1. Clinical Approach to Acute Arthritis
DR.AFSAR SAYEEDA
MRCP(UK)
CONSULTANT INTERNIST & RHEUMATOLOGIST
HEAD CTU DIVISION,DEPT OF MEDICINE
KING KHALID UNIVERSITY HOSPITAL

2. Normal Joint..

3. ARTHRALGIA / ARTHRITIS
INTRAARTICULAR / PERIARTICULAR /NONARTICULAR
MONOARTHRITIS/ POLYARTHRITIS
INFLAMMATORY / NONINFLAMMATORY

4. Monoarthritis
Inflammation of a single joint
Can be acute or chronic.

5. Diagnostic approach
Case scenarios
Diagnostic clues
Investigation
Treatment
Picture quiz

6. Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER: INFECTION !
SEPTIC(gonococcal/nongonococcal)
CRYSTAL INDUCED(gout, pseudogout)
TRAUMATIC (fracture, internal derangement)
Other (hemarthrosis, osteonecrosis, presentation of polyarticular disorders)

7. Acute monoarthritis – Diagnostic approach
History
review of symptoms
previous joint disease or trauma
concurrent illnesses
family history
medication use – e.g. diuretics, anticoagulants
other risk factors
travel, sexual history, diet, tick bites, occupational history, alcohol and intravenous drug use

8. Examination
Focus on the involved and contralateral joint and surrounding area
General examination to look for other affected joints
Look for systemic manifestations of disease

9. Scenario 1
A 35 year old man presents with a 1 day history of an intensely painful and swollen left knee. He is struggling to weight bear and cannot bend his knee much.
He is otherwise well except for hypertension.

10. Any previous similar episodes
Onset of pain
“ I went to bed fine doctor. When I woke up I could hardly bend my knee”
Any previous similar episodes
“Never in my knee doc. But I had something similar affecting my foot last year. It lasted about two weeks.”
“A&E treated me for a skin infection and gave me some painkillers.”
Medications
“I take a tablet for my blood pressure.”
Any alcohol?
“No more than average like…… 6 pints a night say”

11. On examination

12. Diagnosis?

13. Acute Gouty Arthritis

14. Gout Most common cause of inflammatory arthritis in adults
Usually men >40 years and post-menopausal women
Initially acute monoarthritis
Risk Factors -Primary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis.
Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure.
Family history in some

15. Caused by monosodium urate crystals.
50-70% of first attacks affect the big toe.
Other frequently affected joints include the midfoot, ankle, knee, wrist, and elbow.
Shoulders and hips rarely involved.

16. Gout Can have low grade temperature.(mimics infection)
Raised inflammatory markers (can be very high) with neutrophilia.
The cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis.
Majority of patients have further attacks.
Tophi can develop in chronic disease.

17. Urate Crystals
Needle-shaped
Strongly negative birefringent

18. Scenario 2 A 35 year old American tourist presents
with a 2 day history of an intensely painful
and swollen left knee. He is unable to
bear weight and has marked difficulty in
bending his knee.
He reports feeling feverish.

19. Any previous similar episodes
Onset of pain
“ It has swollen up over a few days and it feels hot”
Any previous similar episodes
“First time I have had anything like it”
Medications
“I don’t take anything”
Any alcohol?
“Very little”
Associated symptoms
“I felt feverish last night”
“I noticed a couple of new spots on my body ………. ….like acne”
Anything else?
“I had a one-night stand last week …….. I didn’t use any protection”
“Could it be related?”

22. Diagnosis?

23. Gonococcal arthritis
Gonococcal arthritis is caused by infection with the gram- negative diplococcus neisseria gonorhhoeae.
In the US, gonococcal arthritis is the most common form of septic arthritis.
a consequence of disseminated gonococcal infection.
Haematogenous spread of the mucosal infection occurs in up to 3% of cases.
Time from initial infection to manifestations of disseminated infection ranges from 1 day to 3 months.

24. It manifests as either a bacteraemic infection (arthritis-dermatitis syndrome.tenosynovitis; 60% of cases) or as a localized septic arthritis (40%).
Synovial fluid cultures can be positive in up to 50% of cases
Cultures from likely sites of initial infection will increase the yield.
Blood culture / Cervix / Rectum / Urethra / Pharynx.
PCR testing of samples can also increase yield if cultures are negative.
Unlike in Staph. aureus septic arthritis, joint destruction is rare.

25. Scenario 3
An 80 year old woman with type 2 diabetes and rheumatoid arthritis presents with a two week history of increasing pain and swelling in her right wrist.
Her rheumatoid is well controlled on medication but her wrist has been a problem and has been injected with steroids recently.
She is feeling feverish and unwell.

26. On examination

27. Diagnosis?

28. Septic arthritis
More common in those with inflammatory arthropathies, joint prostheses, impaired immunity.(DM,Cancer)
Any age affected but more commonly young and elderly.
Systemic symptoms usually present but not in immunocompromised.
Fever has poor sensitivity and specificity for septic arthritis.
Synovial fluid culture positive in 90%.
Knee joint - commonest .(others-Hip, shoulder)
Most develop from hematogenous spread.
Monoarticular-80% Polyarticular- 20%.

29. Viral – HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus
SEPTIC ARTHRITIS
Bacterial
Gonococcal
Non-gonococcal -Gram positive aerobes (80%)
(Staphylococcus aureus(60%) , non­group-A beta-hemolytic streptococci, gram-negative bacteria(18%), & Streptococcus pneumoniae)
Viral – HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus
Fungal

30. Scenario 4 85 year old woman
RA, OA of the knees, Leg ulcers, Hypertension, PPM
Awaiting Right TKR
2 week history of marked swelling in her left knee
Started suddenly following some physiotherapy
Not systemically unwell.

