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THURSDAY 03.11.2016/03.02.

1438

QUESTION OF THE
WEEK

Good Morning

BACKGROUND
A

60-year-old man reports a 7-day


history of pain and swelling in his left
knee that developed after he returned
from a sightseeing trip to Cambodia.
The pain is exacerbated by walking and
is relieved by rest. There is no locking
of the knee. During the past year, he
has noted morning stiffness affecting
his legs that resolves within 15 minutes
after waking up. He reports no other
recent trauma, injury, or illness.

BACKGROUND
On

physical examination, his temperature


is 36.9C, his blood pressure is 132/72 mm
Hg, his heart rate is 88 beats per minute,
and his respiratory rate is 17 breaths per
minute. There is a large left-knee effusion
without warmth or erythema. Varus
deformity of the left knee is noted, and
range of motion in extension or flexion is
limited by pain. No joint-line tenderness is
found. The remainder of the
musculoskeletal examination is normal.

BACKGROUND
Plain

radiography of the left


knee reveals a large effusion,
narrowing of the medial joint
space, and osteophytes arising
from the patellofemoral and
tibiofemoral joints.

BACKGROUND
Arthrocentesis

is performed, and
a synovial-fluid sample is clear
yellow with a leukocyte count of
900 per mm3(reference range,
450011,000) and a differential
of 92% lymphocytes and 8%
neutrophils.

QUESTION
What

is the most likely diagnosis


in this case?
Meniscal tear
Septic arthritis
Crystalline arthropathy
Rheumatoid arthritis
Osteoarthritis

ANSWER
Osteoarthritis

Key Learning Point


A

noninflammatory effusion
associated with a leukocyte
count in the range of 200 to
2000 per mm3 is most consistent
with a diagnosis of
osteoarthritis.

Detailed Feedback
The

patients symptoms are typical of an


osteoarthritis flare. The principal symptom
of osteoarthritis is pain, which usually
increases with activity and improves with
rest. In more advanced cases, pain may
become persistent and occur at rest or at
night. Morning stiffness that resolves in less
than 30 minutes is also common in patients
with osteoarthritis, although some describe
recurrence of stiffness after a period of
inactivity, known as the gelling
phenomenon.

Detailed Feedback
The

joints most commonly affected in


osteoarthritis are the knees, the hips, and
the distal interphalangeal and first
carpometacarpal joints of the hands.
Examination of an affected knee may be
normal but is often notable for tenderness
on palpation at the joint line, limited range
of motion, crepitus, and/or joint effusion.
The major radiographic features include
joint-space narrowing, subchondral
sclerosis, osteophytes, and subchondral
cysts.

Detailed Feedback
There

is a broad differential diagnosis


for acute or subacute monoarticular
knee pain and swelling.
If a patients symptoms, findings on
physical examination, and radiographic
evidence are suggestive of an
osteoarthritic flare, arthrocentesis can
be done to confirm the diagnosis and
rule out other causes, such as a septic
arthritis or crystalline arthropathy.

Detailed Feedback
The

synovial fluid in patients with


osteoarthritis is typically noninflammatory,
with a leukocyte count from 200 to 1000 per
mm3, a predominance of lymphocytes, and
<25% polymorphonuclear leukocytes.
In contrast, septic arthritis, caused by
bacterial infection, results in purulentappearing synovial fluid, a leukocyte count
that is always inflammatory and usually in
the range of 50,000 to 150,000 per mm 3, and
a strong neutrophil predominance.

Detailed Feedback
Similarly,

crystalline arthropathies (such


as gout or pseudogout) manifest with
inflammatory synovial fluid along with the
presence of monosodium urate or calcium
pyrophosphate dihydrate crystals.
Patients with osteoarthritis often have
deposition of calcium pyrophosphate
dihydrate in the cartilage of affected
joints and are therefore at risk for
pseudogout, but the fluid in an attack of
pseudogout is inflammatory.

Detailed Feedback
Rheumatoid

arthritis is unlikely
in the absence of inflammatory
synovial fluid. Rheumatoid
arthritis also usually features
morning stiffness lasting >30
minutes and does not involve
the distal interphalageal joints;
it typically involves variable
combinations of other small and
medium-sized joints of the

Detailed Feedback
A

meniscal tear may also manifest with


noninflammatory synovial fluid, but in the
absence of recent trauma or symptoms such
as knee popping, locking, catching, or
giving out, this diagnosis is less likely than
osteoarthritis.
The patients history is important in
deciding whether to order an MRI: Physical
examination maneuvers have poor
predictive value for diagnosing meniscal
injury, and MRIs frequently show meniscal
damage that is not clinically significant.

Typical characteristics of synovial fluid

The

characteristics of normal
synovial fluid are as follows:
Appearance: Clear
White blood cell (WBC) count: Less
than 200 cells/L
Polymorphonuclear neutrophils
(PMNs): Less than 25%
Viscosity: High
Glucose level: Similar to that of the
patients serum glucose level

Typical Characteristics of Synovial Fluid


in Noninflammatory Conditions
Appearance:

Clear, yellow
WBC count: Less than 2000
cells/L
PMNs: Less than 25%
Viscosity: High
Glucose level: Similar to that of
the patients serum glucose
level

Non-Inflammatory fluid:
200 - 2000 WBC/mm3
Osteoarthritis

orDegenerative Joint Disease

Trauma
Osteochondritis

Dissecans
Rheumatic Fever
Chronic gout
ChronicPseudogout
ProgressiveSystemic Sclerosis (Scleroderma )
Polymyositis
Systemic Lupus Erythematosus (SLE)
NeuropathicArthropathy Hemorrhage may be
present)
Erythema Nodosum
Pigmented villonodular synovitis
Hypertrophic Osteoarthropathy

Inflammatory fluid:
2000 - 50,000 WBC/mm3 (mild < 20,000)

Rheumatoid

Arthritis
Psoriatic Arthritis
Ankylosing Spondylitis
Acute Rheumatic Fever
Acute gout
AcutePseudogout
ProgressiveSystemic Sclerosis (Scleroderma )
Polymyositis
Systemic Lupus Erythematosus (SLE)
Reiter's Syndrome
Inflammatory Bowel Disease Arthritis
Fungal Infections
Viral Infections
Bacterial Infections (partially treated)

Septic fluid:
Over 50,000 WBC/mm3
(especially

>100,000)
Septic Arthritis until proven
otherwise

REFERENCE
NEJM

, November 1, 2016

Citations
Felson

DT. Clinical practice.


Osteoarthritis of the knee. N
Engl J Med 2006 Feb 24;
354:841.
Bennell KL et al. Management of
osteoarthritis of the knee. BMJ
2012 Aug 1; 345:e4934.

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