1. Dr. Müge Bıçakçıgil Kalaycı
Acute Arthritis
Dr. Müge Bıçakçıgil Kalaycı

2. Acute Arthritis
The sudden onset of inflammation of the joint, causing severe pain, swelling, and redness.
Structural changes in the joint itself may result from persistence of this condition.

3. Signs of Inflammation Swelling Warmth Erythema Tenderness
Loss of function

4. Key Points
Distinguish arthritis from soft tissue non articular syndromes
If the problem is articular distinguish single joint from multiple joint involvement
Inflammatory or non-inflammatory disease
Always consider septic arthritis!

5. Is it an articular or extra-articular problem?
ARTICULAR PERI-ARTICULAR
pain all planes pain in plane of tendon
active = passive active > passive
capsular swelling/effusion linear swelling
joint line tenderness localised tenderness
diffuse erythema/heat localised erythema/heat

6. Arthritis,Bursitis is NOT arthritis Prepatellar bursitis

7. Olecranon bursitis

8. Inflammatory Vs. Noninflammatory
Feature
Inflammatory
Noninflammatory
Pain (when?)
Swelling
Erythema
Warmth
AM stiffness
Systemic features
î ESR, CRP
Synovial fluid WBC
Examples
Yes (AM)
Soft tissue
Sometimes
Prominent
Frequent
WBC >2000
Septic, RA, SLE, Gout
Yes (PM)
Bony
Absent
Minor (< 30 ‘)
Uncommon
WBC < 2000
OA, AVN

9. History Eye and mouth dyrness Raynauds Photosensitivity
Oral and genital ulsers
Recurrent swelling of parotis
Recurrent thrombophlebitis
Recurrent abortus
Uveitis

10. History Inflamatory back pain
Epilepsy history, cerebro-vascular events
depression
Muscle weakness
Recurrent fever
Skinrash
Recurrent serosits

11. INFLAMMATION
•Acute/chronic
•Monoarthritis
•Oligoarthritis
•Polyarthitis

12. Is it acute or chronic?
< 6 weeks  Acute
> 6 weeks  chronic
Minutes to hours : hemarthrosis
Hours to days: septic, reactive, crystals
Days to weeks: autoimmune ( RA), CTD, viral
Weeks to months: degenerative, other

13. Acute Monoarthritis
Inflammation (swelling, tenderness, warmth) in one joint
Occasionally polyarticular diseases can present with monoarticular onset:
(RA, JRA,Reactive and enteropathic arthritis, Sarcoid arthritis, Viral arthritis, Psoriatic arthritis)

15. Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER: INFECTION !
Septic
Crystal deposition (gout, pseudogout)
Traumatic (fracture, internal derangement)
Other (hemarthrosis, osteonecrosis, presentation of polyarticular disorders)

16. Joint aspiration must be done!
Needed for immediate diagnosis.
Bloody joint aspirate- plain X-ray .
Analysis of synovial fluid provide discrimination of infection and crystal artropathy.

17. septic arthritis common organisms Staphylococci or Streptococcus
young adults, significant incidence gonococcal arthritis
Elderly & immunocompromised gram (-) organisms
Anaerobes more common with penetrating trauma

18. Who gets septic arthritis?
pre-existing joint disease
prosthetic joints
low SE status, IV drug abuse, alcoholism
diabetes, steroids, immunosuppression
previous intra-articular steroid injection

19. Symptoms & signs of septic arthritis
Typically hot, swollen, red tender joint with reduced range of movement, difficulty weight bearing
Systemic upset
Night and rest pain
Large joints more commonly affected than small

20. Symptoms & signs of septic arthritis
Delayed or inadequate treatment leads to irreversible joint damage
10-15% of cases, > one joint - so polyarticular presentation does not exclude septic arthritis
presence of fever not reliable indicator- if clinical suspicion high – treat

21. Investigations Synovial fluid aspiration
volume/viscosity/cellularity/appearance
gram stain/culture
Absence of organism does not exclude septic arthritis
polarised light microscopy (crystals)
suspected prosthetic joint sepsis should ALWAYS be referred to orthopaedics

22. Septic Joint - Gonococcal
Often preceded by disseminated gonococcemia
Sexually active individual, fever, chills, skin lesions, migratory arthralgias and tenosynovitis  persistent monoarthritis
Genitourinary disease often asymptomatic

23. Disseminated Gonococcemia – Pustules

24. Tests to Perform on 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.

25. Normal OA
RA/Infl
Septic
Appearance
Clear
Opaque
Viscosity
High
Low
WBC/mm
<200
>30.000
%PM
<25%
<50%
>50%
>75%

26. Urate crystals
Gram positive coccus

27. Investigations Always blood cultures
significant proportion blood cultures + ve in absence of + synovial fluid cultures
FBC ESR & CRP
BUT absence of raised WBC, ESR or CRP not exclude diagnosis of sepsis - if clinical suspicion high always treat

