CONFIRMING DIAGNOSIS Identifying the causative organism in a Gram stain or culture of synovial fluid or a biopsy of synovial membrane confirms septic arthritis. When synovial fluid culture is negative, positive blood culture may confirm the diagnosis.
Joint fluid analysis shows gross pus or watery, cloudy fluid of decreased viscosity, usually with 50,000/µl or more white cells, primarily neutrophils. Synovial fluid glucose is usually more than 40 mg/dl. (See Other types of arthritis, page 584.)
Other diagnostic measures include the following:
❑ X-rays can show typical changes as early as 1 week after initial infection — distention of joint capsules, for example, followed by narrowing of joint space (indicating cartilage damage) and erosions of bone (joint destruction).
❑ White blood cell count may be elevated, with many polymorphonuclear cells; erythrocyte sedimentation rate is increased.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Psoriasis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Diagnosis depends on patient history, appearance of the lesions and, if needed, the results of skin biopsy. Typically, serum uric acid level is elevated as a result of accelerated nucleic acid degradation, but indications of gout are absent. HLA-Cw6, B-13, and B-w57 may be present in early-onset psoriasis. Sudden onset of psoriasis may be associated with human immunodeficiency virus.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
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
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.
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Source: Field Guide to Bedside Diagnosis, 2007
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
Diagnostic Approach
Ascertain that arthritis (joint inflammation) is present by eliciting pain on joint motion. A hot, swollen joint with constitutional symptoms such as fever, weight loss, and malaise suggests infection. The skin may hold clues to psoriasis, systemic lupus, viral exanthems, Lyme disease, and others. Erythema nodosum occurs with sarcoidosis or inflammatory bowel disease. Urethritis suggests gonorrhea or Reiter syndrome. A monoarticular presentation of a polyarticular disease may be rarely seen in rheumatoid arthritis, Reiter syndrome, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, and sarcoidosis.
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Source: Field Guide to Bedside Diagnosis, 2007
Osteoarthritis:
Diagnosis
(Handbook of Diseases)
A thorough physical examination confirms typical symptoms, and the absence of systemic symptoms rules out an inflammatory joint disorder. X-rays of the affected joint help confirm diagnosis of osteoarthritis but may be normal in the early stages. X-rays may require many views and typically show:
❑ narrowing of joint space or margin
❑ cystlike bony deposits in joint space and margins
❑ sclerosis of the subchondral space
❑ joint deformity due to degeneration or articular damage
❑ bony growths at weight-bearing areas
❑ fusion of joints.
No laboratory test is specific for osteoarthritis.
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Source: Handbook of Diseases, 2003
Psoriatic arthritis:
Diagnosis
(Handbook of Diseases)
Inflammatory arthritis in a patient with psoriatic skin lesions suggests psoriatic arthritis. X-rays confirm joint involvement and show:
❑ marginal erosion at interphalangeal joints with areas of thin, “fluffy” new bone formation
❑ “whittling” of the distal end of the terminal phalanges
❑ “pencil-in-cup” deformity of the distal interphalangeal joints
❑ relative absence of osteoporosis
❑ sacroiliitis
❑ atypical spondylitis with syndesmophyte formation, resulting in hyperostosis and paravertebral ossification, which may lead to vertebral fusion.
Blood studies indicate negative rheumatoid factor and elevated erythrocyte sedimentation rate and uric acid levels.
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Source: Handbook of Diseases, 2003
Psoriasis:
Diagnosis
(Handbook of Diseases)
Diagnosis depends on patient history, appearance of the lesions and, if needed, the results of skin biopsy. In severe cases, the serum uric acid level is typically elevated due to accelerated nucleic acid degradation; however, indications of gout are absent. HLA antigens may be present in early-onset familial psoriasis.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
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