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Approach to the Patient with Polyathritis CHAPTER Approach to the Patient with Polyathritis 32 Ved Chaturvedi, Molly M Thabah INTRODUCTION oligoarthritis, while poyarthritis is defined as pain (and Polyarthritis is a cardinal manifestation in rheumatology. It swelling) involving 4 or more joints. is essential to recognize and find the most correct cause for What is the duration of arthritis? Conventionally if the polyarthritis in an individual patient. The diagnosis of the duration of arthritis is less than 6 weeks it is acute arthritis, cause of inflammatory polyarthritis relies heavily on good and more than 6 weeks it is chronic arthritis.1 history taking and physical examination. Rheumatology as a speciality is unique in that inflammatory rheumatic Inflammatory versus non-inflammatory arthritis- diseases evolve over time. Hence one rheumatologist may Probably most important is to decide whether it is 1,3 label a patient of polyarthritis as undifferentiated arthritis inflammatory or non-inflammatory. This is so because which over a few months or years may manifest signs inflammatory arthritis especially RA if not diagnosed of rheumatoid arthritis (RA) or psoriatic arthritis (PsA). and treated early will cause bony erosion, deformity to This is also true for connective tissue diseases such as the joints and impair the patient’s quality of life. SLE can undifferentiated connective tissue disease (UCTD) which have life threatening major organ involvement. may evolve in to systemic lupus erythematosus (SLE). The classical signs of inflammation are pain, warmth, 2,3 GENERAL APPROACH TO A PATIENT WITH swelling, and erythema. All patients may not have all these signs. Inflammatory arthritis is characterized by MUSCULOSKELETAL (JOINT) PAIN presence of prolonged morning stiffness. Morning stiffness Does the patient have arthritis?- A patient is said to have is defined as the time to maximal improvement after an arthritis if one has joint pain and swelling, and the origin extended period of inactivity, and typically improves of “joint pain” (true arthritis) is from the joint (articular) with movement. In inflammatory arthritis early morning structures, in contrast to pain arising from peri-articular stiffness (after waking up in the morning) is prolonged 1 structures. Articular structures include synovium, and is present at least for 30 min, some patients may have synovial fluid, cartilage, intra-articular ligaments, the joint morning stiffness lasting for hours. The pain and stiffness 2 capsule, and adjacent bone. RA a disease of synovium, is of inflammatory arthritis often improve on gentle use of a classic example of polyarthritis. Osteoarthritis (OA) of joints and activity. An example is the low back pain, or hands a disease of articular cartilage, presents with joint buttock pain of ankylosing spondylosis which worsens pain is also polyarthritis. with rest and improves with activity. By contrast non- Joint pain also arises from involvement of peri-articular inflammatory conditions such as OA is characterized structures: ligaments, tendons, bursae, muscle, fascia, by pain which is precipitated by brief periods of rest bone and nerve.2 Examples of peri-articular (non- (gel phenomenon), exacerbated by use of the joint articular) origin of joint pain include Baker’s cyst (activity) and stiffness is brief. Inflammatory arthritis is (bursitis) producing knee pain, Achilles tendinitis can characterised by spontaneous “flares”.1 In clinical practice produce ankle pain, carpal tunnel syndrome can produce we often see inflammatory arthritis patients (prototype wrist pain. In arthritis the pain is deep or diffuse, with RA) whose disease appears well controlled but then they limited and painful range of motion on both passive and present with arthritis flare. So a spontaneous up and active movement of the involved joint, there is palpable down course is indicative of inflammatory disease. Most swelling due to synovial proliferation (synovitis), joint inflammatory arthritis is accompanied by constitutional space effusion, crepitation, and deformity. By contrast symptoms especially fatigue, low-grade fever, weight non-articular disorders tend to be painful on active loss. Fatigue is an important symptom of RA, SLE, (but not passive assisted) range of motion, example is polymyalgia rheumatica. periarthritis of shoulder (frozen shoulder). Also there On investigations a patient with inflammatory arthritis 2 is no swelling, deformity, crepitus or instability. Local may have one or more of the following;1 High erythrocyte tenderness is present in regions away from the joint line. sedimentation rate (ESR), high C-reactive protein (CRP) Patients with arthritis tend to hold the joint in partial levels. There may be normocytic normochromic anaemia. flexion, hence