1. Clinical Approach to Acute Arthritis Azam amini Rheumatologist Boushehr university of medical science

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 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 Clinical featureArticularPeriarticular Anatomic structure Painful site Pain on movement Swelling Synovium, cartilage, capsule Diffuse, deep Active/passive, all planes Common Tendon, bursa, ligament, muscle, bone Focal “point” Active, in few planes Uncommon

6. Inflammatory Vs. Noninflammatory FeatureInflammatoryNoninflammatory Pain (when?) Swelling Erythema Warmth AM stiffness Systemic features î ESR, CRP Synovial fluid WBC Examples Yes (AM) Soft tissue Sometimes Prominent Sometimes Frequent WBC >2000 Septic, RA, SLE, Gout Yes (PM) Bony Absent Minor (< 30 ‘) Absent Uncommon WBC < 2000 OA, AVN

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 FeatureInflammatoryMechanical Morning stiffness Fatigue Activity Rest Systemic Corticosteroid >1 h Profound Improves Worsens Yes < 30 min Minimal Worsens Improves No

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/polyarthritis 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 Löfgren’s 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. Reactive Arthritis - Conjunctivitis

43. Reactive Arthritis – Palate Erosions

44. 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

45. Acute Polyarthritis - Psoriatic

46. Dactylitis “Sausage Toes” – Psoriasis

47. Psoriasis

48. 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.

49. Butterfly Rash – SLE

50. Photosensitivity

51. Alopecia - SLE

52. 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.

53. Erythema Marginatum – Rheumatic Fever Circinate Evanenscent Nonpruritic rash

54. Rheumatic Fever – Subcutaneous Nodes

55. Gouty Arthritis

56. Skin Lesions Useful in Diagnosis Psoriatic plaques Keratoderma Blenorrhagicum (reactive arthritis) Butterfly rash (SLE) Salmon-colored rash of JRA, adult Still’s Erythema marginatum (Rheumatic Fever) Vesicopustular lesions (gonococcal arthritis) Erythema nodosum (acute sarcoid, enteropathic arthritis)

57. Disseminated Gonococcemia – Pustules

58. Keratoderma Blenorrhagica – Reactive Arthritis

59. Erythema Marginatum – Rheumatic Fever Circinate Evanenscent Nonpruritic rash

60. Adult Still’s Disease and JRA Rash Salmon or pale-pink Blanching Macules or maculopapules Transient (minutes or hours) Most common on trunk Fever related

61. SLE – Face Rash

62. SLE – Interarticular Rash Hands

63. Keratoderma Blenorrhagicum

64. Erythema Nodosum Sarcoidosis Inflammatory Bowel Disease – related arthritis

65. 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.

66. Tenosynovitis in JRA

67. Dactylitis “Sausage Toes” – Psoriasis, Reactive, Enteropathic

68. Enthesitis

69. 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)

70. Reactive Arthritis - Conjunctivitis

71. Episcleritis

72. Reactive Arthritis – Palate Erosions

73. Alopecia - SLE

74. Nail Pitting - Psoriasis

75. Nail Changes in Reactive Arthritis