The following drugs, medications, substances or toxins are some of the possible
causes of Arthralgia as a symptom.
This list is incomplete and various other drugs or substances
may cause your symptoms.
Always advise your doctor of any medications or treatments you are using,
including prescription, over-the-counter, supplements, herbal or alternative treatments.
As with all medical conditions,
there may be many causal factors.
Further relevant information on causes of Arthralgia may be found in:
Pseudogout
–Calcium pyrophosphate deposition disease
–Can affect the toe, but the knee is most
common
- Seronegative spondyloarthropathy
–Psoriatic arthritis: Spondyloarthropathy involving middle-aged patients at multiple joints associated with classic skin lesions
–Reiter's syndrome: Arthritis, uveitis, urethritis
- Septic arthritis
–Fever, joint redness, pain with passive and active range of motion
–Most often due to skin flora such as Staphylococcus aureus and various streptococci
–Neisseria gonorrhoeae in young sexually active adults
–Often associated with previous penetrating trauma to the toe
- Less common etiologies (“zebras”) include cholesterol emboli, infective endocarditis, Lyme disease (presents as monoarticular arthritis in 10% of cases), and paronychia (bacterial infection of the posterior nail folds)
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Source: In a Page: Signs and Symptoms, 2004
Wrist & Hand Pain/Swelling:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Carpal tunnel syndrome
–Most common cause of significant wrist discomfort and morbidity
–Associated with repetitive use activities (e.g., typing)
–Pain and numbness symptoms result from entrapment of the median nerve under the transverse ligament
-
Overuse injury
-
Osteoarthritis
-
Tenosynovitis (DeQuervain's) of the radial wrist
–Results from inflammation of the tendon sheaths of the extensor pollicis brevis and abductor pollis longus
- Ganglion cysts
–Common growths of tendons and ligaments in the wrist area occurring on both the dorsal and ventral surface
–They are compressible, round, often tender, and mobile
-
Trauma
–The most common mechanism of injury is a fall on the outstretched hand
–The most commonly fractured carpal bone is the scaphoid
–Other mechanisms include direct blows, crush injuries, fall on an angulated wrist, and severe twisting motions
-
Fibromyalgia
-
Compartment syndrome
-
Chest or shoulder masses, resulting in compression of lymphatic or venous systems
-
Venous thrombosis of the subclavian or distal veins
-
Flaccid paralysis following a CVA
-
Angioedema secondary to hymenoptera sting
-
Rheumatologic disease
-
Peripheral neuropathy
-
Insect or animal bite/sting
-
Infection (e.g., staphylococcus aureus, streptococci)
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Source: In a Page: Signs and Symptoms, 2004
Arthritis – Multiple Joints:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Infectious
–Reactive arthritis (postenteric or genital including Reiter syndrome, postviral, poststreptococcal)
–Acute rheumatic fever (ARF): Migratory, painful; usually affects large joints; diagnosis is based on Jones criteria, which includes five major (arthritis, carditis, Sydenham chorea, erythema marginatum, subcutaneous nodules) and several minor (fever, arthralgia, elevated ESR or CRP, prolonged P-R interval) manifestations
–Lyme disease: Arthritis is monoarticular or oligoarticular, is rarely symmetric, and is the second most common manifestation of Lyme disease after erythema migrans
–SBE-related arthritis
–Septic polyarthritis (unusual)
- Rheumatic
–Polyarticular JRA: Arthritis in five or more joints in first 6 months of disease, insidious onset, symmetric involvement, may be RF+ (erosive, similar to adult RA) or RF-
–Systemic-onset JRA: Presents with severe systemic involvement (fever, rash, serositis), which may precede the arthritis, usually oligoarticular
–Juvenile ankylosing spondylitis (JAS): Initially affects lower extremity joints; later affects axial skeleton, also affects tendons
–Psoriatic arthritis
–Arthritis of IBD: Usually more transient than JRA
–SLE: May present only with arthritis, may be misdiagnosed as JRA
–Other connective tissue diseases (scleroderma)
–Vasculitis (HSP, Kawasaki disease)
-
Malignancy such as leukemia
-
Other systemic disorders: Serum sickness, sarcoidosis, Behçet disease, Ehler-Danlos syndrome, mucopolysaccharidoses, Noonan syndrome, Turner syndrome
-
Medications (minocyline, carbamazapine)
-
Sickle cell disease
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Source: In A Page: Pediatric Signs and Symptoms, 2007
Arthritis – Single Joint:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Septic arthritis
–Rapid diagnosis critical: Untreated septic arthritis causes irreversible joint and bone destruction
–Usually presents hyperacutely with very tender, swollen, warm, red joint with severely restricted range of motion
–Usual pathogens: Haemophilus influenzae type b, Staphylococcus aureus, group B strep in neonates, and Neisseria gonorrhoeae in adolescents; fungal and mycobacterial arthritis are seen rarely, may have chronic course
-
Lyme arthritis
–Second most common manifestation of Lyme disease (after erythema migrans)
–Monoarthritis of a knee occurs in about two-thirds of children with Lyme disease
-
Reactive arthritis
–Probably the most common etiology of childhood rheumatic diseases
–Transient sterile arthritis following a bacterial GI infection
–Usually full resolution, but a few children have a chronic course
-
Trauma, overuse, fracture
–Often acute onset with significant pain
-
Malignancy such as leukemia, neuroblastoma and osteogenic sarcoma
-
Pauciarticular juvenile rheumatoid arthritis (JRA)
-
Spondyloarthropathies (SpA)
-
Congenital hip dysplasia
-
Slipped capital femoral epiphysis (SCFE)
–Most common adolescent hip disorder
–Separation of the femoral growth plate
–More common in obese males
-
Spontaneous osteonecrosis of the joint
–Mostly in hip (Legg-Calvé-Perthes disease), shoulder, and knee
–More common in males
-
Internal structural abnormality
–Discoid meniscus, osteochondritis dissecans, synovial chondromatosis
-
Hemarthrosis due to trauma, bleeding disorder such as hemophilia, or benign tumors such as hemangiomas and pigmented villonodular synovitis
-
Periodic fever syndromes such as familial Mediterranean fever
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Scrotal Swelling:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Hydrocele
–Fluid surrounding the testicle
–Typically seen in infancy
–Results from remnant of testicular descent from the abdomen through the inguinal canal into the scrotum
–May be communicating or noncommunicating; communicating hydroceles have retained patency of the tract of descent, and noncommunicating hydroceles do not
–Communicating hydroceles may be reducible and are likely to fluctuate in size depending on the amount of fluid within the scrotal sac; crying or any increase in intra-abdominal pressure results in an increase in size
–Usually is noncommunicating; i.e., not reducible, and does not change in size with crying
–Testes may be difficult to palpate because surrounded by the hydrocele
- Hernia
–Protrusion of a loop of bowel into the scrotum
–Direct hernias represent a channel directly through the musculature of the pelvic floor; indirect hernias have proceeded through the inguinal canal
–Usually painless unless incarcerated
–Usually reducible and changes in size with changes in intra-abdominal pressure
–Testes usually palpable below the hernia
-
Varicocele
–A collection of dilated veins in the scrotum
–Usually painless, but patients may complain
of heaviness
-
Edema
–Generalized edema often is accompanied by scrotal edema
-
Tumor
–Presents as painless nodule on testes
–May be accompanied by sexual precocity or
gynecomastia secondary to hormone production by the tumor
-
Leukemia
–Patients may present with unilateral scrotal swelling (common site for relapse)
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Scrotal swelling:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Epididymal cysts
Located in the head of the epididymis, epididymal cysts produce painless scrotal swelling.