31. On examination
Large, warm effusion left knee.
Any further info?

32. Haemarthrosis history of trauma. Not always associated
Usually significant swelling.
Traumatic causes include cruciate ligament rupture and intra-articular fracture.
Other causes include pigmented villonodular synovitis and bleeding diatheses.

33. Pseudogout More elderly age group. Mean age early 70’s.
Acute monoarticular presentation.
Occ polyarticular- .
Often affects the knee, wrist, or shoulder.
Triggers include:
Intercurrent illness
Trauma
Surgery
CPPD disease may be asymptomatic (deposition of CPP in cartilage).

34. CPPD Crystals
Rod or rhomboid-shaped
Weakly positive birefringent

35. In approximately 1/3 of cases of monoarthritis no definitive diagnosis will be identified even after appropriate investigation.

36. Diagnostic clues

37. Sudden onset of pain over seconds to minutes
Trauma
Onset of pain, swelling, tenderness maximal within 12 hours
Crystal arthropathy
Onset of pain over several hours or 1-2 days
Septic arthritis
Monoarthritic presentation of other inflammatory arthropathy

38. Insidious onset of pain & swelling over days-weeks
Low grade/atypical infection, OA, malignancy, granulomatous disease.
Previous similar attacks?,drugs-diuretics – crystals or inflammatory arthritis.
DM, Cellulitis, Prosthetic joints, RA, IV drug abuse,a recent infection
Septic arthritis
Steroid exposure
Avascular necrosis
Coagulopathy, Use of anticoagulants
Haemarthrosis

39. Other causes of monoarthritis

40. Seronegative spondyloarthropathies

41. Monoarthritic presentation of polyarthritis

42. JOINT ASPIRATE !!! Investigations Gram stain C & S Total leucocyte
count
Polarising
microscopy
(Crystal analysis)

43. Investigations Blood cultures Bloods – ESR/CRP, FBC, U+E’s, Clotting
X-ray – affected and contralateral joint
Consider: serum urate, CXR, sputum sample, urine culture, skin swabs

44. Treatment – depends on the cause!
Aspirate joint
Analgesia – NSAIDs, Colchicine
Rest / Ice / Elevation
Antibiotics if indicated – 2 weeks IV, 4 weeks oral follow-on
Intra-muscular/Intra-articular/Oral steroids if indicated

45. Learning points
In acute inflammatory monoarthritis, symptoms reaching their maximum within 6-12 hours are highly suggestive of a crystal arthropathy.
Serum uric acid levels do not confirm or exclude gout.
Demonstration of urate crystals in synovial fluid or tophus aspirates is diagnostic of gout.
Beware that gout and sepsis can co-exist.
Repeated culture of synovial fluid, blood and other sources of sepsis may be needed if initial samples are negative but clinical suspicion remains high.
In a young patient with a monoarthritis but no history of trauma, refer to rheumatology NOT orthopaedics.

46. Polyarthritis
Definite inflammation (swelling, tenderness, warmth of > 5 joints
A patient with 2-4 joints is said to have pauci- or oligoarticular arthritis

47. Inflammatory Vs. Noninflammatory
Feature
Inflammatory
Mechanical
Morning stiffness
>1 h
Swelling
Warmth
Erythema
Effusion
< 30 min

48. Approach to Inflammatory Arthritis
Main Diagnostic Groupings – 3
RA, SPA, SLE
Crystalline arthritis
Infectious arthritis

49. Temporal Patterns in Polyarthritis
Migratory: Rheumatic fever
Additive : RA, SLE, psoriasis
Intermittent: Gout, reactive arthritis

50. Patterns of Joint Involvement
Symmetric: viral, RA, SLE, psoriasis.
Asymmetric, : reactive arthritis, psoriasis, enteropathic arthritis.
DIP joints: Psoriatic.

51. Phy. Examination.. General Examination:
LAP, parotid enlargement, oral ulceration, heart murmurs, pericardial or pleural friction rubs, crackle…= systemic disease.
Fever= infection, reactive arthritis, RA, SLE, Crystal induced arthritis
Subcutaneous nodules= RA, RHD, Gout (tophi)
Skin manifestations= psoriasis, RA, SLE…
Eye disease (keratoconjunctivitis sicca, uveitis. Conjunctivitis, episcleritis…)

52. Viral Arthritis Younger patients Usually presents with prodrome, rash
Causes: Parvovirus B-19, Rubella, Hep B and C, Acute HIV infection, E-B virus, mumps
Prognosis good; self-limited

53. 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!

54. Acute Polyarthritis - RA

55. Arthritis Of SLE Musculoskeletal manifestation 90%.
Most have arthralgia.
May have acute inflammatory synovitis RA-like.
Do not develop erosions.
Other clinical features help with DD: malar rash, photosensitivity, rashes, alopecia, oral ulceration.

56. Butterfly Rash – SLE

57. Photosensitivity

58. Alopecia - SLE

59. Arthritis of Rheumatic Fever
Etiology: Streptococcus pyogenes (group A); immune response to antecedent infection
Migratory polyarthritis, large joints: knees, ankles, elbows, wrists.
Major manifestations: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules.

60. Key Points Distinguish arthralgia from arthritis
Distinguish arthritis from soft tissue non articular syndromes (discrepancy between “active” and “passive” ROM suggests periarticular/soft tissue).
If the problem is articular distinguish single joint from multiple joint involvement.
Traumatic or nontraumatic.
Inflammatory or non-inflammatory disease.
Always consider septic arthritis!

61. THANK YOU