Critical Diagnostic Questions

State of the Art

Is it arthritis? Is it acute? Is it mono, oligo or polyarthritis? Is it septic? Is it primary arthritis? Is it the tip of an iceberg?

Acute Arthritis
Prof Alan Tyndall Rheumatologische Universittsklinik Basel

Arthritis
Doughy, boggy swelling

Arthritis
But not always ----

Early synovitis MCP only seen with MRI plus gadolinium

Arthritis
Arthralgia is NOT arthritis

Arthritis
Bursitis is NOT arthritis

Primary OA +/carpal tunnel syndrome May have ACTIVATED OA phases- esp knee

Prepatellar bursitis

Arthritis

Arthritis
Other acute, hot swellings near joints:
1. Stress fractures ( e.g. lower tibia, second metatarsal, calcaneus) 2. Erythema nodosum ( ankle) 3. Cellulitis ( e.g. lower leg) 4. Tenosynovitis ( e.g. tib posterior) PRACTICE TIP: joint ultrasound or MRI

Note the difference!

Critical Diagnostic Questions

Is it arthritis? Is it acute? Minutes to hours : hemarthrosis Hours to days: Days to weeks: sepsis, reactive, crystals autoimmune ( RA), CTD, viral

Acute Inflammatory Monoarthritis

Sepsis : Staphylococcus
Gonococcus H. influenzae ( kids) Borrelia burgdorferi ANYTHING

Weeks to months: degenerative, other

Acute Inflammatory Monoarthritis

Crystals: urate ( gout) Ca pyrophosphate (pseudogout) Ca Hydroxyapatite ( shoulder)

Acute Inflammatory Monoarthritis

Crystals: urate ( gout) Ca pyrophosphate (pseudogout) Ca Hydroxyapatite ( shoulder)

Acute Inflammatory Monoarthritis

Crystals: urate ( gout) Ca pyrophosphate (pseudogout) Ca Hydroxyapatite ( shoulder)

Acute Inflammatory Oligoarthritis

Kids: Oligo articular Juvenile Idiopathic Arthritis (JIA)

ANA pos slit lamp

Acute Inflammatory Oligoarthritis

Kids: Systemic JIA ( Stills disease) - mono, oligo onset
rash

Acute Inflammatory Oligoarthritis

Reactive arthritis ( ReA)
GIT : Campylobacter, Yersinia, Salmonella, Shigella Genitourinary: Chlamydia, Gonococcus Throat: hemolytic streptococcus

Fever, rash, arthritis high ESR , CRP very elevated ferritin

Acute Inflammatory Oligoarthritis

Psoriasis associated arthritis ( PsA)

Acute Inflammatory Oligoarthritis

Psoriasis associated arthritis ( PsA)
Hidden psoriasis

Typical joints: DIPs, big and small together

Nail changes Pustulosis Keratodermia blenorrhagicum

Acute Polyarthritis
Viral (especially tendon sheaths) Early RA Polyarticular gout Connective tissue disease, vasculitis Septicaemia, endocarditis Sarcoid poly to oligo, larger joints.

Acute Polyarthritis
Viral (especially tendon sheaths) and painful - parvovirus B19, Hep B and C, others

Slapped cheeks of parvo in kids.

Adults - polyarthritis Lasts < 2-3 weeks

Is there an early RA profile?

Maybe:
Symptom duration > 3 months EMS > 60 mins Arthritis in 3 or more joint groups Bilateral MTP compression pain Pos IgM rheumatoid factor > 5 IU Anti cyclic citrillated protein ( CCP) > 92 IU Erosions on hand or foot X-rays

Is there an early RA profile?

Maybe:
Symptom duration > 3 months EMS > 60 mins Arthritis in 3 or more joint groups Bilateral MTP compression pain Pos IgM rheumatoid factor > 5 IU Anti cyclic citrillated protein ( CCP) > 92 IU Erosions on hand or foot X-rays
MRI erosion - plain Xray normal Early erosion

Polyarticular gout
Pseudogout ( Calcium pyrophosphate mono/ oligo) is rarely polyarticular. Tophi develop with time. Joint aspiration ( 5% gouty arthritis normouricaemic during attack)

Diagnostic criteria for SLE ARA 1985

Photosensitity Raynauds maculopap rash polyarthritis serositis Cytopenias Coombs pos haem. anemia haematuria or proteinuria CNS Pos ANA, SSA,anticardiolipin, LAC Pos double stranded DNA

NEED 4 OF 11 Distinguishes SLE versus other rheumatic diseases, not all other disorders eg lymphoma

SLE-skin and joints

Butterfly rash Muco-cutaneous Rash and arthritis

Systemic Infections and acute arthritis

Meningococcal septicaemia with acute arthritis and cutaneous vasculitis

Photosensitive alopecia

The bits under the water

Hidden proriasis ( or 1st degree family member)

Work-up of Acute Arthritis Mono and oligo

Joint aspiration
3 tubes 1. Plain G stain & bact 2. Plain crystal 3. EDTA- cell count and diff Special: PCR Borrelia, other

Sarcoid BAL CD4/CD8 > 3.5

Asymmetrical sacroiliitis in Crohn and oligoarthritis

Blood cultures if CRP elevated ( 20% septic arthritis pos) CRP, ESR Serum urate, creatinine Urine Chlamydia PCR and stool culture X ray ( chondrocalcinosis, fracture) Ultrasound if atypical or hip

Work-up of Acute Arthritis Polyarthritis (>4 joints)

FULL HISTORY AND PHYSICAL FBC, biochemistry CRP, ESR RF, CCP (filaggrin) , ANA (DNA , ENA if pos) Serology for: parvovirus, Hep B and C, Borrelia X ray both hands and feet (erosions), chest Ultrasound abdomen Blood cultures and Echocardiogram

Baker DG and Schumacher HR, Jr. Acute monoarthritis. N Engl J Med 1993;329(14):1013-20 A scholarlarly and still very clinically relevant review. Cassetta M and Gorevic PD. Crystal arthritis. Gout and pseudogout in the geriatric patient. Geriatrics 2004;59(9):25-30; quiz 1 A logical, complete and practically oriented review which 10 years later remains a classic. Nade S. Septic arthritis. Best Pract Res Clin Rheumatol 2003;17(2):183-200 Very useful summary of a common problem. Pinals RS. Polyarthritis and fever. N Engl J Med 1994;330(11):769-74 Excellent overview of a common problem. Schlesinger N. Management of acute and chronic gouty arthritis: present state-of-theart. Drugs 2004;64(21):2399-416 Opening chapter in an edition entirely devoted to sepsis. Very practical.

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