sign in sign up
<<
Home , Monoarthritis, Oligoarthritis, Polyarthritis

CHAPTER Approach to

35 Liyakat Ali Gauri, BR Ajay, Asim Khan, Nadeem Liyakat, Qadir Fatima

ABSTRACT Arthritis is the of the which is a term derived from Greek in which arthro- means and –itis means inflammation. Once the source of pain is confirmed as originating from joint then decide whether the disease is inflammatory or non-inflammatory in nature. Patients with an inflammatory arthritis are more likely to have palpable synovitis and morning stiffness; if the condition is severe, they may have , weight loss, and fatigue. Then evaluate the temporal pattern of the disorder; especially acute versus chronic duration. Then classify the arthritis according to the spatial pattern: primarily, or poly arthritis and the presence of axial involvement. Then search for the existence of extra- articular and/or systemic manifestations. Arthritis is the inflammation of the joints which is a term derived from Greek in which arthro- means joint and– itis means inflammation. 12th October has been declared as World Arthritis day. Musculoskeletal diseases are among the most common reasons for which medical help is sought. Anywhere between 25% and 30% individuals Fig. 1: Stress pain and restriction at the wrist – there is no pain in the will have a musculoskeletal complaint in their life neutral ‘loose-pack’ position, but progressive pain and some restriction as the wrist moves towards full extension or full flexion Table 1 : Distinctive features of regional syndromes Periarticular pain Articular pain Neurogenic pain Referred pain Enquiry Only a few selective All joint movements Dysaesthesic; Unrelated to movements are are painful aggravated by movement; ‘visceral’ painful compression of nerve timing; poorly or movement of the localised, may be spine improved by rubbing Pain on motion Active> passive; Active~passive; Normal; if root pain: Normal selected movements several directions pain on movement of the affected spine segment Range of motion Active movement May be limited Normal Normal may be limited equally for both by pain; passive active and passive movement: full movement Resisted active Pain on specific No effect No effect No effect movement manoeuvres Local palpation Tenderness over Possible tenderness Normal Normal affected periarticular over joint line, structure (away from , capsular joint line) swelling, effusion, increased heat Neurological Normal Normal May be abnormal Normal examination 158 time. the complaint is (1) articular or non-articular in origin, (2) component. The evaluation should proceed to ascertain if and other musculoskeletal conditions, which have no diagnosed systemic from distinguished be correctly to have conditions These detected, treated. not if threatening life- potentially be may which etc. (SLE) erythematosus lupus (RA),systemic arthritis rheumatoid as systemic such illness fact in have complaints musculoskeletal with Trauma Monoarthritis ) onset ofpolyarthritis, Polyarthritis (e.g.,acute (like RA,SLE) inflammatory polyarthritis Acute onsetof Gonococcal arthritis ( andpseudogout) Crystal inducedarthritis Monoarthritis Acute arthritis ofmonoarthritis onmajorcauses with afocus Table causes ofarthritis 3:Shows ofthe abroad classification Table 2:Differences between inflamedanddamagedjoints Stress pain warmth Increased stiffness Inactivity stiffness Early morning Instability deformity Malalignment/ Erythema Coarse crepitus Effusion tissue swelling Capsular soft- 1,2 A significant proportion of patients who present who patients of proportion significant A Non-inflammatory Inflamed joint Inflammatory Prolonged Prolonged +++ Yes +/− + − − − + ) Polyarthritis (e.g., synovitis Pigmented villonodular Osteonecrosis Neuropathic Single jointosteoarthritis Monoarthritis spondyloarthritis) RA, psoriaticarthritis, Polyarthritis (e.g., Crystal inducedarthritis arthritis Immunoinflammatory Brucellosis) Other infections(e.g Fungal arthritis Tubercular arthritis Monoarthritis Chronic arthritis Damaged joint Brief Brief +++ No +/− +/− +/− − – − Articular structures include the synovium, synovial fluid, • • • b. a. allow thedistinctionoffour mainorigins(Table 1): is to confirm that the origin of pain is from thejoint. from is pain of witharthritis basis). (anatomical origin to apatient the that confirm to in approach is step first The indistribution. widespread (polyarticular) or (monoarticular) localized (4) and duration, in chronic inflammatory or non-inflammatory in nature, (3) acute or ARTICULARNONARTICULAR VERSUS erythema nodosum Hilar adenopathy, and feet,dermatitis tendon sheathsofhands inflammation ofthe migratory polyarthralgias, Young adulthood, back pain Eye inflammation,low stones oralcoholicbinges of tophi,historyrenal Use ofdiuretics,presence changes suchaspitting Psoriatic patchesornail diarrhea, andrash Urethritis, conjunctivitis, anticoagulants Coagulopathy, useof of corticosterioidtherapy Recent prolongedcourse spontaneous resolution in anyjoint,with Previous acuteattacks immunosuppression Intravenous druguse, over daystoweeks Insidious onsetofpain hours oronetotwodays Onset ofpainover several seconds orminutes Sudden onsetofpainin physical examination Clues fromhistoryand Pain Table inPatients Clues 4:Diagnostic Presenting withJoint referred pain. neurogenic pain periarticular pain Extra articularpain: Articular pain 3 usinn ad xmnto will examination and Questioning Sarcoidosis Gonococcal arthritis Gout Reactive arthritis Hemarthrosis necrosis Infection, avascular arthritic condition other inflammatory Crystal deposition disease, Septic arthritis disease, tumor osteoarthritis, infiltrative Indolent infection, condition inflammatory arthritic deposition disease,other Infection, crystal loose body derangement, Trauma, Fracture, internal Diagnoses toconsider CHAPTER 35 159 Patient has Patient bone disease or firbomyalgia bursitis, tendinitis, tumor, or metabolic Patient has fracture, Patient Patient has osteoarthritis, Patient Yes internal derangement, soft tissue , or viral infection Joint fluid is sterile pelvic radiography) Abnormal Lyme disease serology, and consider testing for HLA-B27 juvenile , rheumatoid juvenile erythematosus, Lyme disease, viral infection, systemic lupus (check CBC, ESR and RF level; and ANA and liver function testing, ANA and liver and sarcoidosis, or Patient may have rheumatoid arthritis, have may Patient No Perform radiography trigger points? No Does patient have point tenderness or Normal Yes Patient has Patient The existence of extra-articular manifestations. and/or systemic WBCs 3 infectious arthritis Yes Cultures are positive INFLAMMATORY VERSUS NON-INFLAMMATORY VERSUS NON-INFLAMMATORY INFLAMMATORY DISORDERS 4. Determine the nature process and whether inflammatory or non-inflammatory of the findings exist. Inflammatory underlying Disorders may be infectious pathologic (Neisseria gonorrhoeae or Mycobacterium ), crystal-induced (gout, erythematosus lupus systemic [RA], arthritis (rheumatoid pseudogout), immune-related [SLE]), reactive(rheumatic or fever, idiopathic. reactive Non-inflammatoryrelated to arthritis), disorders trauma may(bursitis, (rotator tendinitis), be degeneration cuff or ineffective tear),(Osteoarthritis), repair repetitive neoplasm use synovitis) or pain amplification (fibromyalgia). (pigmented villonodular The most important goal is to differentiate the