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Clinical Approach to Acute Arthritis

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Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics) ... Can cause monoarthritis clinically indistinguishable from gout Pseudogout. ... – PowerPoint PPT presentation

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Title: Clinical Approach to Acute Arthritis


1
Clinical Approach to Acute Arthritis
  • Yolanda Farhey, MD
  • Assistant Professor
  • Division of Immunology

2
Acute Arthritis
  • The sudden onset of inflammation of the joint,
    causing severe pain, swelling, and redness.
  • Structural changes in the joint itself may result
    from persistence of this condition.

3
Signs of Inflammation
  • Swelling
  • Warmth
  • Erythema
  • Tenderness
  • Loss of function

4
Key Points
  • Distinguish arthritis from soft tissue non
    articular syndromes (discrepancy between active
    and passive ROM suggests periarticular/soft
    tissue)
  • If the problem is articular distinguish single
    joint from multiple joint involvement
  • Inflammatory or non-inflammatory disease
  • Always consider septic arthritis!

5
Articular Vs. Periarticular
6
Inflammatory Vs. Noninflammatory
7
Acute Monoarthritis
  • Inflammation (swelling, tenderness, warmth) in
    one joint
  • Occasionally polyarticular diseases can present
    with monoarticular onset
  • (RA, JRA,Reactive and enteropathic arthritis,
    Sarcoid arthritis, Viral arthritis, Psoriatic
    arthritis)

8
Acute Monoarthritis - Etiology
  • THE MOST CRITICAL DIAGNOSIS TO CONSIDER
    INFECTION !
  • Septic
  • Crystal deposition (gout, pseudogout)
  • Traumatic (fracture, internal derangement)
  • Other (hemarthrosis, osteonecrosis, presentation
    of polyarticular disorders)

9
Questions to Ask History Helps in DD
  • Pain come suddenly, minutes? fracture.
  • 0ver several hours or 1-2 days? infectious,
    crystals, inflammatory arthropathy.
  • History of IV drug abuse or a recent infection?
    septic joint.
  • Previous similar attacks? crystals or
    inflammatory arthritis.
  • Prolonged courses of steroids? infection or
    osteonecrosis of the bone.

10
Acute Monoarthritis
11
Indications for Arthrocentesis
  • The single most useful diagnostic study in
    initial evaluation of monoarthritis SYNOVIAL
    FLUID ANALYSIS
  • 1. Suspicion of infection
  • 2. Suspicion of crystal-induced arthritis
  • 3. Suspicion of hemarthrosis
  • 4. Differentiating inflammatory from
    noninflammatory arthritis

12
Tests to Perform on Synovial Fluid
  • Low threshold for doing Gram stain and cultures .
  • Total leukocyte count/differential inflammatory
    vs. non-inflammatory.
  • Polarized microscopy to look for crystals.
  • Not necessary routinely Chemistry (glucose,
    total protein, LDH) unlikely to yield helpful
    information beyond the previous tests.

13
Septic Joint
  • Most articular infections a single joint
  • 15-20 cases polyarticular
  • Most common sites knee, hip, shoulder
  • 20 patients afebrile
  • Joint pain is moderate to severe
  • Joints visibly swollen, warm, often red
  • Comorbidities RA, DM, SLE, cancer,etc

14
Septic Joint - Nongonococcal
  • 80-90 monoarticular
  • Most develop from hematogenous spread
  • Most common
  • Gram positive aerobes (80)
  • Majority with Staph aureus (60)
  • Gram negative 18

15
Septic Joint - Gonococcal
  • Most common cause of septic arthritis
  • Often preceded by disseminated gonococcemia
  • Sexually active individual, 5-7 days h/o fever,
    chills, skin lesions, migratory arthralgias and
    tenosynovitis ? persistent monoarthritis
  • Women often menstruating or pregnant
  • Genitourinary disease often asymptomatic

16
Disseminated Gonococcemia Pustules
17
Gout
  • Caused by monosodium urate crystals
  • Most common type of inflammatory monoarthritis
  • Typically first MTP joint, ankle, midfoot, knee
  • Pain very severe cannot stand bed sheet
  • May be with fever and mimic infection
  • The cutaneous erythema may extend beyond the
    joint and resemble bacterial cellulitis

18
Acute Gouty Arthritis
19
Risk Factors
  • Primary gout Obesity, hyperlipidemia, diabetes
    mellitus, hypertension, and atherosclerosis.
  • Secondary gout alcoholism, drug therapy
    (diuretics, cytotoxics), myeloproliferative
    disorders, chronic renal failure.

