthritis of the hands Mainly upper limbs are typical examples of symmetric polyarthritis. While the first • Haemochromatosis two conditions are inflammatory, the latter is non-inflammatory. Gout and seronegative spondyloarthropathies are typically asym- metric oligo arthritides (Table I). Rarely, gout may be polyarticu- lar. Psoriasis may cause asymmetric oligoarticular disease or symmetric polyarthritis (Fig. 1). The most important practical

TABLE I. Asymmetrical v. symmetrical arthritis Asymmetrical • Seronegative spondyloarthritis • Psoriasis • Gout Symmetrical • Psoriasis • Rheumatoid arthritis • Systemic lupus erythematosus

Department of Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India FIG2. Fusiform swelling of RA © The National Medical Journal of India 1999 HANDA: POLYARTHRITIS 169

TABLEIII. Patterns of arthritis TABLEV. Arthritis associated with nodules Intermittent Additive • Rheumatoid arthritis • Gout • Rheumatoid arthritis • Tophaceous gout • Reiter's syndrome • Osteoarthritis • Rheumatic fever • Behcet's syndrome • Seronegative spondyloarthritis • Multicentric reticulohistiocytosis • Palindromic • Psoriasis • Sarcoidosis Migratory • Erythema nodosum • Rheumatic fever • Vasculitides • Gout • Gonococcal TABLEVI. Important causes of arthritis with mucocutaneous lesions

• Systemic lupus erythromatosus TABLEIV. Arthritic conditions associated with fever • Gonococcal arthritis • Reactive arthritis (including Reiter's syndrome) • Systemic lupus erythematosus • Behcet's syndrome • Juvenile rheumatoid arthritis* (systemic onset type)-Still's disease • Erythema nodosum • Infective endocarditis • Psoriasis • Rheumatic fever • Vasculitides • Vasculitis • Scleroderma • Adult-onset Still's disease

• also known as lCA-juvenile chronic arthritis TABLEVII. Arthritis associated with erosions on X-rays*

• Rheumatoid arthritis WHAT IS THE PATTERN OF ARTHRITIS? • Psoriasis The three common patterns of joint involvement are intermittent, additive and migratory (Table III). In intermittent arthritis, the • Gout signs and symptoms corne and go with intervening periods when • Systemic sclerosis the patient may be totally asymptomatic, whereas in additive • Multicentric reticulohistiocytosis arthritis, more and more joints become involved with time. In • systemic lupus erythromatosus causes non-erosive arthritis migratory arthritis, the joints become symptomatic and then quiescent; the.arthritis then attacks new joints. The difference high grade fever is not seen with RA and should necessitate a between this and the additive pattern is that previously involved search for other causes. joints in the migratory pattern return to normal as new joints become involved, whereas in the former the joint involvement IS THE ARTHRITIS ASSOCIATED-WITH NODULES OR persists (Table III). These patterns may co-exist in the same MUCOCUTANEOUS LESIONS? patient, but when one dominates, the clinical presentation may The presence of nodules in a patient with arthritis should arouse suggest a specific diagnosis. suspicion of the causes listed in Table V. In contrast to western patients, nodules are uncommon in Indian patients with RA. Table IS FEVER ASSOCIATED WITH THE ARTHRITIS? VI lists the arthritides associated with mucocutaneous lesions. The presence of fever along with arthritis narrows down the diagnostic possibilities to those listed in Table IV. Fig. 3 depicts WHICH JOINTS ARE INVOLVED? the typical appearance of tophaceous gout. It is important to The specific joints involved can provide a clue to the nature ofthe realize that although malaise is very common in RA, moderate-to- arthritic illness, e.g. distal interphalangeal (DIP) joint involve- ment is characteristic of osteoarthritis, while they are spared in RA. Other conditions which give rise to DIP joint involvement are psoriasis and scleroderma. Involvement of the first carpometa- carpal joint is typical of osteoarthritis, while the ankle and shoulder are rarely involved in primary osteoarthritis.

DO THE RADIOGRAPHS REVEAL EROSIONS? The presence or absence of erosions on radiographs can provide valuable clues to the diagnosis (Table VII). Inflammatory arthritis in SLE may be virtually indistinguishable from RA except for erosions which are never seen in SLE. A careful clinical examination which addresses these ques- tions can enable a diagnosis to be made in most cases of poly- arthritis.

SELECTED READING 1 Pinals S. Polyarticular joint disease. In: Klippel lH, Weyand CM, Wortman·RL (eds). FIG 3. Tophaceous gout Primer on the rheumatic diseases. Atianta:Arthritis Foundation, 1998: 119-22.