features of joint damage, predominantly caused by OA, from those 2). of inflammatory joint disease (Table No No and > 75% PMNs? > 2,000/mm Does aspirate contain signs of inflammation? Does patient have effusion or Does patient have trauma or focal bone pain? trauma or focal Does patient have significant have Does patient Fig. 2: Diagnosing Monoarthritis Acute Fig. Yes Patient has limited to one or a very few joints few one or a very limited to has arthralgia Patient Elicit complete history and perform physical examination history and perform Elicit complete Successful Patient has Patient Patient has pseudogout (calcium has Patient pyrophosphate dihydrate crystals) joint Aspirate contains Perform aspiration intra-articular fracture bone marrow elements Crystals are present in joint fluid Unsuccessful Patient has gout has Patient bloody Aspirate is (monosodium urate crystals) Whether the disease inflammatory in nature. is inflammatory or non- The temporal pattern of the chronic duration. acute versus disorder; especially The spatial pattern: primarily, polyarticular monoarthritis arthritis or and the presence involvement. of axial process pseudogout, tumor, Reevaluate (check PT, PTT, platelet PTT, (check PT, trauma, or Charcot joint count, and bleeding time) Patient has coagulopathy, has Patient Patient probably Patient has inflammatory articular cartilage, intraarticular ligaments, joint capsule, and juxta-articular bone. Non articular (or periarticular) structures, such as supportive extra overlying and articular nerve, ligaments, bone, fascia, muscle, bursae, tendons, in the pathologic process. skin, may be involved – that is, diseases affecting the joints – are at the heart of rheumatology. As the first step articular havewe syndrome. Once this is done to recognisefour fundamental that features of the articular pattern should be defined: this is an 1. 2. 3. RHEUMATOLOGY 160 their joints. Morning stiffness is often prolonged, lasting prolonged, move often is to stiffness Morning start joints. their and up get they as relieved is and early) little a up wakingpatient (often the morning the in worst is pain disease inflammatory active In swelling). or pain, warmth, (erythema, inflammation of signs cardinal four the of any by identified be may disorders Inflammatory MRI, magneticresonanceimaging; PVNS,pigmentedvillonodularsynovitis;RF,rheumatoidfactor; SF,synovialfluid;XR,radiograph. ACPA, anticitrullinated protein antibody; ANA, antinuclear antibody; CPPD, calcium pyrophosphate dehydrate deposition; CXR, chest radiograph; Amyloid Lyme disease Charcot’s PVNS Sarcoidosis Rarer Causes Ischemic necrosis Trauma derangement Internal Osteoarthritis moioarthropathies Inflammatory arthritis Tuberculous Crystal arthritis arthritis Gonococcal Bacterial arthritis Diagnosis the Cause Table Situations, withImagingandInvestigation intheClinical 5:Synovial Fluid Characteristics Techniques BestUsed to Identify 2000-10,000 Mononuclear 0-5000 Neutrophils 0-2000 Mononuclear cells Red blood 5000-20,000 Mononuclear cells Red blood cells Red blood 0-2000 Mononuclear 5000-50,000 Neutrophils 5000-50,000 Mononuclear 10,000-100,000 Neutrophils 10,000-100,000 Neutrophils 10,000-100,000 Neutrophils Cells — — — — — — often negative Acid-fast stain usually positive Gram stain usually positive Gram stain Microorganisms Turbid Clear/turbid Turbid Clear/turbid Clear/turbid Clear Slightly turbid Turbid/pus Turbid/pus Turbid/pus Turbid/pus Appearance specific features such as fatigability, weight loss, night sweats (thecommonest symptomofpyrexia weight asfatigability, such features specific non- of complain additionally may patient the response, phase acute the to trigger sufficient