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Differential Diagnosis of Polyarticular Arthritis GEORGE G.A

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Differential Diagnosis of Polyarticular Arthritis GEORGE G.A Differential Diagnosis of Polyarticular Arthritis GEORGE G.A. PUJALTE, MD, Mayo Clinic Health System, Waycross, Georgia SHIRLEY A. ALBANO-ALUQUIN, MD, Pennsylvania State University College of Medicine, Hershey, Pennsylvania Polyarticular arthritis is commonly encountered in clinical settings and has multiple etiologies. The first step is to distinguish between true articular pain and nonarticular or periarticular conditions by recognizing clinical patterns through the history and physical examination. Once pain within a joint or joints is confirmed, the next step is to clas- sify the pain as noninflammatory or inflammatory in origin. Noninflammatory arthritis, which is mostly related to osteoarthritis, has a variable onset and severity and does not have inflammatory features, such as warm or swollen joints. Osteoarthritis usually presents with less than one hour of morning stiffness and pain that is aggravated by activity and improves with rest. A review of systems is usually negative for rashes, oral ulcers, or other internal organ involvement. In contrast, inflammatory arthritis generally causes warm, swollen joints; prolonged morning stiffness; and positive findings on a review of systems. Once inflammatory arthritis is suspected, possible diagnoses are sorted by the pattern of joint involvement, which includes number and type of joints involved, symmetry, and onset. The suspicion for inflammatory arthritis should be confirmed by the appropriate serologic/tissue and/or imaging studies in the clinical setting or in consultation with a subspecialist. (Am Fam Physician. 2015;92(1):35-41. Copyright © 2015 American Academy of Family Physicians.) CME This clinical content hen a patient presents with considered chronic after two weeks. The conforms to AAFP criteria pain in multiple joints, the pattern of chronic symptoms should be for continuing medical pain can originate from the classified as intermittent or constant (fluctu- education (CME). See CME Quiz Questions on joint (true arthritis); the ating from mild, moderate, or severe) to help page 16. Wadjacent structures, such as bone, tendon, identify the behavior of the inflammatory Author disclosure: No rel- or bursa; or from psychogenic/metabolic process, possible triggers, and concurrent evant financial affiliations. factors, such as depression or hypothyroid- problems. ism. Once arthritis is suspected, physicians The pattern of joint involvement is pro- should distinguish between noninflamma- filed by assessing symmetry, and number tory and inflammatory forms of arthritis and types of joints involved. A symmet- while recognizing potentially disabling and ric pattern affects both sides of the body as life-threatening problems. opposed to an asymmetric pattern, which Conditions with polyarthritis are often has a spotty distribution. Possible condi- accompanied by synovitis. On the other tions are classified based on number of hand, conditions that cause pain outside of joints affected: pauciarticular pattern (two the joints are considered when there is no to four joints) vs. polyarticular pattern (five apparent joint inflammation. Nearly 50% or more joints). The spondyloarthropathies of patients with polyarticular pain will have are classically pauciarticular, whereas rheu- unclassifiable conditions; these patients may matoid arthritis (RA) is usually polyarticu- not need medications and may go into remis- lar. However, spondyloarthropathies, such sion within one year.1 However, patients with as psoriatic arthritis, may also present in a unclassifiable conditions may benefit from polyarticular manner, whereas RA may ini- medications for symptomatic relief. tially affect just a few joints. The size and kind of joints involved Patient History also provide major diagnostic clues. For The first step in the diagnosis is to determine instance, spondyloarthropathies often the onset and timing (acute vs. chronic) involve the spine, including sacroiliac joints of symptoms. Acute symptoms last from and medium/large joints, such as the shoul- hours to two weeks, whereas symptoms are ders, hips, knees, and ankles. Smaller joint JulyDownloaded 1, 2015 from◆ Volume the American 92, Number Family Physician 1 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2015 American Academy of FamilyAmerican Physicians. Family For the private,Physician noncom 35- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Polyarticular Arthritis SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Joint