Epididymitis
Key features of inflammation are pain, extreme tenderness, and swelling in the groin and scrotum. The patient waddles to avoid pressure on the groin and scrotum during walking. He may have a high fever, malaise, an urethral discharge and cloudy urine, and lower abdominal pain on the affected side. His scrotal skin may be hot, red, dry, flaky, and thin.
Hydrocele
Fluid accumulation produces gradual scrotal swelling that’s usually painless. The scrotum may be soft and cystic or firm and tense. Palpation reveals a round, nontender scrotal mass.
Idiopathic scrotal edema
Swelling occurs quickly with idiopathic scrotal edema and usually disappears within 24 hours. The affected testicle is pink.
Orchitis (acute)
Mumps, syphilis, or tuberculosis may precipitate orchitis, which causes sudden painful swelling of one or, at times, both testicles. Related findings include a hot, reddened scrotum; a fever of up to 104° F (40° C); chills; lower abdominal pain; nausea; vomiting; and extreme weakness. Urinary signs are usually absent.
Scrotal trauma
Blunt trauma causes scrotal swelling with bruising and severe pain. The scrotum may appear dark or bluish.
Spermatocele
Spermatocele is a usually painless cystic mass that lies above and behind the testicle and contains opaque fluid and sperm. Its onset may be acute or gradual. Less than 1 cm in diameter, it’s movable and may be transilluminated.
Testicular torsion
Most common before puberty, testicular torsion is a urologic emergency that causes scrotal swelling; sudden, severe pain; and, possibly, elevation of the affected testicle within the scrotum. It may also cause nausea and vomiting.
Testicular tumor
Typically painless, smooth, and firm, a testicular tumor produces swelling and a sensation of excessive weight in the scrotum.
Torsion of a hydatid of Morgagni
Torsion of this small, pea-sized cyst severs its blood supply, causing a hard, painful swelling on the testicle’s upper pole.
Other causes
Surgery
An effusion of blood from surgery can produce a hematocele, leading to scrotal swelling.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Rheumatoid arthritis:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
RA occurs worldwide, striking three times more females than males. Although it can occur at any age, it begins most often between ages 25 and 55. This disease affects more than 7 million people in the United States alone.
What causes the chronic inflammation characteristic of RA isn’t known, but various theories point to infectious, genetic, and endocrine factors. Currently, it’s believed that a genetically susceptible individual develops abnormal or altered immunoglobulin (Ig) G antibodies when exposed to an antigen. This altered IgG antibody isn’t recognized as “self,” and the individual forms an antibody against it — an antibody known as RF. By aggregating into complexes, RF generates inflammation. Eventually, cartilage damage by inflammation triggers additional immune responses, including activation of complement. This in turn attracts polymorphonuclear leukocytes and stimulates release of inflammatory mediators, which enhance joint destruction.
Much more is known about the pathogenesis of RA than about its causes. If unarrested, the inflammatory process within the joints occurs in four stages. First, synovitis develops from congestion and edema of the synovial membrane and joint capsule. Formation of pannus — thickened layers of granulation tissue — marks the second stage’s onset. Pannus covers and invades cartilage and eventually destroys the joint capsule and bone. Progression to the third stage is characterized by fibrous ankylosis — fibrous invasion of the pannus and scar formation that occludes the joint space. Bone atrophy and malalignment cause visible deformities and disrupt the articulation of opposing bones, causing muscle atrophy and imbalance and, possibly, partial dislocations or subluxations. In the fourth stage, fibrous tissue calcifies, resulting in bony ankylosis and total immobility.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Neurogenic arthropathy:
Causes
(Professional Guide to Diseases (Eighth Edition))
Neurogenic arthropathy is most common in men older than 40 years. In adults, the most common cause of neurogenic arthropathy is diabetes mellitus. Other causes include tabes dorsalis (especially among patients age 40 to 60), syringomyelia (progresses to neurogenic arthropathy in about 25% of patients),myelopathy of pernicious anemia, spinal cord trauma, paraplegia, hereditary sensory neuropathy, and Charcot-Marie-Tooth disease. Amyloidosis, peripheral nerve injury, myelomeningocele (in children), leprosy, and alcoholism may cause neurogenic arthropathy, but only in rare occurrences.