28. Other investigations CRP useful for monitoring response to treatment
Urate may be normal in acute gout and of no diagnostic value in acute gout or sepsis
Measure urea, electrolytes & liver function for end organ damage (poor prognostic feature)
Renal function may influence antibiotic choice

29. Other tests?
If skin pustule is present, suggestive of gonococcal infection, then skin swab should be taken
If history suggests possibility of genitourinary or respiratory tract infection then culture sputum (and CXR) & urine & take anogenital & throat swabs where appropriate

30. Questions to Ask – History Helps in DD
Pain come suddenly, minutes? – fracture.
0ver several hours or 1-2 days? –infectious, crystals, inflammatory arthropathy.
History of IV drug abuse or a recent infection? – septic joint.
Previous similar attacks? – crystals or inflammatory arthritis.
Prolonged courses of steroids? – infection or osteonecrosis of the bone.

31. Imaging
Plain X rays no benefit in diagnosis but form baseline for any future joint damage. May show chondrocalcinosis.
MRI useful in distinguishing sepsis from OA but less good between sepsis & inflammation
MRI sensitive for osteomyelitis

32. Antibiotic treatment of septic arthritis
Local and national guidelines
Liaise with micro. guided by gram stain
Conventionally given iv for 2 weeks or until signs improve, then orally for around 4 weeks

33. Joint drainage & surgical options
medical aspiration, surgical aspiration via arthroscopy or open arthrotomy
Suspected hip sepsis – early orthopaedic referral – may need urgent open debridement

34. Gout Caused by monosodium urate crystals
Most common type of inflammatory monoarthritis
Typically: first MTP joint, ankle, knee
Pain very severe
May be with fever and mimic infection
The cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis

35. Acute Gouty Arthritis

36. Risk Factors
Primary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis.
Secondary gout: alcoholism, drug therapy (diuretics), myeloproliferative disorders, chronic renal failure.

37. Urate Crystals
Needle-shaped
Strongly negative birefringent

38. CPPD Crystals Deposition Disease
Can cause monoarthritis clinically indistinguishable from gout – Pseudogout.
Pseudogout is most common in the knee (50%) and wrist.
Reported in any joint (Including MTP).
CPPD disease may be asymptomatic (deposition of CPP in cartilage).

39. Ca pyrophosphate (pseudogout)
Rod or rhomboid-shaped
Weakly positive birefringent

40. What are other differentials for
acute monoarticular pain?

41. Monoarthritis - differential diagnosis
Psoriatic arthritis
Onycholysis
Subungual hyperkeratosis
Pitting
Extensor surfaces, scalp, umbilicus

42. Monoarthritis - differential diagnosis
Reactive arthritis
Prodromal GI /GU
Infection eg
campylobacter,
salmonella, shigella,
Yersinia,chlamydia
Pustular psoriasis
and circinate balanitis

43. Monoarthritis - differential diagnosis
Trauma and haemarthroses (warfarin, bleeding disorders)
Palindromic rheumatism – hours inflammatory monoarthritis, can evolve into polyarthritis eg RA

44. Other Tests Indicated for Acute Arthritis
1. Almost always indicated:
Radiograph, bilateral
CBC
2. Indicated in certain patients:
Cultures
PT/PTT
ESR
Serum Uric acid level
3. Rarely indicated:
Serologic: ANA, RF

45. Acute Inflammatory Oligoarthritis
A patient with 2-4 joints is said to have pauci- or oligoarticular arthritis

46. Differential diagnosis of acute inflammatory oligoarthritis
Infection
Disseminated gonococcal infection
Nongonococcal septic arthritis
Bacterial endocarditis
Viral
Postinfection
Reactive arthritis
Rheumatic fever (post strep)
Spondyloarthropathy
Ankylosing spondylitis
Psoriatic arthrit
Inflammatory bowel disease
Oligoarticular presentation of RA, SLE, still disease
Gout and pseudogout

47. Acute Inflammatory Oligoarthritis Reactive arthritis ( ReA) GIT : Campylobacter, Yersinia, Salmonella, Shigella Genitourinary: Chlamydia, Gonococcus Throat: β hemolytic streptococcus

48. Acute Inflammatory Oligoarthritis Psoriasis associated arthritis ( PsA) Typical joints: DIPs, big and small together

49. Polyarthritis Inflammation of 5 or more joints
Diagnosis cannot always be made
with certainty in <6 weeks
Bacterial infection less likely but
viruses common cause of acute polyarthritis

50. Acute Polyarthritis Infection Gonococcal Meningococcal Rheumatic fever
Bacterial endocarditis
Viral (rubella, parvovirus, Hep. B)
Inflammatory RA
JRA
SLE
Reactive arthritis
Psoriatic arthritis
Polyarticular gout
Sarcoid arthritis

51. Temporal Patterns in Polyarthritis
Migratory pattern: Rheumatic fever, gonococcal (disseminated gonococcemia)
Additive pattern: RA, SLE, psoriasis
Intermittent: Gout, reactive arthritis

52. Patterns of Joint Involvement
Symmetric polyarthritis involving small and large joints: viral, RA, SLE, one type of psoriatic (the RA-like).
Asymmetric, oligo- and polyarthritis involving mainly large joints, preferably lower extremities, especially knee and ankle : reactive arthritis, one type of psoriatic, enteropathic arthritis.
DIP joints: Psoriatic.