disease inflammatory With min. 5 than more for persist may rest after Stiffness hours. several for sometimes and min 30 than more for MRI Ultrasound and XR MRI XR changes erosions synovitis and MRIfor early Ultrasound/ XR,CPPD ultrasound may need to dryness; Aspiration ultrasound may need to dryness: Aspiration Modality Imaging XR CXR disease MRI inearly Congo red stain Synovial biopsyfor Serology forBarmlia found SF eosinophiliamaybe Synovial biopsyessential normal diagnosis ifradiograph Tc bonescanmayaid necessary Arthroscopy maybe may bepresent noninflammatory CPPD Usually such asRF, AC PA, ANA Serum autoantibodies biopsy may benecessary Ziehl-Neelsen stain At-risk population unreliable Acute serumurate crystals Presence ofappropriate culture Blood andsynovialfluid Gram stain Systemic symptoms, culture Blood andsynovialfluid Gram stain Systemic symptoms. Comments CPPD maybepresent advanced cases XR abnormalonlyin CHAPTER 35 161 Nongonococcal Staphylococcus 4,5 4,7 found that the most important risk factors 4 Gonococcal arthritis is the most common type of 4 THE SPATIAL PATTERN PATTERN SPATIAL THE aureus is the most common pathogen in non-gonococcal septic arthritis, the is most monoarticular (80 destructive percent type, of affects cases) the generally and knee most (50 percent often of cases). Monoarthritis either can joint single a of arthritis is which Monoarthritis be acute(of < 6 weeks duration) or chronic (of > 6 weeks non-inflammatory or inflammatory either be or duration) as Acute 3. given monoarthritis in in the adults Table can have many but crystals, trauma, which infection, joint of diagnosis Prompt and common. most infection are the often is acquired hematogenously, is crucial because of its destructive course (Figure 2). A year study prospective, three- for septic arthritis are a prosthetic hip or knee joint, skin infection, joint surgery, rheumatoid arthritis, age greater than 80 years, and diabetes mellitus. Intravenous use drug and large-vein factors for sepsis in unusual catheterization joints (e.g., sternoclavicular are joint). predisposing arthritis) arthritis) and/or bony swelling () joint along margin. the Deformity may and OA. damage of joint stages also be present in later In inflammatoryinflamed, engorged diseases and eventually hypertrophied the and the volume of synovium synovial fluidarticular increases. becomes Causing hypertension intra- leading restriction to of pain, movement. stiffnesshypertension A and is joint most comfortable with in minimises the intra-articular pressure increase. the This position, generally position that mild to and loosest its at normally mid is capsule the which in flexion,position, and termedis therefore can accommodate an increase in fluid and soft the ‘loose-pack’ tissue. Conversely, the positions in which the capsule is extremes at the the ‘tight-pack’ positions naturally tight – – are the positions that of are range the of first movement to be painful when synovitis is developing, and the first to become restricted. movements This uneven distribution of pain, maximal pack positions, is called ‘universal stress pain’ – the most in all tight sensitive sign of synovitis, occurring even before there is visible swelling or restricted movement (Figure 1). Joint damage is associated with a more even spread throughout the range of movement. of pain Joint inflammation may alsopalpable cause increased over warmth the features capsular that contour. allow distinction The and joint inflammation are shown in Age table. is also an between summated joint damage important factor. Joint conditions before the age of 40 are likely to be inflammatory if not traumatic. Inflammatory arthritis will usually