Frequent intra-articular injection of corticosteroids has also been linked to neurogenic arthropathy. The analgesic effect of the corticosteroids may mask symptoms and allow continuous stress to accelerate joint destruction.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Juvenile rheumatoid arthritis:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
The cause of JRA remains puzzling. Research continues to test several theories, such as those linking the disease to genetic factors or to an abnormal immune response. Viral or bacterial (particularly streptococcal) infection, trauma, and emotional stress may be precipitating factors, but their relationship to JRA remains unclear.
Considered the major chronic rheumatic disorder of childhood, JRA affects an estimated 150,000 to 250,000 children in the United States; overall incidence is twice as high in females, with variation among the types of JRA.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Psoriatic arthritis:
Causes
(Professional Guide to Diseases (Eighth Edition))
Evidence suggests that predisposition to psoriatic arthritis is hereditary; 20% to 50% of patients are human leukocyte antigen-B27 positive. However, onset is usually precipitated by streptococcal infection or trauma.
About 5% to 7% of patients with psoriasis develop psoriatic arthritis. It occurs in up to 1% of the general population.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Septic arthritis:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
In most cases of septic arthritis, bacteria spread from a primary site of infection — usually in adjacent bone or soft tissue — through the bloodstream to the joint. Common infecting organisms in children are group B Streptococcus and Haemophilus influenzae. Adults are usually infected by Staphylococcus, Streptococcus (pneumonia), and group B Streptococcus, whereas chronic septic arthritis is caused by Mycobacterium tuberculosis and Candida albicans.
Various factors can predispose a person to septic arthritis. Any concurrent bacterial infection (of the genitourinary or the upper respiratory tract, for example) or serious chronic illness (such as malignancy, renal failure, rheumatoid arthritis, systemic lupus erythematosus, diabetes, or cirrhosis) heightens susceptibility. Consequently, elderly people and those who abuse I.V. drugs run a higher risk of developing septic arthritis. Of course, diseases that depress the immune system and immunosuppressive therapy increase susceptibility. Other predisposing factors include recent articular trauma, joint arthroscopy or other surgery, intra-articular injections, and local joint abnormalities.
Septic arthritis may be seen at any age in children, but it occurs most often in children younger than age 3. It’s uncommon from age 3 until adolescence, at which time the incidence increases again.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Scrotal swelling:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Elephantiasis of the scrotum
With this disorder (common in some tropical countries), infection by a filaria worm obstructs lymphatic drainage, causing chronic gross scrotal edema and pain. Associated findings include other areas of pitting and, eventually, brawny edema (especially the legs), thickened subcutaneous tissue, hyperkeratosis, and skin fissures.
Epididymal cysts
Located in the head of the epididymis, these cysts produce painless scrotal swelling.
Epididymal tuberculosis
This disorder produces an enlarged scrotal mass separated from the testicle. Other findings include palpable beading along the vas deferens, induration of the prostate or seminal vesicles, and pus or tubercle bacilli in the urine.
Epididymitis
Key features of inflammation are pain, extreme tenderness, and swelling in the groin and scrotum. The patient waddles to avoid pressure on the groin and scrotum during walking. He may have high fever, malaise, urethral discharge and cloudy urine, and lower abdominal pain on the affected side. His scrotal skin may be hot, red, dry, flaky, and thin.
Gumma
This rare, painless nodule—usually associated with benign tertiary syphilis—can affect any bone or organ. If it affects the testicle, it causes edema.
Hernia
Herniation of bowel into the scrotum can cause swelling and a soft or unusually firm scrotum. Occasionally, bowel sounds can be auscultated in the scrotum.
Hydrocele
Fluid accumulation produces gradual scrotal swelling that’s usually painless. The scrotum may be soft and cystic or firm and tense. Palpation reveals a round, nontender scrotal mass.
Idiopathic scrotal edema
Swelling occurs quickly with this disorder and usually disappears within 24 hours. The affected testicle is pink.
Orchitis (acute)
Mumps, syphilis, or tuberculosis may precipitate this disorder, which causes sudden painful swelling of one or, at times, both testicles. Related findings include a hot, reddened scrotum; fever of up to 104° F (40° C); chills; lower abdominal pain; nausea; vomiting; and extreme weakness. Urinary signs are usually absent.
Scrotal burns
Burns cause swelling within 24 hours of injury. Depending on the burn’s severity, associated findings may include severe pain, erythema, chafing, tissue sloughing, and maceration with a weeping exudate.
Scrotal trauma
Blunt trauma causes scrotal swelling with bruising and severe pain. The scrotum may appear dark or bluish.
Spermatocele
This usually painless cystic mass lies above and behind the testicle and contains opaque fluid and sperm. Its onset may be acute or gradual. Less than 1 cm in diameter, it’s movable and may be transilluminated.
Testicular torsion
Most common before puberty, this urologic emergency causes scrotal swelling; sudden, severe pain; and, possibly, elevation of the affected testicle within the scrotum. It may also cause nausea and vomiting.
Testicular tumor
Typically painless, smooth, and firm, a testicular tumor produces swelling and a sensation of excessive weight in the scrotum.
Torsion of a hydatid of Morgagni
Torsion of this small, pea-sized cyst severs its blood supply, causing a hard, painful swelling on the testicle’s upper pole.
Other causes
Surgery
An effusion of blood from surgery can produce a hematocele, leading to scrotal swelling.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Acute Monoarticular Arthritis:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Injury
❑ Gout
❑ Osteoarthritis
❑ Lyme disease
❑ Gonococcal arthritis
❑ Seronegative spondyloarthropathy
❑ Septic arthritis
❑ Pseudogout
❑ Septic bursitis
❑ Avascular necrosis
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Arthritis/Dermatitis:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑Lyme disease
❑Erythema nodosum
❑Rheumatoid arthritis
❑Systemic lupus erythematosus
❑Psoriatic arthritis
❑Disseminated gonococcemia
❑Sarcoidosis
❑Scleroderma
❑Dermatomyositis
❑Reiter syndrome
❑Rheumatic fever
❑Behçet syndrome
❑Still disease
❑Hypersensitivity vasculitis
Clinical Findings
Lyme disease Erythema migrans, a rapidly expanding annular rash with a clearing center, is the key early finding. The site of the ixodid tick bite at the center of the lesion is usually intensely indurated, vesicular, or necrotic. The arthritis is an asymmetric oligoarthritis that usually occurs after the rash has resolved.
