clinical approach to acute arthritis
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Clinical Approach to Acute Arthritis. Azam amini Rheumatologist Boushehr university of medical science. Acute Arthritis. The sudden onset of inflammation of the joint, causing severe pain, swelling, and redness. - PowerPoint PPT PresentationTRANSCRIPT
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Clinical Approach to Acute Arthritis
Azam aminiRheumatologist
Boushehr university of medical science
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Acute ArthritisThe 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.
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Signs of InflammationSwellingWarmthErythemaTendernessLoss of function
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Key PointsDistinguish arthritis from soft tissue non articular syndromes If the problem is articular distinguish single joint from multiple joint involvementInflammatory or non-inflammatory diseaseAlways consider septic arthritis!
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Articular Vs. PeriarticularClinical feature Articular PeriarticularAnatomic structure
Painful site Pain on movementSwelling
Synovium, cartilage, capsuleDiffuse, deepActive/passive, all planesCommon
Tendon, bursa, ligament, muscle, boneFocal “point”Active, in few planesUncommon
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Inflammatory Vs. Noninflammatory
Feature Inflammatory NoninflammatoryPain (when?)SwellingErythemaWarmthAM stiffnessSystemic featuresî ESR, CRPSynovial fluid WBCExamples
Yes (AM)Soft tissue SometimesSometimesProminent SometimesFrequentWBC >2000Septic, RA, SLE, Gout
Yes (PM)BonyAbsentAbsentMinor (< 30 ‘)AbsentUncommonWBC < 2000OA, AVN
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Acute MonoarthritisInflammation (swelling, tenderness, warmth) in one jointOccasionally polyarticular diseases can present with monoarticular onset: (RA, JRA,Reactive and enteropathic arthritis,
Sarcoid arthritis, Viral arthritis, Psoriatic arthritis)
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Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER: INFECTION !SepticCrystal deposition (gout, pseudogout)Traumatic (fracture, internal derangement)Other (hemarthrosis, osteonecrosis, presentation of polyarticular disorders)
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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.
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Acute Monoarthritis
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Indications for Arthrocentesis
The single most useful diagnostic study in initial evaluation of monoarthritis: SYNOVIAL FLUID ANALYSIS1. Suspicion of infection2. Suspicion of crystal-induced arthritis3. Suspicion of hemarthrosis4. Differentiating inflammatory from noninflammatory arthritis
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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.
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Septic JointMost articular infections – a single joint15-20% cases polyarticularMost common sites: knee, hip, shoulder20% patients afebrileJoint pain is moderate to severeJoints visibly swollen, warm, often redComorbidities: RA, DM, SLE, cancer,etc
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Septic Joint - Nongonococcal
80-90% monoarticularMost develop from hematogenous spreadMost common:Gram positive aerobes (80%)Majority with Staph aureus (60%)Gram negative 18%
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Septic Joint - GonococcalMost common cause of septic arthritisOften preceded by disseminated gonococcemiaSexually active individual, 5-7 days h/o fever, chills, skin lesions, migratory arthralgias and tenosynovitis persistent monoarthritisWomen often menstruating or pregnantGenitourinary disease often asymptomatic
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Disseminated Gonococcemia – Pustules
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GoutCaused by monosodium urate crystalsMost common type of inflammatory monoarthritisTypically: first MTP joint, ankle, midfoot, kneePain very severe; cannot stand bed sheetMay be with fever and mimic infectionThe cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis
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Acute Gouty Arthritis
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Risk FactorsPrimary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis.Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure.
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Urate CrystalsNeedle-shaped
Strongly negative birefringent
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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).
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Associated ConditionsHyperparathyroidismHypercalcemiaHypocalciuriaHemochromatosisHypothyroidismGoutAging
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CPPD Crystals
Rod or rhomboid-shaped
Weakly positive birefringent
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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
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PolyarthritisDefinite inflammation (swelling, tenderness, warmth of > 5 jointsA patient with 2-4 joints is said to have pauci- or oligoarticular arthritis
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Acute PolyarthritisInfectionGonococcalMeningococcalLyme diseaseRheumatic feverBacterial endocarditisViral (rubella, parvovirus, Hep. B)
InflammatoryRAJRASLEReactive arthritisPsoriatic arthritisPolyarticular goutSarcoid arthritis
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Inflammatory Vs. Noninflammatory
Feature Inflammatory Mechanical
Morning stiffnessFatigueActivityRestSystemicCorticosteroid
>1 h
Profound ImprovesWorsensYesYes
< 30 min
MinimalWorsensImprovesNoNo
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Temporal Patterns in Polyarthritis
Migratory pattern: Rheumatic fever, gonococcal (disseminated gonococcemia), early phase of Lyme diseaseAdditive pattern: RA, SLE, psoriasisIntermittent: Gout, reactive arthritis
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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.