20
Urate Crystals
  • Needle-shaped
  • Strongly negative birefringent

21
CPPD Crystals Deposition Disease
  • Can cause monoarthritis clinically
    indistinguishable from gout Pseudogout.
  • Often precipitated by illness or surgery.
  • Pseudogout is most common in the knee (50) and
    wrist.
  • Reported in any joint (Including MTP).
  • CPPD disease may be asymptomatic (deposition of
    CPP in cartilage).

22
Associated Conditions
  • Hyperparathyroidism
  • Hypercalcemia
  • Hypocalciuria
  • Hemochromatosis
  • Hypothyroidism
  • Gout
  • Aging

23
CPPD Crystals
  • Rod or rhomboid-shaped
  • Weakly positive birefringent

24
Other Tests Indicated for Acute Arthritis
  • 1. Almost always indicated
  • Radiograph, bilateral
  • CBC
  • 2. Indicated in certain patients
  • Cultures
  • PT/PTT
  • ESR
  • 3. Rarely indicated
  • Serologic ANA, RF
  • Serum Uric acid level

25
Polyarthritis
  • Definite inflammation (swelling, tenderness,
    warmth of 5 joints
  • A patient with 2-4 joints is said to have pauci-
    or oligoarticular arthritis

26
Acute Polyarthritis
  • Infection
  • Gonococcal
  • Meningococcal
  • Lyme disease
  • Rheumatic fever
  • Bacterial endocarditis
  • Viral (rubella, parvovirus, Hep. B)
  • Inflammatory
  • RA
  • JRA
  • SLE
  • Reactive arthritis
  • Psoriatic arthritis
  • Polyarticular gout
  • Sarcoid arthritis

27
Inflammatory Vs. Noninflammatory
28
Temporal Patterns in Polyarthritis
  • Migratory pattern Rheumatic fever, gonococcal
    (disseminated gonococcemia), early phase of Lyme
    disease
  • Additive pattern RA, SLE, psoriasis
  • Intermittent Gout, reactive arthritis

29
Patterns of Joint Involvement
  • Symmetric polyarthritis involving small and large
    joints viral, RA, SLE, one type of psoriatic
    (the RA-like).
  • Asymmetric, oligo- and polyarthritis involving
    mainly large joints, preferably lower
    extremities, especially knee and ankle reactive
    arthritis, one type of psoriatic, enteropathic
    arthritis.
  • DIP joints Psoriatic.

30
Viral Arthritis
  • Younger patients
  • Usually presents with prodrome, rash
  • History of sick contact
  • Polyarthritis similar to acute RA
  • Prognosis good self-limited
  • Examples Parvovirus B-19, Rubella, Hepatitis B
    and C, Acute HIV infection, Epstein-Barr virus,
    mumps

31
Parvovirus B-19
  • The virus of fifth disease, erythema
    infectiosum (EI).
  • Children slapped cheek adults flu-like
    illness, maculopapular rash on extremities.
  • Joints involved more in adults (20 of cases).
  • Abrupt onset symmetric polyarthralgia/polyarthriti
    s with stiffness in young women exposed to kids
    with E.I.
  • May persist for a few weeks to months.

32
Viral Arthritides - Parvovirus
33
Rubella Arthritis
  • German measles.
  • Young women exposed to school-aged children.
  • Arthritis in 1/3 of natural infections also
    following vaccination.
  • Morbilliform rash, constitutional symptoms.
  • Symmetric inflammatory arthritis (small and large
    joints).

34
Rheumatoid Arthritis
  • Symmetric, inflammatory polyarthritis, involving
    large and small joints
  • Acute, severe onset 10-15 subacute 20
  • Hand characteristically involved
  • Acute hand deformity fusiform swelling of
    fingers due to synovitis of PIPs
  • RF may be negative at onset and may remain
    negative in 15-20!
  • RA is a clinical diagnosis, no laboratory test is
    diagnostic, just supportive!