Erythema nodosum A prodromal syndrome of fever, chills, malaise, and polyarthralgia is followed by the development of lesions that are discrete, tender, slightly raised subcutaneous nodules on the shins or ankles. They represent a hypersensitivity reaction to group A streptococcal infection, tuberculosis, sarcoidosis, inflammatory bowel disease, or drugs such as oral contraceptives and sulfonamides.
Rheumatoid arthritis Symmetric polyarticular arthritis with synovial proliferation, especially of the wrist, and morning stiffness lasting more than 1 hour characterize the early joint involvement. Rheumatoid nodules appear over extensor surfaces. Vasculitic lesions are frequently found on the digits, appearing as small red or purpuric macules that progress to painful nodules or ulcers.
Systemic lupus erythematosus A classic butterfly rash occurs in 40% and is exacerbated by sun exposure. A diffuse maculopapular rash in areas exposed to the sun heralds disease flares. Discoid lesions and scaling plaques that range in color from red to violaceous, with central atrophy and telangiectasias, occur in 20%. Vasculitis, in the form of painful ulcers on the extremities, palpable purpura, or lupus profundus (firm nodules in the subcutaneous fat on the forehead, cheeks, buttocks, and upper arms) are found. The arthritis is typically one of symmetric fusiform swelling of the proximal interphalangeal and metacarpophalangeal joints, diffuse puffiness of the hands, and tenosynovitis.
Psoriatic arthritis Psoriatic plaques, erythematous with a silvery scale, are critical to diagnosis, but may be hidden in the scalp, umbilicus, or gluteal folds. Nail changes such as pitting or yellow discoloration of the nail plate are other clues. The arthritis typically involves the proximal interphalangeal and distal interphalangeal joints, creating sausage digits. The arthritis may become erosive, leading to telescoping of the hands. One-fourth of patients have axial skeletal arthritis.
Disseminated gonococcemia Acral lesions are typically hemorrhagic pustules, but petechiae, hemorrhagic papules, or hemorrhagic bullae can occur. Fever, rigor, tenosynovitis, and polyarthritis are other findings.
Sarcoidosis Transient maculopapular eruptions of the trunk, face, and extremities are often accompanied by uveitis, adenopathy, and parotid enlargement. Translucent reddish-brown to purple indolent plaques may develop on the face (lupus pernio), buttocks, or extremities. Joint symptoms consist of migratory transient arthralgias.
Scleroderma Early findings are primarily Raynaud phenomenon and puffy fingers. Later findings include sclerodactyly (smooth, shiny, tapered fingers with taut, bound-down skin); contractures with “claw hand” deformity; expressionless face (with thin lips, a beak-like nose, and sunken cheeks); microstomia; mat telangiectasias on the nail folds, face, lips, oral mucosa, or trunk; and calcinosis with leathery crepitation over the joints.
Dermatomyositis The classic skin manifestation is a lilac-colored heliotrope rash on the eyelids and in a butterfly distribution. Gottron papules are violaceous, scaly, flat lesions on the extensor aspect of the interphalangeal joints, elbows, knees, and medial malleoli; these occur as a late manifestation. Proximal muscle aching/weakness, not arthritis, is prominent. The patient is unable to reach overhead or arise from a chair. Neck flexors are more involved than extensors.
Reiter syndrome Arthritis, urethritis, conjunctivitis, and mucocutaneous ulcers are found. The arthritis is asymmetric, usually involving the lower extremity joints. Solitary sausage digits may be seen. Tendinitis and fasciitis are common. The mucocutaneous lesions are eroded red vesicles or papules of the corona and glans, which when confluent are called circinate balanitis. Pustules may change into thick hyperkeratotic plaques on the palms and soles, keratoderma blennorrhagicum.
Rheumatic fever There is an acute migratory polyarthritis with fever. Subcutaneous nodules appear over the bony prominences of the elbows, knuckles, ankles, scapulae, and occiput. They are associated with carditis. Erythema marginatum, appearing as evanescent pink lesions with serpiginous borders, is also associated with carditis.
Behçet syndrome The classic triad is arthritis, iritis, and oral and genital ulcerations. Recurrent aphthous ulcers are a sine qua non. They begin as macular erythema that develops into superficial gray ulcers. Scrotal or labial ulcerations are also found. Hypopyon uveitis, a hallmark, is a rare finding. The arthritis is primarily of the knees and ankles.
Still disease Skin lesions are red, flat, and less than 1 cm in diameter. Lesions are evanescent, occurring with fever spikes. A migratory polyarthralgia occurs.