establish itself in a matter ofto days weeks or months, whereas patients with OA tend to present to doctors only after years of variable but pain. increasing slowly very non-traumatic acute times four to three is It monoarthritisin States. United the in persons active young, sexually more common in women than in men. Chronic Rheumatoid arthritis Undifferentiated polyarthritis Inflammatory osteoarthritis MCTD Lupus Scleroderma JIA Polyarticular Adult Still’s disease Osteoarthritis (DIP, PIP, CMC1) (≥4 joints) Polyarthritis Acute Viral arthritis Viral Serum sickness Drug-induced arthritis Early onset of CTD RS3PE Hemoglobin- opathies Amyloid arthropathies Mono/ (1-3 joints) complaint Distribution Musculoskeletal Chronic Psoriatic arthritis JIA Pauciarticular Indolent infectious arthritis* Osteoarthritis (hip or knee) Osteonecrosis Neuropathic arthritis Hemochromatosis Pigmented

Nonarticular Trauma Fracture Fibromyalgia Reflex sympathetic dystrophy Bursitis/tendinitis Polymyalgia rheumatica

inflammatory

Inflammatory Non- Acute

Meniscal tear (internal derangement) Osteoarthritis flare Reflex sympathetic dystrophy Infectious arthritis Gout Pseudogout arthritis Reactive Chlamydial arthritis

inflammatory

Inflammatory Non- Table 6: Algorithm for assessing initial historyassessing for 6: Algorithm and Table CMC, carpometacarpal; connectiveexamination. tissue CTD, idiopathic JIA, juvenile distal interphalangeal; disease; DIP, connective PIP, tissue disease; arthritis; mixed MCTD, interphalangeal proximal Joint damage/OA is typically associated with pain increases that with repeated use of the joint, which is relieved by rest, and which is often worst towards the end of the day. Patients may describe pain that increases again and after resting that stiffness(gelling) subsides after just a few minutes. Early morning stiffness in off’OA in well is ‘worn under 30 minutes. Although OAbe signs may detected in many joints on examination (many being asymptomatic), OA usually causes pain in just one or a few joints at any one time. Extra-articular manifestations problems) bowel or lung lesions, skin uveitis, anterior (eg, are not associated with OA, which is purely a condition of the joints, although obesity, age-related co-morbidities (eg, hypertension, occur in older depression) patients with OA and contribute to may their participation restriction. commonly It is noteworthy ‘flares’ of pain that which may relate to minor people inflammation or with OA be may biomechanically exacerbations suffer initiated. patients During morning and activity inflammationstiffness. is However, may such have pain not a prominent clinical feature and OA does not trigger more prolonged the acute phase response. Conversely, longstanding but ‘inactive’ inflammatory arthritis will be associated with ‘mechanical’ pain reflecting joint damage caused by their inflammatory disease. Physical examination will if support there is joint coarse damage/OA crepitus, localised joint-line tenderness rather (often than universal as in inflammatory RHEUMATOLOGY 162 ot ad acu prpopae iyrt (CPPD, dihydrate pyrophosphate causes calcium (which and urate gout) monosodium but monoarthritis, ru- bt-eoyi srpooc, gram-negative present. be streptococci, can non– pneumoniae Streptococcus and bacteria, but series), beta-hemolytic some in group-A percent (60 arthritis septic only. = PIP interphalangeal; lupus distal = SLE=systemic DIP nodosa; polyarteritis cell; = proximal interphalangeal. PAN *—The arthritis; clues listed in this rheumatoid table blood are not, in = themselves, diagnostic white or RA complete; they are presented disease; for WBC, illustrative purposes bowel polyarthritis; inflammatory = undifferentiated IBD UPA, erythematosus; factor; rheumatoid RF, arthritis; rheumatoid RA, arthritis; MCP, metacarpophalangeal; MTP, metatarsophalangeal; OA, osteoarthritis; test; PIP, proximal interphalangeal; PMR, polymyalgiafunction rheumatica; PsA, psoriatic liver LFT, hemochromatosis; hereditary sedimentation HHC, virus; erythrocyte C hepatitis HCV, ESR, virus; B interphalangeal; hepatitis HBV, arthritis; distal gonococcal GC, DIP, rate; protein; C-reactive CRP, carpometacarpal; CMC, protein; citrullinated cyclic CCP, infection. (HIV) virus immunodeficiency human of the initial manifestation be can inflammation Monoarticular rare. are infections viral and fungal, Mycobacterial, disease. Lyme a in present be of may knee, the especially joint, Inflammation large single persons. common immunocompromised are in infections gram-negative and Anaerobic HCV) Viral (HBV. UPA RA Pseudogout PsA PMR OA HHC Gout GC Arthritis Table DifferentCauses of 7:Distinguishing Polyarthritis 8 ay ye o cytl cn rge acute trigger can crystals of types Many factors Hepatitis risk F>M F>M. 35-50yr patients M =F,older psoriasis Long historyof M= F, older white w/ kneeorhip F >M.Agemen 50 M >F.meanage, women postmenopausal Men, active sexually F >M,young, Patient Profile polyarthritis Acute, additive four joints Insidious, oneto additive Insidious, polyarticular oligoarticular or Intermittent additive Insidious, loss soreness, weight stiffness or Prolonged AM polyarticular oligoartictlar or Additive polyarticular oligoarticular or Intermittent later polyarticular early, oligoarticular Intermittent polyarthritis oligoarthritis or Fever, acute History/Onset 3

ankle wrist, knee, PIP, MCP, Same asRA ankle MTP, knee, PIP, MCP,wrist finger, MTP Knee, wrist feet, spine DIP, PIP,knees, synovitis muscles; seldom shoulder) Girdle (hip, hip, MTP,spine CMC1, knee, DIP, PIP,first feet MCP, hip,knee, [hands late] ankle, knee MTP, toes, tenosynovitis Wrist, knee, Joints Involved hc cue pedgu) r te ot common. most crystals lipid and apatite, dialysis), renal the are receiving are who patients in (especially oxalate Calcium pseudogout) causes which skin source, is also possible and requires urgent attention. a from commonly Infection, joint. prosthetic a in pain of source the often is loosening Aseptic use. corticosteroid in patients with risk factors such as alcoholism or chronic as manifest occur may osteonecrosis Spontaneous effusion. and and pain suddenly worsen may corticosteroids. Osteoarthritis of injection intra-articular sometimes from arthritis results Transient 4). (Table monoarthritis Inflammatory Inflammatory inflammatory Symmetric inflammatory or chronic Intermittent oligoarticjular asymmetric Inflammatory, chronic Inflammatory, swelling symmetric, bony asymmetric or Noninflammatory inflammatory or chronic Intermittent with attacks onset severe pain Acute sudden Inflammatory Type of Arthritis Type serologies +HCWHBV LFTs, ESR/CRP, CRP/ESR +CCP CRP/ESR, +RF, CRP, WBC Uric acid HLA-B27, negative RF, CRP/ESR, CRP, LFTs Anemia, ESR/ laboratory results Normal and osteophytosis gene, x-rays— LFTs, HFE ESR/CRP, in 40%acutely Normal uricacid CRP, WBC WBC ESR/CRP, Supportive Tests 9 also elicit acute elicit also CHAPTER 35 163 Contd.. Diagnoses to consider to Diagnoses Scleroderma amyloidosis, Scleroderma, fasciitis eosinophilic SLE Hypothyroidism, Fibromyalgia Osteoarthritis RA, SLE, Ehlers-Danlos syndrome Spondyloarthropathies Spondyloarthropathies Bacterial or viral infection, Still’s disease, subacute bacteria endocarditis, neoplasm Hypothyroidism Rheumatic fever spondylitis, Ankylosing rheumatic fever, relapsing polychondritis, arthritis, Marfan reactive syndrome, Takayasu’s arteritis