APPROACH TO PATIENT WITH MONOARTHRITIS Dr Maryum khalil HO MU1 HFH

MONOARTHRITIS “Inflammation of a single joint” *Acute *Chronic

CAUSES OF ACUTE MONOARTHRITIS IN A PREVIOUSLY NORMAL JOINT: Septic arthritis Crystal synovitis Trauma Haemarthrosis Foreign body reaction Monoarticular presentation of oligo- / polyarthritis R.A Erythema nodosum Juvenile Idiopathic arthritis Reactive, Psoriatic or other Seronegative spondarthritis

IN A PREVIOUSLY ABNORMAL JOINT DAMAGED JOINT: Pseudogout in assc with O.A Bone disease Cartilage disease Haemarthrosis Septic arthritis EXISTING INFLAMMATORY DISEASE ( WITH OR WITHOUT DAMAGE): Septic arthritis Exacerbation of underlying disease

CAUSES OF CHRONIC MONOARTHRITIS Foreign body Infection Ch. Sarcoidosis Enteropathic Arthritis (mainly Crohn’s) Amyloidosis Pigmented villonodular synovitis Synovial pathology (sarcoma, chondromatosis) Monoarticular presentation of oligo- / poly articular disease

HISTORY & PHYSICAL EXAMINATION Acute monoarthritis can be the initial manifestation of many joint disorders. The first step in diagnosis is to verify that the source of pain is the joint, not the surrounding soft tissues. The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. A careful history and physical examination are important because diagnostic studies frequently are only supportive.

DIAGNOSTIC CLUES Clues from history and physical examination Sudden onset of pain in seconds or minutes Onset of pain over several hours or one to two days Insidious onset of pain over days to weeks Diagnoses to consider Fracture, internal derangement, trauma, Infection, crystal deposition disease, other inflammatory arthritic condition Indolent infection, osteoarthritis, infiltrative disease, tumor

Intravenous drug use, immunosuppression Previous acute attacks in any joint, with spontaneous resolution Recent prolonged course of corticosteroid therapy Coagulopathy, use of anticoagulants Urethritis, conjunctivitis, diarrhea, and rash Psoriatic patches or nail changes such as pitting Septic arthritis Crystal deposition disease, other inflammatory arthritic condition Infection, avascular necrosis Hemarthrosis Reactive arthritis Psoriatic arthritis

Use of diuretics, presence of tophi, history of renal stones Eye inflammation, low back pain Young adulthood, migratory polyarthralgias, inflammation Hilar adenopathy, erythema nodosum Gout Ankylosing spondylitis Gonococcal arthritis of the tendon sheaths of hands and feet, dermatitis Sarcoidosis

DIAGNOSTIC STUDIES 1-SYNOVIAL FLUID EXAM: Arthrocentesis is required in most patients with monoarthritis and is mandatory if infection is suspected. In some instances, obtaining as little as one or two drops of synovial fluid can be useful for culture and crystal analysis. Cell counts Microscopy C/S

Categorization of Synovial Fluid Noninflammatory: <2,000 WBC per mm3 Osteoarthritis Trauma Avascular necrosis Charcot's arthropathy Hemochromatosis Pigmented villonodular synovitis Inflammatory: >2,000 WBC per mm3 Septic arthritis Crystal-induced monoarthritis (e.g., gout, pseudogout) Rheumatoid arthritis Spondyloarthropathy SLE Juvenile R.A Lyme disease

MICROSCOPY: C/S: Synovial fluid cultures are more likely to be positive in patients with nongonococcal arthritis (90 percent) than in those with gonococcal arthritis (less than 50 percent).

2- CBC & ESR 4- BLOOD CULTURE Blood cultures should be obtained in patients with suspected septic arthritis. Cultures are positive in about 50 percent of nongonococcal infections but are rarely positive (about 10 percent) in gonococcal infection. Pharyngeal, urethral, cervical, and rectal swabs are necessary if gonococcal infection is suspected

5-RADIOGRAPHY: Although plain-film radiographs often show only soft tissue swelling, they are indicated in patients with a history of trauma or patients who have had symptoms for several weeks. Occasionally, unsuspected bony lesions, such as osteomyelitis or malignancy, may be detected.

5-MRI: Magnetic resonance imaging is superior in detecting ischemic necrosis, occult fractures, and meniscal and ligamentous injuries.

6-RADIONUCLIDE SCANS: Radionuclide scanning can detect infection in deep-seated joints. 7- OTHERS: Other diagnostic procedures, such as synovial biopsy or arthroscopy, may be useful to rule out deposition diseases (e.g., hemochromatosis, atypical infections) and intra-articular tumors.

SEPTIC ARTHRITIS Bacterial Gonococcal Non-gonococcal(Staphylococcus aureus , non­group-A beta-hemolytic streptococci, gram-negative bacteria, and Streptococcus pneumoniae) Viral – HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus Fungal

MANAGEMENT 1- Hospitalization 2- Gen. Supportive care 3- I/V Antibiotics 4- Repeated Arthrocentesis 5- Surgical Drainage

CRYSTAL INDUCED SYNOVITIS A- GOUT: ACUTE: NSAIDs, Glucocorticoids,Colchicine CHRONIC: Allopurinol, Uricosuric Drugs

- NSAIDs, Glucocorticoids, Colchicine C- APATITE DISEASE: B- PSEUDOGOUT: - May present as acute mono- or oligoarthritis mimicking Gout, or as a chronic polyarhthritis mimicking R.A & O.A - NSAIDs, Glucocorticoids, Colchicine C- APATITE DISEASE: - May present with periarthritis or tendinitis - Rx same as Pseudogout

QUESTIONS

A 67 year old male presents with his first episode of knee pain and swelling together with the following x-ray. Which of the following investigations is the next investigation indicated diagnostically? (a) Thyroid function tests (b) Serum urate (c) Knee aspiration (d) Serum iron (e) Skeletal survey

The following pelvic x-ray displays radiographic features of which of the following rheumatic disorders? (a)Rheumatoid arthritis (b) Paget’s disease (c) Osteonecrosis (d) Osteoarthritis (e) None of the above

Which of the following types of joint involvement is not seen in psoriatic arthritis? (a) Symmetrical small joint arthropathy (b) Jaccoud’s arthropathy (c) Sacroiliitis (d) Monoarthritis (e) DIP joint arthropathy

In septic arthritis which one of the following pairings is most commonly found in hospital practice? (a) Ankle joint and Staph Aureus (b) Knee joint and MRSA (c) Wrist joint and Beta haemolytic streptococci (d) Knee joint and Staph Aureus (e) Hip joint and Staph Aureus

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