Hypersensitivity vasculitis After an upper respiratory infection, young adults may develop palpable purpura over the extensor surfaces and buttocks. Arthritis, edema, and colicky abdominal pain, followed by bloody stools, suggests the diagnosis.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Polyarticular Arthritis:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Osteoarthritis
❑ Rheumatoid arthritis
❑ Lyme arthritis
❑ Systemic lupus erythematosus
❑ Psoriatic arthritis
❑ Polyarticular gout
❑ Viral arthritis
❑ Scleroderma
❑ Reiter syndrome
❑ Inflammatory bowel disease
❑ Gonococcal arthritis
❑ Ankylosing spondylitis
❑ Systemic vasculitis
❑ Sarcoidosis
❑ Pseudogout (CPPD)
❑ Acute rheumatic fever
❑ Still disease
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Scrotal Pain/Swelling:
Differential Overview
(Field Guide to Bedside Diagnosis)
Pain Predominant
❑ Epididymitis
❑ Testicular torsion
❑ Prostatitis
❑ Referred pain
❑ Trauma
❑ Orchitis
❑ Torsion of the appendix testis
❑ Inguinal hernia/incarcerated
Swelling Predominant
❑ Varicocele
❑ Inguinal hernia
❑ Hydrocele
❑ Spermatocele
❑ Sebaceous cyst
❑ Testicular cancer
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Rheumatoid arthritis:
Causes
(Handbook of Diseases)
What causes the chronic inflammation characteristic of RA isn’t known. One theory states that abnormal immune activation (occurring in a genetically susceptible individual) leads to inflammation, complement activation, and cell proliferation within joints and tendon sheaths. Although no single environmental factor has been found to be a consistent and reproducible cause of this response, infection (viral or bacterial), hormonal factors, and lifestyle factors may all influence disease onset.
Some RA patients develop an immunoglobulin (Ig) M antibody against their body’s own IgG, which is called RF. Increased production of this antibody may also play a role in genetic inflammation.
Pathogenesis
Much more is known about the pathogenesis of RA than about its causes. If unarrested, the inflammatory process within the joints occurs in four stages.
In the first stage, synovitis develops from congestion and edema of the synovial membrane and joint capsule. Infiltration by lymphocytes, macro-phages, and neutrophils perpetuates the local inflammatory response. These cells, as well as fibroblast-like synovial cells, produce enzymes that help to degrade bone and cartilage.
Formation of pannus — thickened layers of granulation tissue — marks the onset of the second stage. Pannus covers and invades cartilage and eventually destroys the joint capsule and bone.
Progression to the third stage is characterized by fibrous ankylosis — fibrous invasion of the pannus and scar formation that occludes the joint space. Bone atrophy and malalignment cause visible deformities and disrupt the articulation of opposing bones, causing muscle atrophy and imbalance and, possibly, partial dislocations or subluxations.
In the fourth stage, fibrous tissue calcifies, resulting in bony ankylosis and total immobility.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Neurogenic arthropathy:
Causes
(Handbook of Diseases)
In adults, the most common cause of neurogenic arthropathy is diabetes mellitus. Other causes include tabes dorsalis (especially among patients ages 40 to 60), syringomyelia (which progresses to neurogenic arthropathy in about 25% of patients), myelopathy of pernicious anemia, spinal cord trauma, paraplegia, hereditary sensory neuropathy, and Charcot-Marie-Tooth disease. Rarely, amyloidosis, peripheral nerve injury, myelomeningocele (in children), leprosy, or alcoholism causes neurogenic arthropathy.
Frequent intra-articular injections of a corticosteroid have also been linked to neurogenic arthropathy. The analgesic effect of the corticosteroid may mask symptoms and allow continuous damaging stress to accelerate joint destruction.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Juvenile rheumatoid arthritis:
Causes
(Handbook of Diseases)
JRA is thought to be an autoimmune disorder. Research has linked causation to genetic and immune factors. Viral or bacterial (particularly streptococcal) infection, trauma, and emotional stress have been identified as precipitating factors.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Psoriatic arthritis:
Causes
(Handbook of Diseases)
Evidence suggests that predisposition to psoriatic arthritis is hereditary; 20% to 50% of patients are human leukocyte antigen-B27-positive. However, its onset may be precipitated by streptococcal infection or trauma.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Septic arthritis:
Causes
(Handbook of Diseases)
In most cases of septic arthritis, bacteria spread from a primary site of infection, usually in adjacent bone or soft tissue, through the bloodstream to the joint.
Common infecting organisms include four strains of gram-positive cocci — Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Streptococcus viridans — and two strains of gram-negative cocci — Neisseria gonorrhoeae and Haemophilus influenzae. Various gram-negative bacilli — Escherichia coli, Salmonella, and Pseudomonas, for example — also cause infection.
Anaerobic organisms such as gram-positive cocci usually infect adults and children older than age 2. H. influenzae most often infects children younger than age 2.
Risk factors
Various factors can predispose a person to septic arthritis. Any concurrent bacterial infection (of the genitourinary or the upper respiratory tract, for example) or serious chronic illness (such as cancer, renal failure, rheumatoid arthritis, systemic lupus erythematosus, diabetes, or cirrhosis) heightens susceptibility. Consequently, alcoholics and elderly people run a higher risk of developing septic arthritis.
Of course, susceptibility increases with diseases that depress the autoimmune system or with prior immunosuppressant therapy. I.V. drug abuse (by heroin addicts, for example) can also cause septic arthritis.
Other predisposing factors include recent articular trauma, joint surgery, intra-articular injections, and local joint abnormalities.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Scrotal swelling:
Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Elephantiasis of the scrotum
With elephantiasis of the scrotum (common in some tropical countries), infection by a filaria worm obstructs lymphatic drainage, causing chronic gross scrotal edema and pain. Associated findings include other areas of pitting and, eventually, brawny edema (especially the legs), thickened subcutaneous tissue, hyperkeratosis, and skin fissures.
Epididymal cysts
.Located in the head of the epididymis, these cysts produce painless scrotal swelling.
Epididymal tuberculosis
Epididymal tuberculosis produces an enlarged scrotal mass separated from the testicle. Other findings include palpable beading along the vas deferens, induration of the prostate or seminal vesicles, and pus or tubercle bacilli in urine.
Epididymitis
Key features of inflammation are pain, extreme tenderness, and swelling in the groin and scrotum. The patient waddles to avoid pressure on the groin and scrotum during walking. He may have high fever, malaise, urethral discharge and cloudy urine, and lower abdominal pain on the affected side. His scrotal skin may be hot, red, dry, flaky, and thin.
Gumma
Gumma is a rare, painless nodule — usually associated with benign tertiary syphilis — that can affect any bone or organ. If it affects the testicle, it causes edema.