infection, Viral sarcoidosis, amyloidosis, SLE, polymyositis Bacterial endocarditis, rheumatic fever Giant cell arteritis, arteritis Takayasu’s Felty’s syndrome, tumor- associated arthritis Whipple’s disease, hemochromatosis, Wilson’s amyloidosis, disease Physical finding Physical continued. mucous membranes Skin and Telangiectasia skin Thickened Hair thinning Musculoskeletal system points Tender (DIP Heberden’s nodes nodes joints), Bouchard’s (PIP joints) Boutonniere and swan- neck deformities (“sausage Dactylitis digits”) Bursitis and enthesitis Constitutional conditions Fever Bradycardia system Cardiovascular Mitral regurgitation and stenosis Aortic regurgitation Cardiomyopathies New murmur, fever Diminished peripheral pulses Gastrointestinal system Splenomegaly Hepatomegaly Diagnoses to consider to Diagnoses B19 Human parvovirus infection B19 Human parvovirus infection SLE, human parvovirus B19 infection, Lyme disease, rosacea, seborrhea, dermatomyositis Psoriasis Dermatomyositis Lyme disease Rheumatic fever Sarcoidosis, Crohn’s disease IBD, RA, SLE, anklyosing sarcoidosis, spondylitis, granulomatosis Wegener’s Hypersensitivity vasculitis, Schonlein-Henoch purpura, PAN Antiphospholipid- antibody syndrome, cholesterol vasculitis, emboli arthritis, psoriatic Reactive arthritis Discoid , SLE, sarcoidosis Dermatomyositis Gonococcal arthritis Spondyloarthropathies, sarcoidosis, Wegener’s granulomatosis Spondyloarthropathies, SLE, Wegener’s granulomatosis SLE Skin and mucous membranes Skin and Rash infectiosum Erythema (lacy) rash Reticulated Facial exanthem (slapped cheek) Malar rash (scalp, navel, Plaques gluteal cleft) Heliotrope Erythema chronicum migrans Erythema marginatum rheumaticum Erythema nodosum Pyoderma gangrenosum purpura Palpable reticularis Livedo Lesions Keratoderma blennorrhagicum Discoid skin lesions Gottron’s papules or plaques on Vesicopustule erythematous base Eyes Iritis or uveitis Conjunctivitis Cytoid bodies (retinal exudates) Table 8: Selected Pain* Joint in Polyarticular Result Extra-Articular that with Conditions Associated Table Manifestations finding Physical RHEUMATOLOGY 164 1. approach toarthritis. and course, patient demographics. Algorithm 1 gives the summary of disease 8), (Table extra- manifestations articular distribution, inflammation, chronology, disease factors: clinical six of investigation through narrowed be can diagnosis differential The caution. the clinical with and in context beinterpreted desired should the results specificity, lack the tests laboratory 4 of rheumatologic Because many than because &7). 6 challenge more (Tables diagnosis diagnostic differential in extensive a pain poses (i.e., joints) pain joint Polyarticular Synovial fluid characteristicsaregiven in Table 5. monoarthritis. in necessary is aspiration Joint complete; theyarepresentedforillustrative purposesonly. or diagnostic themselves, in not, are table this in listed clues *—The interphalangeal. proximal = PIP interphalangeal; distal = DIP nodosa; polyarteritis = arthritis; PAN rheumatoid = RA disease; bowel inflammatory = IBD erythematosus; lupus systemic = SLE 2. REFERENCE POLYARTICULAR ARTHRITIS Hyperpigmentation Jaundice Tophi Nodules Clubbing Pitting Onycholysis Nails Inflammation ofearlobe Bloody orsevere sinusitis Scalp tenderness Macroglossia Parotid enlargement Oral ulcers Ears, noseandthroat Ischemic opticneuritis Scleritis Physical finding ManifestationsTable Associated withConditions Extra-Articular That 8:Selected Result inPolyarticular JointPain* Woolf AD, Pfleger B. Burden of major musculoskeletal ofmajor conditions. BullWorldHealthOrgan Burden B. Pfleger AD, Woolf ol A, kso K Udrtnig h bre of not burden and huge the is burden