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Viral ArthritisYounger patientsUsually presents with prodrome, rashHistory of sick contactPolyarthritis similar to acute RAPrognosis good; self-limitedExamples: Parvovirus B-19, Rubella, Hepatitis B and C, Acute HIV infection, Epstein-Barr virus, mumps
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Parvovirus B-19The 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/polyarthritis with stiffness in young women exposed to kids with E.I.May persist for a few weeks to months.
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Viral Arthritides - Parvovirus
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Rubella ArthritisGerman 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).
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Rheumatoid ArthritisSymmetric, inflammatory polyarthritis, involving large and small jointsAcute, severe onset 10-15 %; subacute 20%Hand characteristically involvedAcute hand deformity: fusiform swelling of fingers due to synovitis of PIPsRF may be negative at onset and may remain negative in 15-20%! RA is a clinical diagnosis, no laboratory test is diagnostic, just supportive!
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Acute Polyarthritis - RA
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Acute Sarcoid ArthritisChronic inflammatory disorder – noncaseating granulomas at involved sites15-20% arthritis; symmetrical: wrists, PIPs, ankles, kneesCommon with hilar adenopathyErythema nodosumLöfgren’s syndrome: acute arthritis, erythema nodosum, bilateral hilar adenopathy
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Acute Polyarthritis in Sarcoidosis
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Reactive ArthritisInfection-induced systemic disease with inflammatory synovitis from which viable organisms cannot be cultured Association with HLA B 27 Asymmetric, oligoarticular, knees, ankles, feet40% have axial disease (spondylarthropathy)Enthesitis: inflammation of tendon-bone junction (Achilles tendon, dactylitis)Extraarticular: rashes, nails, eye involvement
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Asymmetric, Inflammatory Oligoarthritis
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Enthesitis in Reactive Arthritis
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Keratoderma Blenorrhagica – Reactive
Arthritis
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Reactive Arthritis - Conjunctivitis
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Reactive Arthritis – Palate Erosions
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Psoriatic ArthritisPrevalence of arthritis in Psoriasis 5-7%Dactilytis (“sausage fingers”), nail changesSubtypes: 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
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Acute Polyarthritis - Psoriatic
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Dactylitis “Sausage Toes” – Psoriasis
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Psoriasis
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Arthritis Of SLEMusculoskeletal 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.
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Butterfly Rash – SLE
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Photosensitivity
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Alopecia - SLE
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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.
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Erythema Marginatum – Rheumatic Fever
CircinateEvanenscentNonpruritic rash
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Rheumatic Fever – Subcutaneous Nodes
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Gouty Arthritis
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Skin Lesions Useful in Diagnosis
Psoriatic plaquesKeratoderma Blenorrhagicum (reactive arthritis)Butterfly rash (SLE)Salmon-colored rash of JRA, adult Still’sErythema marginatum (Rheumatic Fever)Vesicopustular lesions (gonococcal arthritis)Erythema nodosum (acute sarcoid, enteropathic arthritis)
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Disseminated Gonococcemia – Pustules
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Keratoderma Blenorrhagica – Reactive
Arthritis
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Erythema Marginatum – Rheumatic Fever
CircinateEvanenscentNonpruritic rash
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Adult Still’s Disease and JRA Rash
Salmon or pale-pink BlanchingMacules or maculopapulesTransient (minutes or hours)Most common on trunkFever related
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SLE – Face Rash
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SLE – Interarticular Rash Hands
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Keratoderma Blenorrhagicum
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Erythema Nodosum
Sarcoidosis
Inflammatory Bowel Disease – related arthritis
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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.
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Tenosynovitis in JRA
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Dactylitis “Sausage Toes” – Psoriasis, Reactive,
Enteropathic
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Enthesitis
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Extraarticular Features Helpful in DD
Eye involvement: conjunctivitis in reactive arthritis, uveitis in enteropathic and sarcoidosis, episcleritis in RAOral ulcerations: painful in reactive arthritis and enteropathic, not painful in SLENail lesions: pitting (psoriasis), onycholysis (reactive arthritis)Alopecia (SLE)
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Reactive Arthritis - Conjunctivitis
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Episcleritis
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Reactive Arthritis – Palate Erosions
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Alopecia - SLE
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Nail Pitting - Psoriasis
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Nail Changes in Reactive Arthritis