Hernia
Herniation of bowel into the scrotum can cause swelling and a soft or unusually firm scrotum. Occasionally, bowel sounds can be auscultated in the scrotum.
Hydrocele
Fluid accumulation produces gradual scrotal swelling that’s usually painless. The scrotum may be soft and cystic or firm and tense. Palpation reveals a round, nontender scrotal mass.
Idiopathic scrotal edema
Swelling occurs quickly with idiopathic scrotal edema and usually disappears within 24 hours. The affected testicle is pink.
Orchitis (acute)
Mumps, syphilis, or tuberculosis may precipitate acute orchitis, which causes sudden painful swelling of one or, at times, both testicles. Related findings include a hot, reddened scrotum accompanied by fever of up to 104° F (40° C), chills, lower abdominal pain, nausea, vomiting, and extreme weakness. Urinary signs are usually absent.
Scrotal burns
Burns cause swelling within 24 hours of injury. Depending on the burn’s severity, associated findings may include severe pain, erythema, chafing, tissue sloughing, and maceration with a weeping exudate.
Scrotal trauma
Blunt trauma causes scrotal swelling with bruising and severe pain. The scrotum may appear dark or bluish.
Spermatocele
This usually painless cystic mass lies above and behind the testicle and contains opaque fluid and sperm. Its onset may be acute or gradual. Less than 1 cm in diameter, it’s movable and may be transilluminated.
Testicular torsion
Most common between ages 12 and 25 years, testicular torsion — a urologic emergency — causes scrotal swelling with sudden, severe pain and, possibly, elevation of the affected testicle within the scrotum. It may also cause nausea and vomiting.
Testicular tumor
Typically painless, smooth, and firm, a testicular tumor produces swelling and a sensation of excessive weight in the scrotum.
Torsion of a hydatid of Morgagni
Torsion of a hydatid of Morgagni — a small, pea-sized cyst — severs its blood supply, causing hard, painful swelling on the testicle’s upper pole.
Other causes
Surgery
An effusion of blood from surgery can produce a hematocele, leading to scrotal swelling.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Scrotal swelling:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Epididymal cysts
Located in the head of the epididymis, epididymal cysts produce painless scrotal swelling. Most men, however, are asymptomatic and discover the cyst on self-examination.
Epididymitis
Key features of epididymitis are inflammation, pain, extreme tenderness, and swelling in the groin and scrotum. The patient waddles to avoid pressure on the groin and scrotum during walking. He may have high fever, malaise, urethral discharge and cloudy urine, and lower abdominal pain on the affected side. His scrotal skin may be hot, red, dry, flaky, and thin.
Hernia
Herniation of bowel into the scrotum can cause swelling and a soft or unusually firm scrotum. Occasionally, bowel sounds can be auscultated in the scrotum. If bowel obstruction occurs, anorexia, nausea, vomiting, and reduced bowel sounds may occur.
Hydrocele
With hydrocele, fluid accumulation produces gradual scrotal swelling that’s usually painless. The scrotum may be soft and cystic or firm and tense. Palpation reveals a round, nontender scrotal mass.
Orchitis (acute)
Mumps, syphilis, or tuberculosis may precipitate acute orchitis, which causes sudden painful swelling of one or, at times, both testicles. Related findings include a hot, reddened scrotum; fever of up to 104° F (40° C); chills; lower abdominal pain; nausea; vomiting; and extreme weakness. Urinary signs are usually absent.
Scrotal trauma
Blunt trauma causes scrotal swelling with bruising and severe pain. The scrotum may appear dark or bluish. Nausea, vomiting, and difficulty urinating might also occur.
Spermatocele
A spermatocele, a usually painless cystic mass, lies above and behind the testicle and contains opaque fluid and sperm. Its onset may be acute or gradual. Less than 1 cm in diameter, it’s movable and may be transilluminated.
Testicular torsion
Most common before puberty, testicular torsion is a urologic emergency that causes scrotal swelling; sudden, severe pain; and, possibly, elevation of the affected testicle within the scrotum. Testicular torsion may also cause nausea and vomiting.
Testicular tumor
Typically painless, smooth, and firm, a testicular tumor produces swelling and a sensation of excessive weight in the scrotum. With ureteral obstruction, the patient may have urinary complaints.
Other causes
Surgery
An effusion of blood from surgery can produce a hematocele, leading to scrotal swelling.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Scrotal swelling:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Epididymal cysts. Located in the head of the epididymis, epididymal cysts produce painless scrotal swelling.
Epididymitis.Key features of epididymitis are pain, extreme tenderness, and swelling in the groin and scrotum. The patient waddles to avoid pressure on the groin and scrotum during walking. He may have a high fever, malaise, a urethral discharge and cloudy urine, and lower abdominal pain on the affected side. His scrotal skin may be hot, red, dry, flaky, and thin.
Hydrocele.With a hydrocele, fluid accumulation produces gradual scrotal swelling that's usually painless. The scrotum may be soft and cystic or firm and tense. Palpation reveals a round, nontender scrotal mass.
Idiopathic scrotal edema.Swelling occurs quickly with idiopathic scrotal edema and usually disappears within 24 hours. The affected testicle is pink.
Orchitis (acute).Mumps, syphilis, or tuberculosis may precipitate orchitis, which causes sudden painful swelling of one or, at times, both testicles. Related findings include a hot, reddened scrotum; a fever of up to 104° F (40° C); chills; lower abdominal pain; nausea; vomiting; and extreme weakness. Urinary signs are usually absent.
Scrotal trauma.Blunt trauma causes scrotal swelling with bruising and severe pain. The scrotum may appear dark or bluish.
Spermatocele.Spermatocele is a usually painless cystic mass that lies above and behind the testicle and contains opaque fluid and sperm. Its onset may be acute or gradual. Less than 1 cm in diameter, it's movable and may be transilluminated.