contractures may develop. Therefore the Thrombocytosis i.e. platelet count of more than 400,000/ 3 finding of contracture is a sign of inflamed joint. cumm is also a sign of inflammation. The total leukocyte How many joints are involved? - Single joint arthritis is count (TLC) may be high. A reversal of albumin / monoarthritis. A person with 2-3 joint involvement is 170 Musculoskeletal complaint- Joint pain Non-articular pain/ Arthritis/Arthralgia† Periarticular pain Trauma, fracture Bursitis Tendinitis Nerve entrapment Monoarthritis (1joint) Polyarthritis Oligoarthritis (2-3 joints) RHEUMATOLOGY Non-inflammatory Inflammatory Acute Chronic Acute Chronic Viral arthritis RA Amyloid OA Palindromic rheumatism Undifferentiated arthropathy Onset of CTD arthritis Hemoglobino Acute Rheumatic fever SLE pathies Polyarticular gout SSc RS3PE Poly JIA Drug induced AOSD Serum sickness Inflammatory OA Paraneoplastic Polyarticular gout Sarcoidosis Brucella †See text on how to differentiate arthritis from peri-articular/non-articular pain Abbreviations- CTD, connective tissue disease; RS3PE, remitting seronegative symmetrical synovitis with pedal edema; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; SSc, systemic sclerosis; Poly JIA, Polyarticular juvenile idiopathic arthritis; AOSD, adult onset still’s disease; OA,osteoarthritis; Fig. 1: Approach to the patient with joint pain and differential diagnosis of polyarthritis globulin ratio and moderate elevations of serum alkaline inflammatory polyarthritis and c) Chronic non- phosphatase are all seen in inflammatory arthritis. inflammatory polyarthritis. APPROACH TO POLYARTHRITIS Point to consider while taking the history of a patient Polyarthritis is arthritis of 4 joint or more. Using the presenting with polyarthritis broad principles outlined above we have the following 4 Investigations cannot replace the diagnostic clue one diagnostic categories in polyarthritis (Figure 1).1,4 can get from detail history and physical examination.3 Demographic parameters are important. Some types of a. Acute inflammatory polyarthritis b) Chronic arthritis are seen more commonly in young people while inflammatory polyarthritis c) Acute non- some are more common in older people. A young woman Box 1: Conditions that mimic polyarthritis hands and feet, (with sparing of the DIP joints) in a 171 bilateral symmetrical fashion is almost diagnostic of RA. Acute polyarthritis mimics A pattern of asymmetrical polyarthritis predominantly Fibromyalgia lower limb oligoarthritis (2-3 joint involvement), with or Neuropathies without root joint involvement (either hip or shoulder), Carpal tunnel syndrome presence of inflammatory back pain, alternating buttock Tarsal tunnel syndrome pain in a young male strongly suggest SpA. Peripheral arthritis can be the first manifestation of ankylosing Bone secondaries spondylitis in India. Myeloma A gout patient will give history of attacks of great Leprosy toe arthritis (podagra). Subsequent attacks can be CHAPTER 32 Multiple sclerosis polyarticular and involve the hands also. Therefore when Parkinson’s disease a middle aged, maybe obese man with hypertension and/ or diabetes presents with polyarthritis one should not Tendonitis forget to enquire for past history of podagra. Polymyalgia rheumatic DIP joint involvement without inflammation is Chronic recurrent multifocal osteomyelitis characteristic of primary nodal OA. Involvement of the Multifocal osteonecrosis first carpometacarpal joint is also very common in OA. The pattern of DIP joint involvement with nail findings is with painful swelling of the joints of her hands and typical of PsA. history of Raynaud’s phenomenon suggest a connective The pattern of bilateral ankle arthritis, and ankle tissue disease. Whereas an older man who has diabetes edema, with erythema nodosum is almost diagnostic of and hypertension with history of polyarthritis of large sarcoidosis or tuberculosis. Further distinctions between suggest crystal induced arthritis. these two conditions depend on tuberculin test, findings Apart from musculoskeletal history the respiratory, of chest radiographs, and computed tomography (CT) of cardiovascular, gastrointestinal, central nervous system, chest. has to be reviewed.4 In addition involvement of the Cause of Acute Inflammatory Polyarthritis- In acute airways, lungs, eye, skin, mucous membranes, and renal inflammatory polyarthritis there is involvement of 4 or system involvement is closely linked to rheumatology. more joints, and the duration is less than 6 weeks. This A past or present history of psoriasis suggests psoriatic category often poses a diagnostic challenge because the arthritis. Eye involvement (uveitis, scleritis, conjunctivitis) causes for acute inflammatory polyarthritis could either is
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