The Understanding conditions. musculoskeletal K. Akesson AD, Woolf hemochromatosis Whipple’s disease, hemochromatosis Hepatitis, Gout amyloidosis, sarcoidosis disease, rheumaticfever, RA, gout,Whipple’s hyperthyroidism IBD, Whipple’sdisease, Psoriatic arthritis hyperthyroidism Psoriatic arthritis, Relapsing polychondritis Wegener’s granulomatosis Giant cellarteritis Amyloidosis sarcoidosis Sjogren’s syndrome, Wegener’s granulomatosis reactive arthritis, SLE, Behcet’ssyndrome, Wegener’s granulomatosis Giant cellarteritis, polychondritis RA, relapsing Diagnoses toconsider 2003;81:646-56. Lymphadenopathy Seizures Mononeuritis multiplex Chorea Peripheral neuropathy Facial palsy neuropathies Entrapment Neurologic system Balanitis circinata Hypogonadism Scrotal orvulvar ulcers Urethritis orcervicitis Prostatis Genitourinary system test Positive fecaloccultblood Physical finding 6. 5. 4. 3. 9. 8. 7. Cucurull E, Espinoza LR. Gonococcal arthritis. Gonococcal LR. Espinoza E, Cucurull Medicine [Baltimore] Disseminated PA. and a Rice review of pathophysiology and immune mechanisms. DL, patients 49 of analysis prospective a infection: gonococcal Goldenberg JP, O’Brien Goldenberg DL.Septicarthritis.Lancet1998;351:197-2 clinical approach.BullKuwait InstMedSpec 2004;3:73-82. Malaviya AN. A patient with musculoskeletal (MSK) pains- 80. priorities. health national in reflected Ann RheumDis 1985;44:537-43. crystals. liquid lipid with associated monoarthritis Acute JL. Rabinowitz DA, Allan HR, Schumacher AJ, Reginato 62. characteristics. clinical arthritis: associated infection virus immunodeficiency Human al. et S, Paz E, Lucero A, Spindler H, Perez P, Cahn A, Berman Rheum DisClinNorth Am 1993;19:311-31. arthritis. bacterial Nongonococcal GS. Alarcon IS, Mikhail North Am1998;24:305-22. Clin 1983;62:395-406. SLE Tumor-associated arthritis, SLE vasculitis (e.g.,PAN) RA, SLE,Lymedisease, rheumatic fever antibody syndrome,SLE, Antiphospholipid- SLE, amyloidosis Lyme disease hyperparathyroidism RA, hypothyroidism, Reactive arthritis Hemochromatosis Behcet’s syndrome gonococcal arthritis Reactive arthritis, ankylosing spondylitis Reactive arthritis, IBD Diagnoses toconsider 1999; 26:1158- 1999; J Rheumatol 2001; 322:1079- 2001; BMJ Rheum Dis Rheum CHAPTER 35 165 Yes Yes arthritis >3 Rheumatoid involved? MTP joints Are PIP, MCP, or symmetric? polyarthritis No Is involvement How many No joints involved? Chronic inflammatory 1-3 Yes Consider ● Psoriatic arthritis arthritis ● Reactive Yes Chronic Is it articular? Is complaint > 6 wk? Yes Chronic inflammatory mono/oligoarthritis Consider ● Indolent infection ● Psoriatic arthritis arthritis ● Reactive JA ● Pauciarticular arthritis Chronic inflammatory No Unlikely to be rheumatoid arthritis Consider ● SLE ● Scleroderma ● Polymyositis Is inflammation present? 1. Is there prolonged morning stiffness? 2. Is there soft tissue swelling? there systemic symptoms? Are 3. 4. Is the ESR or CRP elevated? Conclusion No Yes Algorithm 1: Approach to arthritis to Algorithm 1: Approach No Musculoskeletal Complaint Musculoskeletal Osteoarthritis Acute arthritis Chronic Initial rheumatic history and physical history and Initial rheumatic exam to determine 1. Is it articular? 2. Is it acute or chronic present? 3. Is inflammation joints are involved? 4. How many/which noninflammatory Are DIP, CMC1, hip or knee joints involved? No Gout Pseudogout arthritis Reactive Unlikely to be osteoarthritis Consider ● Osteonecrosis ● Charcot arthritis Nonarticular condition Consider ● Trauma/fracture ● Fibromyalgia rheumatica ● Polymyalgia ● Bursitis ● Tendinitis ● Initial presentation of chronic arthritis Consider ● Acute arthritis ● Infectious arthritis ● ● ●