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arthritis

Etiology: 1) monoarticular a) osteoarthritis (also oligoarticular) b) infectious arthritis (also oligoarticular) c) crystalline arthritis 1] gout 2] CPPD (also oligoarticular) 3] hydroxyapatite deposition disease d) trauma e) osteonecrosis (avascular osteonecrosis) f) tumor g) early connective tissue disease 2) oligoarticular a) spondyloarthropathy 1] Reiter's syndrome 2] reactive arthritis (also polyarticular) 3] psoriatic arthritis (also polyarticular) 4] ankylosing spondylitis (may be axial) 5] enteropathic arthritis b) infection-related 1] Lyme disease (Borrelia burgdorferi) 2] endocarditis 3] rheumatic fever 4] HIV1/AIDS c) sarcoidosis (also polyarticular) d) amyloidosis [5] 3) polyarticular a) rheumatoid arthritis b) systemic lupus erythematosus (SLE) c) serum sickness d) viral arthritis 1] rubella 2] parvovirus B19 3] hepatitis B 4) lymphoma/leukemia in children [2] 5) also see bone disease Clinical manifestations: 1) general - pain is elicited on both active & passive motion of joint - joint line is painful or tender on palpation - limited range of motion may be present - may be pain associated with passive range of motion - warmth, swelling, redness or effusion may be present - fatigue, malaise & morning stiffness 2) manifestations of specific etiologies - heel pain in young man suggests spondyloarthropathy - prolonged morning stiffness or pain in small or large joints suggests rheumatoid arthritis - recurrent arthritis with hair loss & photodermatitis suggests systemic lupus erythematosus (SLE) - painful arthritis with swelling developing overnight in the absence of trauma suggests gout (except young women) - insidious onset of prolonged morning stiffness in one buttocks, then the other in a young man suggests ankylosing spondylitis - asymmetric involvement of weight-bearing joints or involvement of interphalangeal joints with brief morning stiffness suggests osteoarthritis - a single inflamed joint in a febrile patient suggests infection - distal finger interphalangeal tenderness is common in psoriatic arthritis, occurs occasionally with Reiter'ssyndrome & may occur in initial phases of development of Heberden's nodes of osteoarthritis - spondylitis is the hallmark of ankylosing spondylitis & occurs in 25% of patients with reactive & psoriatic arthritis - fever, rash suggests inflammatory arthritis Laboratory: 1) if arthritis has been of at least 3 months duration, initial diagnostic workup: a) anti-nuclear antibody (ANA) b) rheumatoid factor (RF) c) serum C-reactive protein (serum CRP) d) erythrocyte sedimentation rate (ESR) e) serum thyroid-stimulating hormone (serum TSH) 2) joint aspiration with synovial fluid analysis a) indicated if suspected bacterial infection b) infection & crystalline arthritis can coexist c) WBC count > 2000/uL predominantly neutrophils suggests active inflammation Radiology: - X-ray a) joint space narrowing (non-specific) a) symmetric joint space narrowing in rheumatoid arthritis b) asymmetric joint space narrowing in osteoarthritis b) erosions, periostitis (inflammatory arthritis) c) osteophytes, subchondral sclerosis (osteoarthritis) - magnetic resonance imaging - asymptomatic individuals frequently with abnormalities on MRI - synovitis 48%, bone marrow edema 58%, tenosynovitis 17% - only 28% with no inflammatory features - only 22% without erosions [1] Differential diagnosis: 1) pain on active but not passive motion of joint & tenderness elicited on palpation of structures around the joint suggests bursitis or tendonitis 2) degenerative arthritis accompanying bone disease -> Paget's disease 3) referred pain suggested by painless full range of motion 4) infectious arthritis may co-occur with crystalline arthritis in hospitalized patients [4] 5) hemarthrosis Complications: - psychosocial stress & depression common [10] Management: 1) trial of steroids, prednisone 40 mg PO QD for 6 days 2) return to clinic in one week 3) if good response to prednisone & seronegative (ANA, RF), begin hydroxychloroquine (9 month trial) 4) see specific type of arthritis

Interactions

disease interactions

Related

arthralgia bone disease; osteopathia

Useful

hydroxychloroquine (Plaquenil) prednisone (Deltasone, Orasone, Liquid Pred, Meticortin, Rayos)

Specific

chronic postrheumatic arthropathy (Jaccoud's arthropathy) crystalline arthritis (crytalline arthropathy) infectious arthritis (septic arthritis) inflammatory arthritis juvenile idiopathic arthritis migratory arthritis monoarticular arthritis neurogenic arthritis (neurogenic arthropathy) ochronosis oligoarticular arthritis osteoarthritis (OA) polyarticular arthritis rheumatoid arthritis (RA) spondylitis spondyloarthropathy (HLA B27-associated arthritis, seronegative spondyloarthropathy) synovitis

General

inflammation joint disease; articular disease; arthropathy

References

  1. Mangnus L et al. Magnetic resonance imaging-detected features of inflammation and erosions in symptom-free persons from the general population. Arthritis Rheumatol 2016 Nov; 68:2593 PMID: 27213695
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16. 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018
  3. Weiner S, In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  4. Papanicolas LE et al. Concomitant septic arthritis in crystal monoarthritis. J Rheumatol 2012 Jan; 39:157 PMID: 22133623
  5. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  6. Finzel S, Ohrndorf S, Englbrecht M et al A detailed comparative study of high-resolution ultrasound and micro-computed tomography for detection of arthritic bone erosions. Arthritis Rheum. 2011 May;63(5):1231-6. PMID: 21538312
  7. Waits JB. Rational use of laboratory testing in the initial evaluation of soft tissue and joint complaints. Prim Care. 2010 Dec;37(4):673-89, PMID: 21050950
  8. Helmick CG, Felson DT, Lawrence RC et al Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum. 2008 Jan;58(1):15-25 PMID: 18163481 - Lawrence RC, Felson DT, Helmick CG et al Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008 Jan;58(1):26-35. PMID: 18163497
  9. Jacobson JA, Girish G, Jiang Y, Sabb BJ. Radiographic evaluation of arthritis: degenerative joint disease and variations. Radiology. 2008 Sep;248(3):737-47. Review. PMID: 18710973
  10. Price JD, Barbour KE, Liu Y, et al. State-Specific Prevalence and Characteristics of Frequent Mental Distress and History of Depression Diagnosis Among Adults with Arthritis - United States, 2017. MMWR Morb Mortal Wkly Rep 2020;68:1173-78. https://www.cdc.gov/mmwr/volumes/68/wr/mm685152a1.htm
  11. Arthritis Home Page Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/arthritis/