swelling, erythema, prolonged morning stiffness (more than one hour), and symmetric pain even at C 3-6 rest are suggestive of inflammatory conditions. Noninflammatory and inflammatory conditions can be differentiated with C-reactive protein and erythrocyte C 7, 8 sedimentation rate tests; however, in the acute phase, erythrocyte sedimentation rate is less reliable than C-reactive protein. In the diagnosis of gout, a high serum uric acid level has little diagnostic value. The standard of diagnosis is C 14, 15 the presence of intracellular monosodium urate crystals on polarized microscopy. Osteoarthritis is noninflammatory; is typically pauciarticular; and often involves the spine and weight-bearing C 3-6 joints, such as the hips and knees. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. involvement, such as the wrists, fingers, and toes, is more a neurologic cause of pain might be combined with a consistent with RA and lupus. Table 1 summarizes clini- rheumatologic cause, leading to mixed characteristics. cal patterns that are helpful in the diagnosis of polyar- Extra-articular symptoms can help narrow the diag- ticular arthritis.2-6 nostic options. For example, weakness may be a sign of neuromuscular disease, whereas dry mouth, dry eyes, INFLAMMATORY AND NONINFLAMMATORY ARTHRITIS Raynaud phenomenon, pleuritic chest pain, nasal ulcers, Arthritis can be divided into two broad categories: oral ulcers, alopecia, adenopathy, or rash might suggest inflammatory and noninflammatory (degenerative systemic inflammatory rheumatologic conditions. Con- arthritis). The presence of joint swelling, erythema, stitutional symptoms such as weight loss, night sweats, prolonged morning stiffness (more than one hour), and fever, and fatigue are also more common with systemic symmetric pain even at rest is suggestive of inflamma- illnesses. tory conditions.3-6 On the other hand, weight bearing Patient history, including social history, can provide and movement worsens the pain of noninflammatory further insight into the patient’s physiologic state. This arthritis conditions, such as osteoarthritis. Noninflam- includes identifying comorbid conditions that might matory arthritis typically causes less than one hour of increase the pain burden, such as diabetes mellitus with morning stiffness. Weight-bearing joints in the lower complications of neuropathy; depression; polypharmacy extremities are likewise more commonly involved in an and use of medications that can cause arthritis, such as asymmetric pattern. A symmetric presentation suggests in drug-induced lupus arthritis; exposure to ticks that an underlying inflammatory arthritis condition.2 can cause Lyme disease in an endemic area; or exposure Signs of systemic inflammation include rashes (e.g., to hepatitis C, parvovirus, or human immunodeficiency psoriasis, photosensitivity), oral and genital ulcerations, virus, which can lead to viral arthritis.3 The history Raynaud phenomenon, serositis with pleurisy and peri- should also include surgical procedures, fractures, and carditis, sicca symptoms of dry eyes and dry mouth, trauma. The patient’s exercise capabilities or ability to eye inflammation, bowel inflammation, neurologic perform activities of daily living should be assessed. symptoms, and ischemic symptoms (including stroke). These signs are integral in correctly diagnosing systemic EMERGENT CONDITIONS inflammatory arthropathy. In general, emergent conditions involving the joints present acutely and should be recognized promptly. OTHER CAUSES OF JOINT PAIN Septic arthritis typically involves a large joint such as Neurologic causes of pain may be determined by char- the knee,3 but can affect several joints and is accompa- acterization; apart from numbness and burning pain, the nied by malaise, weight loss, fever, and swollen and/or pain is unlikely to worsen with joint movement and is warm joints.3 Other conditions include neuropathies, likely to worsen at night. Combinations of causes might radiculopathies, or myelopathies, which cause numb- make characterization of pain difficult. For example, ness or a burning pain, (e.g., cauda equina syndrome); 36 American Family Physician www.aafp.org/afp Volume 92, Number 1 ◆ July 1, 2015 Polyarticular Arthritis compartment syndrome, with joint pain exceeding what polyarthritis who tests negative for the antibodies. would be expected based on physical examination find- Conversely, many rheumatic conditions can be associ- ings; and sepsis or infection. ated with antinuclear antibodies; therefore, a positive test result does not always correlate with SLE, especially Physical Examination in a patient who lacks other specific clinical criteria.2,3
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