Acute Monoarticular Arthritis
Acute Monoarticular Arthritis: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
❑ 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.
Clinical Findings
Injury The patient may not initially put the history of injury together with the delayed joint pain until it is specifically elicited. History then reveals acute torsion, deceleration, or a direct blow. Repetitive motion as the source of injury may only be elicited on directed questioning.
Gout Inflammation is marked by severe redness, pain and swelling which extends beyond the joint. The metatarsophalangeal joint of the great toe is a favored site (podagra), but ankles, knees, wrists, and olecranon bursa are also commonly affected. An alcoholic binge or thiazide diuretic may precipitate an attack. Recurrent attacks, rapid response to colchicine, and tophi are clues.
Osteoarthritis Monoarticular arthritis occurs as an acute flare superimposed on a longstanding history of osteoarthritis. Heberden and Bouchard nodes may be present on the hands. The affected joint will have an increase in bony mass and will be crepitant within its range of motion.
Lyme disease A flulike illness with fever and arthralgias and/or an expanding annular red rash with a clear center precedes the arthritis by days to months. A monoarticular synovitis, particularly in the knee is the most common manifestation. An appropriate epidemiological setting (season and location) should be a background.
Gonococcal arthritis This diagnosis should be thought of in a sexually active young adult. The initial phase of fever, polyarthralgia, tenosynovitis, and pustular or necrotic skin lesions is followed in several days by a septic joint. Concurrent urethritis or cervicitis (accompanied by a purulent discharge) is helpful but not universally present.
Seronegative spondyloarthropathy Psoriatic arthritis, Reiter syndrome, or inflammatory bowel disease can present with a monoarthritis. When the knee joint is involved, there will be a large effusion. When the toe is involved a sausage digit forms due to periosteal involvement.
Septic arthritis Usually occurring in a compromised host or in a previously damaged or prosthetic joint, it involves large joints, such as the knees. It presents with abrupt onset with fever and chills, and joint pain that is progressive, severe, and throbbing. The joint will be hot and very tender to touch. Immunocompromised patients, injection drug users and those with a prosthetic joint are particularly susceptible.
Pseudogout It occurs in older patients and in association with hyperparathyroidism or hemochromatosis.
Septic bursitis Usually appearing in the prepatellar or olecranon bursa, septic bursitis exhibits cellulitis with normal joint motion. Fever, lymphangitis, and a cutaneous portal of entry are important clues.
Avascular necrosis Consider this when precipitating factors such as steroids, or air, fat, or nitrogen embolism are present.
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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Juvenile rheumatoid arthritis (Handbook of Diseases)
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