Testicular torsion.Most common before puberty, testicular torsion is a urologic emergency that causes scrotal swelling; sudden, severe pain; and, possibly, elevation of the affected testicle within the scrotum. It may also cause nausea and vomiting.
Testicular tumor.Typically painless, smooth, and firm, a testicular tumor produces swelling and a sensation of excessive weight in the scrotum.
Torsion of a hydatid of Morgagni.Torsion of this small, pea-size cyst severs its blood supply, causing a hard, painful swelling on the testicle's upper pole.
Other causes
Surgery.An effusion of blood from surgery can produce a hematocele, leading to scrotal swelling.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Back, Joint, and Extremity Pain - Case 5-1: 2-Year-Old Boy:
I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)
Back pain is a relatively common complaint among children, although fewer than
2% of older children with back pain require specific medical evaluation. In a
young child, neoplastic, infectious, and inflammatory disorders should be
considered. Malignant causes may be primary or metastatic and include osteoid
osteoma, neuroblastoma, Wilms tumor, and leukemia. Infectious or inflammatory
causes include pyelonephritis, vertebral osteomyelitis, spinal epidural
abscess, and pyomyositis. Diskitis in children usually involves the lower
thoracic or lumbar spine. The presence of fever, if related to the back pain,
makes diskitis less likely. Local tenderness and elevated CRP and ESR can be
seen with many infectious and neoplastic causes. MRI of the spine readily
differentiates diskitis, vertebral osteomyelitis, and spinal epidural abscess.
Rheumatologic conditions include systemic juvenile rheumatoid arthritis.
Mechanical disorders such as muscle strains and intervertebral disk herniation
are less likely in this age group. The absence of neurologic findings, although
reassuring, does not permit exclusion of any of these entities.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-2: 2-Year-Old Boy:
I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)
Infectious causes of hip pain in a young boy include septic arthritis of the
hip, osteomyelitis of the femur or pelvis, and psoas abscess. The prolonged
duration of symptoms with recent worsening, in conjunction with an elevated CRP
and ESR, may indicate osteomyelitis of the femur with extension of infection
into the hip joint. However, the relatively unimpressive amount of pain on hip
examination, combined with pancytopenia, makes infectious causes unlikely.
Toxic synovitis can cause hip pain in this age group but also is not typically
associated with pancytopenia.
Causes of pancytopenia, hepatosplenomegaly, and bone pain include leukemia,
epiphyseal tumors, neuroblastoma, infectious mononucleosis, and hemophagocytic
syndrome. The normal uric acid and LDH do not exclude malignancy.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-3: 14-Year-Old Boy:
I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)
Diagnosing the cause of knee pain in an adolescent can be difficult. Because
knee pain may actually be pain referred from the hip via the obturator nerve,
diagnostic considerations should include problems involving either the knee or
the hip. In this case, although the patient was adamant in his complaint of
pain localized to the knee, examination of the knee was normal. The lack of
physical findings localized to the knee made septic arthritis of the knee and
fracture of the distal femur, patella, proximal tibia, or fibula unlikely.
Antecedent trauma raised the possibility of knee hyperextension or patellar
dislocation, but the normal knee examination placed these possibilities lower
on the differential diagnosis. Osgood-Schlatter disease typically manifests
with localized tenderness and swelling over the tibial tuberosity, findings
that were absent in this case.
Hip disorders to consider in an adolescent boy include avascular necrosis of the
femoral head, septic arthritis of the hip, femoral or pelvic osteomyelitis,
femoral neck fracture, chronic developmental hip dysplasia, inguinal hernia,
slipped capital femoral epiphysis, Ewing sarcoma, and osteogenic sarcoma.
Avascular necrosis of the femoral head can be caused by corticosteroid use and
also occurs in children with SCD and idiopathically (Legg-Calv
é Perthes disease). The absence of fever, combined with normal CRP and ESR
values, makes acute septic arthritis and osteomyelitis unlikely. In this case,
radiographs of the hip narrowed the differential diagnosis even further.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-4: 16-Year-Old Girl:
I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)
In an adolescent, hematochezia with cramping abdominal pain has several
potential causes. Patients with chronic NSAID use often develop
gastrointestinal tract ulceration, although gastric and duodenal ulcers
typically result in melena rather than bright red blood. Infectious
enterocolitis may be caused by
Salmonella spp., Shigella spp., Campylobacter jejuni, enteroinvasive and enterohemorrhagic E. coli (including E. coli O157:H7), Yersinia enterocolitica, and C. difficile. Parasitic causes include Entamoeba histolytica, Cryptosporidium parvum, Schistosoma, and Strongyloides stercoralis. Exposure to undercooked meat and clusters of patients with similar symptoms
suggest a common infectious source. Although 35% to 90% of patients with
E. coli O157:H7 infection develop bloody diarrhea, only 10% progress to
hemolytic-uremic syndrome. The absence of a pertinent travel history makes some
of the parasitic diseases less likely. Proctitis can be caused by
Neisseria gonorrhoeae, herpes simplex virus, or Treponema pallidum. Henoch-Schönlein purpura (HSP) may manifest with bloody diarrhea. Vascular malformations of
the gastrointestinal tract often manifest with recurrent melena or
hematochezia. Eosinophilic gastroenteropathy, a chronic, relapsing disorder
characterized by eosinophilic inflammatory gastrointestinal tract infiltrate,
often manifests with abdominal pain and rectal bleeding. Abdominal complaints,
including abdominal pain due to ileocecal ulcerations, are seen in up to 15% of
patients with Beh
çet's disease. Both Crohn's disease and ulcerative colitis commonly present with abdominal pain and lower
gastrointestinal tract bleeding.
Joint involvement occurs in some of the previously mentioned conditions.
