DD of arthritis, may be mono, oligo and poly arthritis. How to approach to a case of arthritis?

1. DD of arthritis
Marwa Abo Elmaaty Besar
Lecturer Of Internal Medicine
(Rheumatology Immunology Unit)

2. History Taking
Approach to a case of arthritis

3. I- Is it articular or periarticular?

4. II- Is it Arthritis or Arthralgia?

5. Common causes of arthralgia:-
Fibromyalgia
Bursitis
Tendinitis
Hypothyroidism
 Neuropathic pain
 Metabolic bone disease
 Depression

6. III-Is it inflammatory or mechanical?

7. III-Number of joints:-
Polyarthritis:- involvement > 5 joints
Pauci- or oligoarticular arthritis: involvement 2-4 joints.
Mono-arthritis:- only one joint.

8. IV- Number of joints and Acuteness of symptoms
Acute mono-arthritis:
A. INFLAMMATORY.
Crystal arthritis.
Septic
Spondyloarthropathy.
Palindrome Rheumatism
Rheumatoid arthritis (RA).
Juvenile chronic arthritis.
Sarcoid arthritis
B. NON-INFLAMMATORY
Trauma
Sickle-cell Arthropathy.
Osteonecrosis.

9. IV- Number of joints and Acuteness of symptoms
Chronic mono-arthritis:
A. INFLAMMATORY.
Infectious (TB, Fungal, Lyme disease).
Crystal arthritis.
RA.
Juvenile chronic arthritis.
 Spondyloarthropathy.
Homophilic Arthropathy.
Synovial neoplasms.
Pigmented villo-nodular synovitis
B. NON-INFLAMMATORY
Osteoarthritis
Mechanical derangement.
Osteonecrosis.
Neuropathic arthropathy.
Reflex Sympathetic Dystrophy (RSD).
Adjacent Bone lesion (Tumour, Infection)

10. IV- Number of joints and Acuteness of symptoms
Acute Polyarthritis:
A. INFECTION-RELATED
Bacterial species
Neisseria species
Lyme disease.
Rheumatic fever.
AIDS
 Viral arthritis
B. NON-INFECTIOUS CAUSES.
 RA.
Juvenile chronic arthritis.
 Other Connective Tissue diseases.
Spondyloarthropathy.
Gout and pseudogout.
Henoch-Schonlein purpura.
Sickle-cell Arthropathy.
Hypertrophic osteoarthropathy.
Sarcoidosis
Leukemia.

11. IV- Number of joints and Acuteness of symptoms
Chronic Polyarthritis:
Osteoarthritis
Rheumatoid arthritis (RA).
Juvenile chronic arthritis.
Other Connective Tissue diseases.
Spondyloarthropathy.
Chronic crystal arthritis.
Hypertrophic osteoarthropathy.
Hypothyroidism.
Metabolic and infiltrative bone and joint diseases.

12. Temporal pattern of joint involvement in
polyarthritis
Migratory pattern: Arthritis in certain joints remit to reappear in other joints
e.g Rheumatic fever, Gonococcal arthritis, Viral Arthritis, Acute Leukaemia.
Additive pattern: Arthritis persists, with subsequent involvement of other
joints e.g RA, SLE.
Intermittent pattern: Repetitive attacks of acute polyarthritis with complete
remission between attacks e.g RA, polyarticular gout, sarcoid arthritis, Reiter’s
syndrome & psoriatic arthritis.

13. IV- Number of joints and Acuteness of symptoms
Intermittent arthritis:
 Mechanical
Loose Bodies disease
o Partial tears
o Ligament laxity
Crystals
o Gout
o Pseudogout
o Hydroxyapatite
 Infection
o Lyme disease.
o Whipple’s disease
 Palindromic Rheumatism
 Intermittent Hydroarthrosis
 Episodic RA
 Familial Mediterranean Fever.
 Sarcoidosis

14. V- Demographic data:
V- AGE
<30= SLE, Ankylosis spodylitis ,
Reactive Arthritis.
30-50= RA, Systemic sclerosis, Gout.
 >50= OA, Pseudogout, PMR
Any Age group= Psoriatic arthritis,
Enteropathic arthritis
V- SEX
> Female: SLE, RA, OA, Systemic
sclerosis, PMR.
Male=Female: Psoriatic arthritis,
Pseudogout, Enteropathic arthritis.
>Male: Gout,, Reactive Arthritis.