53. Viral Arthritis Younger patients Usually presents with prodrome, rash
History of sick contact
Polyarthritis similar to acute RA
Prognosis good; self-limited
Examples: Parvovirus B-19, Rubella, Hepatitis B and C, Acute HIV infection, Epstein-Barr virus, mumps

54. Viral Arthritides - Parvovirus

55. Rheumatoid Arthritis
Symmetric, inflammatory polyarthritis, involving large and small joints
Acute, severe onset %; subacute 20%
Hand characteristically involved
Acute hand deformity: fusiform swelling of fingers due to synovitis of PIPs
RF may be negative at onset and may remain negative in 15-20%!
RA is a clinical diagnosis, no laboratory test is diagnostic, just supportive!

56. Acute Polyarthritis - RA

57. Acute Sarcoid Arthritis
Chronic inflammatory disorder – noncaseating granulomas at involved sites
15-20% arthritis; symmetrical: wrists, PIPs, ankles, knees
Common with hilar adenopathy
Erythema nodosum
Löfgren’s syndrome: acute arthritis, erythema nodosum, bilateral hilar adenopathy

58. Acute Polyarthritis in Sarcoidosis

59. Reactive Arthritis
Infection-induced systemic disease with inflammatory synovitis from which viable organisms cannot be cultured
Association with HLA B 27
Asymmetric, oligoarticular, knees, ankles, feet
40% have axial disease (spondylarthropathy)
Enthesitis: inflammation of tendon-bone junction (Achilles tendon, dactylitis)
Extraarticular: rashes, nails, eye involvement

60. Enthesitis in Reactive Arthritis

61. Polyarticular gout
Pseudogout ( Calcium pyrophosphate mono/oligo) is rarely polyarticular.
• Tophi develop with time.
• Joint aspiration ( 5% gouty arthritis
normouricaemic during attack)

62. Diagnostic criteria for SLE ARA 1985
Photosensitity
• Raynaud’s
• maculopapular rash
• polyarthritis
• serositis
• Cytopenias
• Coomb’s pos haem. anemia
• haematuria or proteinuria
• CNS
• Pos ANA, SSA,anticardiolipin, LAC
• Pos double stranded DNA

63. SLE-skin and joints Butterfly rash Rash and arthritis Muco-cutaneous
Photosensitive
alopecia

64. Work-up of Acute Arthritis – Polyarthritis (>5 joints)
FULL HISTORY AND PHYSICAL EXAM.
• FBC, biochemistry
• CRP, ESR
• RF, CCP (filaggrin) , ANA (DNA , ENA if pos)
• Serology for: parvovirus, Hep B and C, Borrelia
• X ray both hands and feet (erosions), chest
• Blood cultures and Echocardiogram

65. Detailed history end Physical exammination
Monoarthritis
Detailed history end Physical exammination
trauma or focal bone pain
X-ray
(+)
(-)
Fracture, tm
Synovial fluid
Coagulopathy
malignancy
Trauma
WBC>2000
PMNL> %75
Bloody
(-)
(+)
Non-inflammatuar
Soft Tissue trauma
Osteoarthritis
Osteonecrosis
Mechanical problem
İınflammatuar arthrritis
Steril inflamatuar
fluid
Culture (+)
Crystal (+)
Septic arthritis
Crystal arthritis
RA, JIA, SpA, FMF,
Behçet, SLE

66. Polyarthritis-polyarthralgia
Detailed history and physical examination
(+)
(-)
FMS,,
myofasial pain, tendinitis
Poliartthritis
Tender points
(+)
(-)
Viral arthralji,
osteomalasia, hypotyroid,
malignancy, PMR, depression
Symptom duration
>6 week
(-)
(+)
Systemic rheumatological diseases,
Osteoarthritis
Viral arthritis, ARA
systhemic rheumatological diseases
Further investigation
Complate blood count, urine analysis, ESR,
CRP, RF, ANA
radiology
Complate blood count, urine analysis, ESR, CRP, ASO, LFT, Hepatitis B, C, viral arthralgia, throat culture

67. Management
Dependent upon diagnosis
If infection cannot be excluded must treat as infection
May need supportive care until
symptoms resolve
Persistent symptoms require
treatment plan