1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. Presented By: Ali Al-blowi Medical Student
Arthritis Mono vs. Poly
Presented By: Ali Al-blowi Medical Student

3. Defenitions Causes History Examination Investigation Conclusion

4. Definitions

5. Arthritis = inflammation of a joint
Arthritis = inflammation of a joint. Inflammation = Joint pain, stiffness, tenderness, redness, hotness, swelling & limited movement. Mono arthritis = one joint affected. Poly arthritis > 4 joints affected. Oligo/pausi-arthritis = 2-4 joints affected.

6. Acute = < 6 weeks Chronic = > 6 weeks Symptoms: Articular symptoms Non articular symptoms

7. Causes

8. Monoarthritis mimickers:
Common inflammatory processes occur in the soft tissues around joints:
Tendonitis of the shoulder.
Olecranon bursitis of the elbow.
Prepatellar bursitis of the knee.

9. Diseases Causing Monoarticutar Symptoms:
A) Septic
Bacterial
Mycobocterial
Lyme disease
Fungal
B) Traumatic
Fracture
Internal derangement
Hemarthrosis

10. C) Crystal deposition dis
Gout Osteoarthritis
CPPD
Hydroxyapatite DD
Calcium oxalate DD
Palindromic rheumatism
D) Others
Juvenile RA
(Pseudogout)
Avascular N
Foreign-body S
Pigmented villonodular syno.
Synovioma
Coagulopathy

11. Polyarticular diseases occasionally present with a monoarticular onset?
Rheumatoid arthritis
Reiter's syndrome/reactive arthritis
Juvenile rheumatoid arthritis
Psoriatic arthritis
Viral arthritis
Enteropathic arthritis
Sarcoid arthritis
Whipple's disease

12. Structural abnormality Internal derangement
The most likely causes of chronic monoarthritis (inflammation within a single joint for > 6 weeks).
INFLAMMATORY
NON-INFLAMMATORY
Inflammatory synovial fluid
Mycobacterial infection
Fungal infection
Lyme arthritis
Monoarticular presentation
of RA
Seronegauve
spondyloarthropathies
Sarcoid arthritis
Foreign-body synovitis
Structural abnormality
Internal derangement
Osteoarthritis
Internal derangement of the
knee
Avascular necrosis of bone
Pigmented villonodular
synovitis
Synovioma

13. Causes of acute polyarthritis:
Infection
Other Inflammatory
Gonococcal
Meningococcal
Lyme arthritis
Acute rheumatic fever
Bacterial endocarditis
Viral (rubella, H BV &
HCV, EBV& HIV) RA
Polyarticular and syst
JRA
Polyarticular gout
SLE
Reiter's syndrome
Psoriatic arthritis
Sarcoid arthritis

14. Causes of chronic polyarthritis:
INFLAMMATORY
NON-INFLAMMATORY RA
Enteropathic arth
Polyarticular JRA
SLE * SSc
CPPD, Polyarticular gout
Polymyositis
Sarcoid arthritis
Reiter's syndrome
Vasculitis
Psoriatic arthritis
Polymyalgia Rh. OA
Paget's disease
CPPD
Fibromyalgia
Benign hypermobility syndrome
Polyarticular gout
Hemochromatosis

15. Rheumatologic emergency
Acute monoarthritis = the joint is infected until proven otherwise.
The septic joint must be diagnosed quickly and managed aggressively to avoid permanent structural damage.

16. History

17. History taking from a patient with monoarthritis
Onset of pain: sudden, in seconds or minutes? (Consider fracture and internal derangement).
Over several hours or 1-2 days? (Consider infection, crystal deposition diseases, inflammatory arthritis and palindromic rheumatism).
Insidiously over days to weeks? (Consider indolent infections, such as mycobacteria and fungi, osteoarthritis, tumor, and infiltrative diseases).

18. Overused or damaged joint, either recently or in the past
Overused or damaged joint, either recently or in the past? (Consider traumatic causes).
History of IV drug abuse? Recent infection of any kind? (Consider septic arthritis).
Previous acute attacks of joint pain and swelling that resolved spontaneously? (Consider crystal deposition and other inflammatory arthritis).

19. Treatment with a prolonged course of corticosteroids
Treatment with a prolonged course of corticosteroids? (Consider infection or osteonecrosis of bone).
Associated skin rash, low-back pain, diarrhea, urethral discharge, conjunctivitis, or mouth sores? (Consider Reiter's syndrome, psoriatic, or enteropathic arthritis).
History of a bleeding diathesis? treatment with anticoagulants? (Consider hemarthrosis).

20. Is the age of the patient useful in the differential diagnosis?
I- In children, consider:
Congenital dysplasia of the hip.
Slipped femoral epiphysism.
Monoarticular presentation of JRA.
Children are unlikely to have GOUT.

21. II- In young adults, consider:
Seronegative spondyloarthropathy.
RA.
Internal derangement of the joint.
They are less likely to have GOUT.
A septic- joint is often due to gonococcal infection.

