Polyarticular Arthritis
Polyarticular Arthritis: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
❑ 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
Diagnostic Approach
Ascertain that the pain is articular; that is, it is exacerbated by the function of the joint. Detecting synovitis limits the differential to inflammatory arthridites and systemic rheumatic diseases. Findings of synovitis include palpable soft tissue bogginess around a joint, warmth over a joint, or effusion. Involvement of the wrists, elbows, or metacarpophalangeal joints implies inflammatory disease rather than osteoarthritis. Morning stiffness persisting for as long as 1 to 2 hours, relieved by NSAIDs, is typical for inflammatory arthritis, as is a history of a red joint.
Differentiating features include the following: Erythema nodosum: sarcoidosis, inflammatory bowel disease-related arthritis, or Behçet disease. Rash: lupus, Still disease, vasculitis, dermatomyositis, endocarditis, disseminated gonorrhea, or Behçet disease. Fever greater than 40˚C: Still disease, bacterial arthritis, or lupus. Fever preceding arthritis: viral arthritis, Lyme, reactive arthritis, Still
desease, or bacterial endocarditis. Spiking fever: bacterial infection or Still
disease. Splenomegaly: rheumatoid arthritis and lupus. Raynaud: scleroderma, mixed connective tissue disease, or lupus. Oral ulcers: lupus, Behçet disease, or viral arthritis. Dry eyes and mouth: Sjögren syndrome, mixed connective tissue
disease, or lupus. Ocular findings: lupus, Behçet disease, sarcoidosis, or reactive arthritis. Migratory arthritis: gonococcemia, rheumatic fever, meningococcemia, viral arthritis, lupus, acute leukemia, or Whipple disease. Episodic recurrences: Lyme, crystal-induced arthritis, inflammatory bowel disease, Still disease, or lupus. Morning stiffness: rheumatoid arthritis, polymyalgia rheumatica, Still
disease, or viral arthritis. Symmetric small-joint synovitis: rheumatoid arthritis, lupus, or viral arthritis.
Clinical Findings
Osteoarthritis It appears as a bland (noninflammatory) symmetric polyarthritis, especially of high stress joints, such as the thumb metacarpophalangeal joint, knees, hips, and lumbar facet joints. Heberden (distal interphalangeal joint) and Bouchard (proximal interphalangeal joint) nodes are usually present. The stiffness increases after rest (“gelling”), with less than 15 minutes of morning stiffness, and it progressively worsens with use. There is restricted range of movement and crepitance of the joints but often relatively little pain. There are no systemic signs.
Rheumatoid arthritis It presents with a subacute symmetrical polyarthritis with synovial swelling of the proximal interphalangeal joints, metacarpophalangeal joints, and wrists; synovial bogginess; and rheumatoid nodules on extensor surfaces. Ulnar deviation of the fingers, and swan neck and boutonnière’s deformities are late findings.
Lyme arthritis It typically presents as a recurrent or migratory arthritis, the second phase of a syndrome that begins with a durable expanding annular rash with a clear center (erythema migrans) and a flulike syndrome with arthralgias. The arthritis is episodic, affecting primarily large joints.
Systemic lupus erythematosus There are symmetrical polyarthralgias or a nondeforming arthritis of the small joints, which may be migratory. Diagnostically, it is associated with a malar rash (50%) which spares the nasolabial fold, Raynaud (30%), alopecia (40%), oral ulcers (40%), pleuritis with a rub (50%), pericarditis with a multicomponent rub (30%), and splenomegaly (15%). Evidence of vasculitis may be found with nailfold or volar pad infarcts, palpable purpura, livedo reticularis, or cutaneous ulcers. In procainamide-induced lupus, polyarthritis and fever are the main manifestations.
Psoriatic arthritis It is an asymmetric oligoarthritis of the distal interphalangeal joints. It may be quite erosive, with hands becoming foreshort-
ened (“watchglass hands”). Psoriatic plaques may be hidden in the scalp, the intergluteal folds, umbilicus, or behind the ears. Nail pitting may be another clue.
Polyarticular gout Flares occur rapidly, with joints becoming exquisitely painful after a few hours. There will often be a history of monoarticular arthritis (especially podagra of the great toe). The pattern will be asymmetric and oligoarticular. Tophi, which are found on the pinnae and extensor surfaces, aid in diagnosis.
Viral arthritis During the preicteric phase of hepatitis B, a migratory polyarthritis, fever, and urticarial rash often occurs. Rubella and Parvovirus B19 can cause a similar clinical syndrome, with a rash and a symmetric polyarthritis of sudden onset, particularly in the hands. HIV is associated with brief episodes of severe arthralgia, acute episodic oligoarthritis, and persistent, symmetrical polyarthritis, but fever is usually not coincident.
Scleroderma Articular symptoms are mild, and sclerodactyly and generalized skin tightening is especially pronounced over the fingers, with leathery crepitance. Raynaud phenomenon, impaired esophageal motility with dysphagia, and cuticular telangiectasias are helpful supportive evidence. Fingertip atrophy or ulcers suggest severe Raynaud.
Reiter syndrome Patients have asymmetric lower extremity arthritis, especially heel pain, plantar fasciitis, and unilateral sacroiliitis, occurring predominantly in young men. Distinctive associated findings include urethritis, iritis or conjunctivitis, oral ulcers, circinate balanitis, and keratoderma blennorrhagicum. It may arise reactively following enteric diarrhea, acute chlamydial urethritis, or HIV with M. avium complex. Keratoderma begins as small vesicles on the soles, toes, and glans, and then progresses to opaque papules, which then become hyperkeratotic coalescing plaques. Circinate balanitis begins as vesicles on the glans, which coalesce into superficial erosions.
Inflammatory bowel disease Bowel disease is usually symptomatically active with fever, abdominal pain, diarrhea, and blood or mucous in the stools when the arthritis develops. The arthritis occurs in the knees, ankles, and wrists along with fever, oral ulcers, erythema nodosum, or pyoderma gangrenosum.
Gonococcal arthritis Characteristically, there is a migratory polyarthritis and tenosynovitis, associated with pustular skin lesions on a red base, and urethritis or cervicitis. The patient will be systemically ill with fever and marked malaise.
Ankylosing spondylitis Arthritis of the axial spine (sacroiliac and lumbar spine) begins insidiously with low back pain that worsens with bedrest and improves with exercise. Reduced flexion is readily demonstrated. Anterior uveitis may be recurrent. Aortic insufficiency is a late finding.
Systemic vasculitis Fever and polyarthritis are common presenting manifestations of vasculitis and are accompanied by characteristic findings such as palpable purpura or hematuria. Giant cell arthritis presents with fever and polymyalgia, but joint pain is not present on careful examination.
Sarcoidosis Prominent ankle involvement with erythema and periarticular swelling in a young woman help to distinguish sarcoidosis from gout. Erythema nodosum, waxy red-brown skin papules, and lymphadenopathy are also clues.
Pseudogout (CPPD) Suspect when osteoarthritis-like changes are present in unusual joints (wrists, shoulders, elbows, or ankles) although the knee is the most commonly involved joint.
Acute rheumatic fever A sore throat is followed by polyarthritis with rapid worsening so that within 24 hours the joints will be markedly swollen, red, hot, and tender. After several days the original inflammation subsides but migrates to other joints. Polyarthritis and fever are more common in adults than cardiac manifestations. The fever usually lasts a week or more.
Still disease A high spiking fever is associated with chills and an evanescent pink rash that blanches. The arthritis is migratory at its onset.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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