35
Acute Polyarthritis - RA
36
Acute Sarcoid Arthritis
  • Chronic inflammatory disorder noncaseating
    granulomas at involved sites
  • 15-20 arthritis symmetrical wrists, PIPs,
    ankles, knees
  • Common with hilar adenopathy
  • Erythema nodosum
  • Löfgrens syndrome acute arthritis, erythema
    nodosum, bilateral hilar adenopathy

37
Acute Polyarthritis in Sarcoidosis
38
Reactive Arthritis
  • Infection-induced systemic disease with
    inflammatory synovitis from which viable
    organisms cannot be cultured
  • Association with HLA B 27
  • Asymmetric, oligoarticular, knees, ankles, feet
  • 40 have axial disease (spondylarthropathy)
  • Enthesitis inflammation of tendon-bone junction
    (Achilles tendon, dactylitis)
  • Extraarticular rashes, nails, eye involvement

39
Asymmetric, Inflammatory Oligoarthritis
40
Enthesitis in Reactive Arthritis
41
Keratoderma Blenorrhagica Reactive Arthritis
42
Circinate Balanitis Reactive Arthritis
43
Reactive Arthritis - Conjunctivitis
44
Reactive Arthritis Palate Erosions
45
Psoriatic Arthritis
  • Prevalence of arthritis in Psoriasis 5-7
  • Dactilytis (sausage fingers), nail changes
  • Subtypes
  • Asymmetric, oligoarticular- associated dactylitis
  • Predominant DIP involvement nail changes
  • Polyarthritis RA-like lacks RF or nodules
  • Arthritis mutilans destructive erosive
    hands/feet
  • Axial involvement spondylitis 50 HLAB27 ()
  • HIV-associated more severe

46
Acute Polyarthritis - Psoriatic
47
Dactylitis Sausage Toes Psoriasis
48
Psoriasis
49
Arthritis Of SLE
  • Musculoskeletal manifestation 90.
  • Most have arthralgia.
  • May have acute inflammatory synovitis RA-like.
  • Do not develop erosions.
  • Other clinical features help with DD malar rash,
    photosensitivity, rashes, alopecia, oral
    ulceration.

50
Butterfly Rash SLE
51
Photosensitivity
52
Alopecia - SLE
53
Arthritis of Rheumatic Fever
  • Etiology Streptococcus pyogenes (group A) there
    is damaging immune response to antecedent
    infection molecular cross reaction with target
    organs molecular mimicry.
  • Migratory polyarthritis, large joints knees,
    ankles, elbows, wrists.
  • Major manifestations carditis, polyarthritis,
    chorea, erythema marginatum, subcutaneous nodules.

54
Erythema Marginatum Rheumatic Fever
  • Circinate
  • Evanenscent
  • Nonpruritic rash

55
Rheumatic Fever Subcutaneous Nodes
56
Gouty Arthritis
57
Skin Lesions Useful in Diagnosis
  • Psoriatic plaques
  • Keratoderma Blenorrhagicum (reactive arthritis)
  • Butterfly rash (SLE)
  • Salmon-colored rash of JRA, adult Stills
  • Erythema marginatum (Rheumatic Fever)
  • Vesicopustular lesions (gonococcal arthritis)
  • Erythema nodosum (acute sarcoid, enteropathic
    arthritis)

58
Disseminated Gonococcemia Pustules
59
Keratoderma Blenorrhagica Reactive Arthritis
60
Circinate Balanitis Reactive Arthritis
61
Erythema Marginatum Rheumatic Fever
  • Circinate
  • Evanenscent
  • Nonpruritic rash

62
Adult Stills Disease and JRA Rash
  • Salmon or pale-pink
  • Blanching
  • Macules or maculopapules
  • Transient (minutes or hours)
  • Most common on trunk
  • Fever related

63
SLE Face Rash
64
SLE Interarticular Rash Hands
65
Keratoderma Blenorrhagicum
66
Erythema Nodosum
  • Sarcoidosis
  • Inflammatory Bowel Disease related arthritis

67
Tenosynovitis and Usefulness in DD
  • Inflammation of the synovial-lined sheaths
    surrounding tendons.
  • Exam tenderness and swelling along the track of
    the involved tendon between the joints.
  • Characteristic of Reactive arthritis, Gout, RA,
    gonococcal arthritis, psoriatic.

68
Tenosynovitis in JRA
69
Dactylitis Sausage Toes Psoriasis, Reactive,
Enteropathic
70
Enthesitis
71
Extraarticular Features Helpful in DD
  • Eye involvement conjunctivitis in reactive
    arthritis, uveitis in enteropathic and
    sarcoidosis, episcleritis in RA
  • Oral ulcerations painful in reactive arthritis
    and enteropathic, not painful in SLE
  • Nail lesions pitting (psoriasis), onycholysis
    (reactive arthritis)
  • Alopecia (SLE)

72
Reactive Arthritis - Conjunctivitis
73
Episcleritis
74
Reactive Arthritis Palate Erosions
75
Alopecia - SLE
76
Nail Pitting - Psoriasis
77
Nail Changes in Reactive Arthritis
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