15. VI- Distribution of joint involvement
Symmetrical: RA, psoriatic A. (RA like), 1ry OA, SS.
Asymmetric: LL>UL: Sero –ve arthropathy, gout.
Large joints: OA, Reactive.
PIP, MCP and PIP: RA, SLE.
DIP: psoriasis, gout, 1ry OA.
1st MTP= Gout, OA
Spine= OA, Ankylosis spodylitis, Psoriatic arthritis, Reactive arthritis
Shoulder= PMR

16. VII- Characteristic
Pain character
oAggravated by motion= Mechanical
oRelieved by motion= Inflammatory.
Duration
o<6 wks= viral arthritis, systemic rheumatic diseases
o >6 wks=systemic rheumatic diseases
Associated Symptoms
oMorning stiffness: >1hr= RA, PMR, Inflammatory, < 30 min= OA
oMulti-system involvement= Systemic rheumatic diseases.
oFever= infection, reactive arthritis, RA, SLE, Crystal induced arthritis…
Past Medical history : Trauma, fracture, surgical procedures…
Medication list: Drug induced lupus, diuretics inducing gout.

17. Drug induced lupus (DIL)

18. Physical Examination
 Inspection
 Palpation, joint movement
 Special test
 Neurovascular assessment

19. I-Inspection:
Skin manifestations: SLE, Psoriasis, Dermatomyositis, sarcoidosis, Behcet, Rheumatic fever,
Cryoglobulinemia, HSP, Still’s disease.
Subcutaneous nodules: RA, RHD, Gout (tophi),1ry OA
Parotid enlargement: Sjogren’s
Mucocutaneous:
o Oral ulcer: Reiter’s, Behcet, SLE
o genital ulcer: Reiter’s, Behcet
Nail changes: Psoriasis.
Eye: RA, AS, Reiter’s, Behcet, Sarcoidosis
Nose: Wegner’s granulomatosis, relapsing polychondritis.
Ear: Relapsing polychondritis.

21. II-Joints examination:-
I- INSPECTION
Soft tissue swelling, warm, effusion…= Inflammation.
Erythematous Joint:-
o Gout, chondrocalcinosis
o Septic arthritis.
o Rheumatic fever
o Leukaemia
Deformity:-
o RA
o Psoriasis
o SS-Sclerodactyly (flexion cont of fingers)
o SLE- Jaccoud Arthropathy.
o Sickle cell disease
II-PALPATION:
Associated Tenosynovitis:-
o RA,
o Gout,
o Reiter’s syndrome,
o Gonococcal arthritis.
o TB arthritis.
o Fungal arthritis.
Normal passive motion with limited active motion= bursitis,
tendinitis, muscle injury.
Limited passive and active motion =Synovitis

22. III- Systemic Examination:-
Nervous System: SLE, Behcet, vasculitis
Lung and pleura: RA,SLE, SS, PM,
Lung: Sarcoidosis, Vasculitis.
Peri- and myocardium: RA,SLE, SS,PM.
Heart valve: Rheum fever, RA, SLE, Reiter’s S.
Kidney: SLE, vasculitis, Polyarticular gout.
GIT: Reiter’s, IBD, SS.
Liver: HCV, SS, IBD, sarcoidosis.

23. Laboratory Work up

24. I- General lab assessment:
Can be misleading.
Basic: CBC, Urinalysis, RFT, LFT.
Acute phase reactant: ESR, CRP.
Uric acid concentration= Gout
CK:PM/DM , hypothyroidism
Ca+² ,P +³:endocrinal, metabolic
Hepatitis B and C
Salmonella, brucella Serology: ReA,
Parvovirus serology

25. II-Specific lab assessment:-
Antibody tests:
o ANA= SLE
o Anti-dsDNA= SLE
o Anti-native DNA, anti-Sm=
SLE
o RF= RA
o Anti-CCP antibody=RA
Rheumatoid Factor
o Rheumatoid Arthritis
o Connective tissue diseases
o Viral infection
o Leishmaniasis
o Leprosy
o Tuberculosis
o Sarcoidosis
o Liver diseases
o Subacute bacterial endocarditis

26. Imaging Work up

27. Imaging:
X-ray:
o OA, RA, Chronic Gout
o Ankylosing spondylitis.
MSUS:
o Assess soft tissue, joint.
o Intervention.
MRI:
o Ankylosing spondylitis.
o Avascular necrosis, Osteomyelitis,
o Pigmented villonodular synovitis.
Bone scan:
o Stress fracture.

28. Synovial Fluid Analysis
Indications:-
1. Infection
2. Crystal induced arthritis.
3. Hemarthrosis (traumatic, pigmented vill-nodular synovitis).
4. Differentiate inflammatory from noninflammatory arthritis (WBCs count).
Tests to perform to synovial fluid:
• Gram stain and cultures .
• Total leukocyte count/differential: inflammatory vs. non-inflammatory.
• Polarized microscopy to look for crystals.
• Not necessary routinely: Chemistry (glucose, total protein, LDH) unlikely to yield
helpful information beyond the previous tests.