Reactive arthritis can be associated with
Campylobacter enteritis as well as with Salmonella, Shigella, and Yersinia enteritis. However, the arthritis usually begins 1 to 6 weeks after the onset of
diarrhea and resolves within 3 weeks. Arthritis or arthralgias occur in 65% to
85% of children with HSP. Though HSP may recur, prolonged, unremitting symptoms
without rash or nephritis are unusual. Children with Beh
çet's disease usually have recurrent oral ulcers, genital ulcers, and iritis or
uveitis in addition to the joint findings. Arthritis may be seen in 10% to 15%
of children with Crohn
's disease or ulcerative colitis.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-5: 13-Year-Old Boy:
I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)
Back pain is less common in children than in adults, but in children is more
often the result of a serious underlying pathology. In adolescents, traumatic
or overuse injuries such as compression fractures, musculoskeletal strain,
spondylolysis, spondylolisthesis, and lumbar disc herniation should be
considered. Most of these injuries manifest during the adolescent growth spurt
and are associated with repeated lifting and back extension, especially in
sports. Infections of the vertebral column that cause back pain include
osteomyelitis and diskitis especially in toddlers and young children. Less
common but serious causes include spinal epidural, paraspinal, or psoas
abscess; transverse myelitis; and pyomyositis. Urinary tract infections and
pneumonia can cause back pain but are less likely in the absence of urinary or
respiratory symptoms. Neoplastic diseases such as leukemia and lymphoma should
be considered, especially in the presence of progressive, indolent pain.
Malignancies are usually accompanied by constitutional symptoms including
weight loss, fatigue, fever, and loss of appetite. Rare causes of back pain
include spinal hematoma, spinal tuberculosis (Pott
's disease), and brucellosis, a zoonotic infection transmitted from animals to
humans that causes flu-like symptoms including back pain. Back pain secondary
to acute bone infarction often occurs in adolescents with SCD. Patients usually
have normal or mildly elevated temperature and ESR. However, in some cases this
condition is indistinguishable from acute osteomyelitis. SCD should be included
in the differential diagnosis of an African-American child with back pain,
anemia, and a family history of sickle cell trait. In this case, the acute fall
in the patient
's hemoglobin level, splenomegaly, vertebral abnormalities, and the persistence
and severity of the symptoms prompted further evaluation, which led to the
diagnosis. Although most patients are diagnosed by newborn screening tests,
some patients may inadvertently not be screened or may be lost to follow-up.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Back, Joint, and Extremity Pain - Case 5-6: 9-Year-Old Boy:
I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)
This previously healthy young man presented with a 1-month history of joint
pains, with true arthritis of the ankle demonstrated at the office visit. The
arthritis involved relatively large joints affected in a nonsimultaneous
sequence. This pattern is referred to as a migratory pattern, one in which new
joint inflammation occurs after previous joint inflammation resolves. The
fever, weight loss, elevated inflammatory markers, and mild anemia were also
noteworthy and suggested an infectious, rheumatologic, or malignant process.
Joint or extremity pain, with fever and weight loss, can certainly raise the
suspicion of a malignancy. True arthritis (joint effusion, calor, rubor, and
pain with range of motion) is not a typical presentation of musculoskeletal
tumors but may be part of a paraneoplastic syndrome with reactive arthritis.
Disseminated malignancies, such as neuroblastoma or leukemia, may also involve
joints or the skeletal system through direct bony destruction in close
proximity to a joint. Abnormalities may or may not be detected by plain
radiographs of the involved limb.
Infectious etiologies of arthritis include primary infection of a joint space or
infection of bone or soft tissue in close proximity to a joint, with or without
direct communication of the infection with the joint. These infections are more
likely to involve a single site, but multifocal infections may be seen, with
ongoing or intermittent bacteremia leading to multiple, hematogenously seeded
sites. If more than one joint is involved, postinfectious arthritis should be
considered. These inflammatory joint reactions are sequelae of preceding
infections and are usually considered to be sterile and mediated through an
immune response. Epstein-Barr virus and parvovirus B19 are among the common
viral agents associated with this reaction, and meningococcus is a notorious
bacterial cause. Arthritis characterizes late-stage Lyme disease and develops 6
to 12 weeks after the bite of an infected tick. Large joints, especially the
knees, are involved and recurrence of arthritis mimics a migratory pattern.
Each bout of arthritis lasts 1 to 2 weeks but may become prolonged if left
untreated. The involved joint often appears remarkably swollen, with little or
no erythema, and ambulation is often maintained despite impressive effusion in
the involved lower-extremity joint. Carditis, presenting as heart block, can
also complicate the picture, but it is more common in the early disseminated
stage of the disease, which occurs a few weeks to months after infection.
The involvement of multiple joints and stigmata of acute inflammation make
rheumatologic conditions an important consideration. Systemic-onset juvenile
rheumatoid arthritis can manifest initially with or without arthritis, but
chronic arthritis of at least 6 weeks duration is required for diagnosis.
Systemic lupus erythematosus (SLE) most often manifests with joint involvement
with constitutional complaints of fatigue, weight loss, fever, and a typical
rash, and there is almost always an elevation in the antinuclear antibody (ANA)
titer. Progressive muscle weakness is characteristic of dermatomyositis;
patients may present with extremity complaints, and infrequently with true
arthritis. Back pain eventually develops in ankylosing spondylitis, which is
much more common in boys than in girls and is associated with the human
leukocyte antigen HLA-B27 in 90% of cases.
Mixed connective tissue diseases can have overlapping features of many of these
conditions, but the arthritis often involves small joints. Vasculitis syndromes
may also cause arthritis, with HSP being the most common vasculitis of
children. The characteristic palpable petechial or purpuric rash, especially
evident on the lower extremities, in the absence of thrombocytopenia, is key in
the diagnosis of this immunoglobulin A
–mediated vasculitis. Other inflammatory conditions, including Crohn's disease, ulcerative colitis, Reiter syndrome, Behçet's disease, and Sjögren syndrome, may also result in arthritis, constitutional symptoms, and
elevated ESR, but other features of the illnesses are usually present or
eventually manifest themselves.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
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