CHAPTER Approach to Arthritis 35 Liyakat Ali Gauri, BR Ajay, Asim Khan, Nadeem Liyakat, Qadir Fatima ABSTRACT Arthritis is the inflammation of the joints which is a term derived from Greek in which arthro- means joint 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 fever, 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, monoarthritis 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 crepitus, capsular joint line) swelling, effusion, increased heat Neurological Normal Normal May be abnormal Normal examination 158 Table 2: Differences between inflamed and damaged joints Table 4: Diagnostic Clues in Patients Presenting with Joint Inflamed joint Damaged joint Pain Early morning Prolonged Brief Clues from history and Diagnoses to consider stiffness physical examination Inactivity Prolonged Brief Sudden onset of pain in Fracture, internal stiffness seconds or minutes derangement, Trauma, loose body Increased + − warmth Onset of pain over several Infection, crystal hours or one to two days deposition disease, other Stress pain Yes No inflammatory arthritic Capsular soft- + – condition tissue swelling Insidious onset of pain Indolent infection, Effusion +++ +/− over days to weeks osteoarthritis, infiltrative Coarse crepitus − +++ disease, tumor RHEUMATOLOGY Erythema +/− − Intravenous drug use, Septic arthritis immunosuppression Malalignment/ − +/− deformity Previous acute attacks Crystal deposition disease, in any joint, with other inflammatory Instability − +/− spontaneous resolution arthritic condition Table 3: Shows a broad classification of the causes of arthritis Recent prolonged course Infection, avascular with a focus on major causes of monoarthritis of corticosterioid therapy necrosis Coagulopathy, use of Hemarthrosis Acute arthritis Chronic arthritis anticoagulants Inflammatory Urethritis, conjunctivitis, Reactive arthritis Monoarthritis Monoarthritis diarrhea, and rash Crystal induced arthritis Tubercular arthritis Psoriatic patches or nail Psoriatic arthritis (gout and pseudogout) Fungal arthritis changes such as pitting Septic arthritis Other infections (e.g Use of diuretics, presence Gout Gonococcal arthritis Brucellosis) of tophi, history of renal stones or alcoholic binges Acute onset of Immunoinflammatory inflammatory polyarthritis arthritis Eye inflammation, low Ankylosing spondylitis back pain (like RA, SLE) Crystal induced arthritis Young adulthood, Gonococcal arthritis Polyarthritis (e.g., acute Polyarthritis (e.g., migratory polyarthralgias, onset of polyarthritis, RA, psoriatic arthritis, inflammation of the reactive arthritis) spondyloarthritis) tendon sheaths of hands Non-inflammatory and feet, dermatitis Monoarthritis Monoarthritis Hilar adenopathy, Sarcoidosis Hemarthrosis Single joint osteoarthritis erythema nodosum Trauma Neuropathic arthropathy inflammatory or non-inflammatory in nature, (3) acute or Osteonecrosis chronic in duration, and (4) localized (monoarticular) or Pigmented villo nodular widespread (polyarticular) in distribution. synovitis ARTICULAR VERSUS NONARTICULAR Polyarthritis Polyarthritis (e.g., The first step in approach to a patient with arthritis osteoarthritis) is to confirm that the origin of pain is from the joint. (anatomical basis).3 Questioning and examination will time.1,2 A significant proportion of patients who present allow the distinction of four main origins (Table 1): with musculoskeletal complaints have in fact systemic illness such as rheumatoid arthritis (RA), systemic lupus a. Articular pain erythematosus (SLE) etc. which may be potentially life- b. Extra articular pain: threatening if not detected, correctly diagnosed and • periarticular pain treated. These conditions have to be distinguished from other musculoskeletal conditions, which have no systemic • neurogenic pain component. The evaluation should proceed to ascertain if • referred pain. the complaint is (1) articular or non-articular in origin, (2) Articular structures include the synovium, synovial fluid, 159 Patient has arthralgia limited to one or a very few joints Elicit complete history and perform physical examination Yes Abnormal Does patient have significant Perform Patient has fracture, trauma or focal bone pain? radiography tumor, or metabolic bone disease No Unsuccessful Yes Normal Patient probably Perform Does patient have effusion or has inflammatory joint signs of inflammation? CHAPTER 35 process aspiration No Does patient have Yes Patient has Successful point tenderness or bursitis, tendinitis, Reevaluate trigger points? or firbomyalgia No No Aspirate is Aspirate contains Does aspirate contain Patient has osteoarthritis, bloody bone marrow elements > 2,000/mm3 WBCs internal derangement, soft and > 75% PMNs? tissue injury, or viral infection Patient has coagulopathy, Patient has pseudogout, tumor, intra-articular fracture Yes trauma, or Charcot joint (check PT, PTT, platelet count, and bleeding time) Crystals are present in joint fluid Cultures are positive Joint fluid is sterile Patient has gout Patient has pseudogout (calcium Patient has Patient may have rheumatoid arthritis, (monosodium urate crystals) pyrophosphate dihydrate crystals) infectious arthritis juvenile rheumatoid arthritis, viral infection, systemic lupus erythematosus, Lyme disease, sarcoidosis, or spondyloarthropathy (check CBC, ESR and RF level; consider testing for HLA-B27 and ANA and liver function testing, Lyme disease serology, and pelvic radiography) Fig. 2: Diagnosing Acute Monoarthritis articular cartilage, intraarticular ligaments, joint capsule, 4. The existence of extra-articular and/or systemic and juxta-articular bone. Non articular (or periarticular) manifestations. structures, such as supportive extra articular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying INFLAMMATORY VERSUS NON-INFLAMMATORY skin, may be involved in the pathologic process. DISORDERS Determine the nature of the underlying pathologic Arthropathies – that is, diseases affecting the joints – are process and whether inflammatory or non-inflammatory at the heart of rheumatology. findings exist. Inflammatory Disorders may be infectious As the first step we have to recognise that this is an (Neisseria gonorrhoeae or Mycobacterium tuberculosis), articular syndrome. Once this is done four fundamental crystal-induced (gout, pseudogout), immune-related features of the articular pattern should be defined: (rheumatoid arthritis [RA], systemic lupus erythematosus [SLE]), reactive(rheumatic fever, reactive arthritis), 1. Whether the disease is inflammatory or non- inflammatory in nature. or idiopathic. Non-inflammatory disorders may be related to trauma (rotator cuff tear), repetitive use 2. The temporal pattern of the disorder; especially (bursitis, tendinitis), degeneration or ineffective repair acute versus chronic duration. (Osteoarthritis), neoplasm (pigmented villonodular 3. The spatial pattern: primarily, monoarthritis or synovitis) or pain amplification (fibromyalgia). polyarticular arthritis and the presence of axial The most important goal is to differentiate the features of involvement. joint damage, predominantly caused by OA, from those of inflammatory joint disease (Table 2). 160 Table 5: Synovial Fluid Characteristics in the Clinical Situations, with Imaging and Investigation Techniques Best Used to Identify the Cause Diagnosis Cells Microorganisms Appearance Imaging Comments Modality Bacterial arthritis Neutrophils Gram stain Turbid/pus Aspiration Systemic symptoms. 10,000-100,000 usually positive to dryness: Gram stain may need Blood and synovial fluid ultrasound culture Gonococcal Neutrophils