Lecture 28: Polyarticular Syndromes Flashcards
Difference between arthritis and arthralgia
Arthralgia (Hepatitis, Rubella, Parvo, Dengue, Alpha virus)
– Pain localized in a joint
• Arthritis
– Objective evidence of joint inflammation, or
degenerative changes of the joint
Signs and symptoms of arthritis
Pain • Joint stiffness • Swelling of joints • Warmth • Redness • Crepitus • Joint tenderness • Joint deformity, bony enlargement • Loss of function (functio laesa)
Physical exam helpful in polyarthritis (involvement of 5 or more joints, oligoarthritis is between 2 and 4 joint involvement)
Presence of fever
• Skin changes (psoriasis; subcutaneous nodules)
• Cardiac (new murmur; pericardial rub)
• Pulmonary (inspiratory crackles)
• Hematologic (lymph nodes, anemia)
• Nervous system (polyneuritis, mononeuritis
multiplex)
• Oral/genital (ulcers; oral dryness)
• Eye (uveitis; scleritis; keratoconjunctivitis)
What else can help in the diagnosis of polyarthritis?
Review slide on synovial fluid characteristics
Arthrocentesis for crystals
• Plain radiograph (hand/feet erosions-rheumatoid arthritis; knee chondrocalcinosis; CPPD
SI joint – Ankylosing spondylitis),
CT scan, MRI, scintigraphy
(malignancy, infection, Paget’s disease), contrast studies
• Immunology/Genetics: Rheumatoid factor, anti-Cyclic citrullinated peptide
antibody, ANA, ANCA, HLA-B27
• Hematology: RBC, WBC, Platelet count
• Biochemistry: ESR, CRP, Uric acid, Calcium, Phosphate, Ferritin, Liver function tests
• Arthroscopy
• Synovial biopsy: patohistology (rheumatoid arthritis, sarcoidosis, tuberculosis, fungal infection)
• Other tissue biopsy: intestine- Whipple’s disease; lungs – granulomatosis with
polyangiitis, sarcoidosis; renal – SLE, vasculitis; liver –
autoimmune hepatitis; Hemochromatosis
• Neurophysiology – EMG/NCV
Inflammatory vs. Non-inflammatory arthritis
Inflammatory arthritis
– Symptoms typically worse in AM and improve with activity
– Associated AM stiffness (lasting > 1h): Morning stiffness is very typical of inflammatory arthritis
– Joint exam showing inflammatory signs
– Synovial fluid: >2,000 WBCs
• Non-inflammatory arthritis
– Symptoms typically worse after activity and in PM
– Minimal or no AM stiffness [
Causes of inflammatory polyarthritis
Review the slide on page 8
Positive rheumatoid factor does not mean rheumatoid arthritis
Causes of positive RF without RA Age (>60 y, up to 25%) • Bacterial endocarditis (25-50%) • Hepatitis C (or B) infection (25-75%)
Mode of onset acute (4-6 weeks) or insidious
Basics of arthritis - terms
• Mode of onset
– Sudden (Acute) –Gout; Septic arthritis, Rheumatic
fever; Reactive arthritis; Palindromic rheumatism;
Rheumatoid arthritis (less common); Psoriatic
arthritis (less common); Parvovirus
– Insidious – Juvenile chronic arthritis; Rheumatoid
arthritis (more common); Osteoarthritis; Psoriatic
arthritis; Charcot’s arthropathy; Hypertrophic
osteoarthropathy; Fungal/mycobacterial arthritis
Sequence of involvement
Additive – progressive course resulting in more joints
being involved over time without the resolution of arthritis in initially affected joints (Polyarticular OA;
Rheumatoid arthritis; Reactive arthritis)
– Migratory – inflammation starts in 1 joint then stops, then
starts in other previously normal joint (Rheumatic fever;
Neisserial arthritis)
– Intermittent (discontinues pattern)– complete remission
of joint symptoms until the next recurrence affecting the
same or different joint (Crystal-induced arthritis; Palindromic rheumatism; Familial Mediterranean Fever; Whipple’s disease; Still’s disease; Systemic Lupus)
Distribution of affected joints
Symmetric (fusiform swelling of PIP joints in
rheumatoid arthritis; systemic lupus; systemic
sclerosis)
– Asymmetric (Heberden’s nodes in osteoarthritis;
Erosive osteoarthritis; Chronic sarcoidosis; chronic
polyarticular tophaceous gout; Psoriatic arthritis)
Localization of affected joints
Axial (spine, SI joints, sternoclavicular and
manubriosternal joints, some also include shoulders
and hips). Typical in Ankylosing spondylitis
(common), Diffuse idiopathic skeletal hyperosthosis.
– Appendicular
– Combined (both axial and appendicular):
Osteoarthritis; Psoriatic arthritis; Enteropathic
arthritis; reactive arthritis. Apophyseal joints of the
cervical spine can be affected in Rheumatoid arthritis
Individual patterns (upper extremity)
Rheumatoid arthritis: bilateral symmetric involvement of small and large peripheral joints. MCP, PIP, wrists (but not DIP) are frequently involved. Similar pattern of MCP and PIP joint involvement can be seen in SLE, Systemic sclerosis and parvoviral infection.
• Inflammatory DIP joint involvement: Psoriatic
arthritis; Nodal osteoarthritis (Heberden’s nodes); Hypertrophic osteoarthropathy
• Bilateral bony enlargement of MCP2 and MCP3 joints is characteristic of Hemochromatosis
Individual patterns (upper extremity)
Acute sternoclavicular joint involvement – in IV drug users suggests septic arthritis.
• Acute bilateral shoulder (and hip) pain with minimal objective findings is suggestive of PMR (polymyalgia rheumatica)
Individual pattern of lower extremities
The first MTP of the big toe (podagra): Typically affected in
acute gout. Can also be seen in Pseudo-gout, Osteoarthritis,
and Psoriatic arthritis.
• Asymmetric involvement of knees and ankles: Suggests
seronegative spondyloarthropathies (reactive arthritis).
May also present with the sausage toe (dactylitis).
• Intermittent synovitis of the knee: May suggest late Lyme
disease, but can be seen in early Juvenile chronic arthritis.
• Entesopathy of the Achilles tendon and plantar fascia:
suggests seronegative spondyloarthropathy. Other areas
can also be involved: ischial tuberosity; greater trochanters;
costosternal joints; manubriosternal joint; iliac crests.
Helpful tips
In most cases well taken history and physical
exam can help identify the cause of polyarthritis
• For acute polyarthritis, consider viral or post-viral
etiologies; obtain CBC, LFT, parvovirus & hepatitis
virus serologies. Ask about travel. Alphaviruses
are already in Florida.
• For chronic polyarthritis, consider systemic
rheumatic disease as primary diagnosis, obtain
RF/anti-CCP, ANA, CBC, UA, ESR, chem, SF analysis
and x-rays if lasting longer than 6 months.