22. III- Older adults :
Crystalline arthritis.
OA.
Osteonecrosis.
Internal derangement of the joint.
A septic joint in these individuals is less likely due to gonococcal organisms.

23. What are the most likely diagnoses in hospitalized patients with acute monoarthritis?

24. Acute monoarthritis:
* Pyogenic infection
* Acute crystal deposition diseases
Risk factors known to provoke gout or pseudogout:
trauma, surgery, hemorrhage, infection
or medical stress such as:
CRF, MI & CVS.

25. Polyarthritis Pains differ:
Polyarthritis = inflammation (swelling, tenderness, warmth) of > 4 joints by examination.
Polyarthralgia = pain in > 4 joints without demonstrable inflammation; eg: SLE, systemic sclerosis, vasculitis, polymyalgia rheumatica, and chronic non-inflammatory.
Diffuse aches and pains are poorly localized symptoms originating in joints, bones, muscles, or other soft tissues. Polymyalgia rheumatica, fibromyalgia, polymyositis, and hypothyroidism.

26. Sequence of joint involvement:
1- Migratory (fleeting) polyarthritis: Symptoms disappear in the affected joints to reappear in others. Ex.: ARF, Gonococcal, Viral, early phase of Lyme.
2- Additive: Symptoms persist with addition of new joint inflammation Ex.: RA, SLE.
3- Intermittent: Attacks of remissions & exacerbations in the same joint. Ex.:
Gout, sarcoid arthritis, Reiter's syndrome
and psoriatic.
Gout - Chronic tophaceous gout in an untreated patient with end-stage renal disease

28. Benign hypemobility syndrome.
What are the most likely diagnoses in women aged who present with chronic polyarticular symptoms?
OA.
RA.
SLE.
Fibromyalgia.
Benign hypemobility syndrome.

29. Ankylosing Spondylitis. OA. Hemochromatosis.
What are the most likely diagnoses in men aged who present with chronic oligoarticular or polyarticular symptoms?
Gonococcal arthritis.
Reiter Syndrome.
Ankylosing Spondylitis.
OA.
Hemochromatosis.

30. And in patients over age 50 presenting with chronic polyarticular symptoms?
OA.
RA.
CPPD disease.
Polymyalgia rheumatica.
Paraneoplastic polyarthritis.

31. Distribution of Joint Involvement
Symmetrical
Asymmetrical
Ex. RA
SLE
Reiter PA AS
Axial
Peripheral
PA (70% also affects IPJ--- sausage digits)
Large
Small
Seronegative
ARF

32. DISEASE JOINTS COMMONLY INVOLVED SPARED Knee, wrist, ankle, hand IP
Gonococcal arthritis
Knee, wrist, ankle, hand IP
Axial
Lyme arthritis
Knee, shoulder, wrist, elbow
Rheumatoid arthritis
Wrist, MCP, PIP, elbow, glenohumeral, cervical spine, hip, knee, ankle, tarsal, MTP
DIP, thoracolumbar spine OA
First CMC, DIP, PIP, cervical spine, thoraco-lumbar spine, hip, knee, first MTP, toe IP
MCP, wrist, elbow, shoulder, ankle, tarsal
Reiter's syndrome
Knee, ankle, tarsal. MTP, toe IP, elbow, axial
Psoriatic arthritis
Knee, ankle, MTP. toe IP, wrist. MCP, hand IP. axial
Enteropathic arthritis
Knee, ankle, elbow, shoulder, MCP, PIP, wrist, axial
Polyarticular gout
First MTP, instep, heel, ankle, knee
CPPD disease
Knee, wrist, shoulder, ankle, MCP, hand IP, hip, elbow
Sarcoid arthritis
Ankle, knee
Heroochromatosis
MCP, wrist, knee, Hip, feet, shoulder

33. Extra-articular Organ Involvement:
ARF Ht, pleura
Viral A Liver
SBE Ht valves & kidney
RA Lung, pl., ht.
SLE Lung, pl., ht., kidney, CNS
Scleroderma Lung, pl., ht., kid., GI., Liver

34. PM/DM Lung, pl., ht.
Reiter Valves, GI.
Enteropathic A: GI., Liver
Gout Kidney
Sarcoid A: Lung, Liver
Vasculitis Lung, Kidney
Hemochromatosis: Ht, liver, Pnc

35. Morning stiffness
Morning stiffness = time it takes for patients with polyarthritis to move after arising in the morning, or after rest.
Site: Affecting hands in RA & back in AS.
Inflammatory arthritis, morning stiffness lasts > I hour & tends to parallel the activity.
Non-inflammatory, eg. OA, ---MS < 15 minutes.

36. Examination

37. Is Fever a useful sign? Misleading !! Infectious arthritis.
Acute attacks of gout and CPPD disease.
RA, juvenile RA.
Sarcoidosis.
Reiter's syndrome.

38. Inability to bear weight
Skin
Nodules: RA, gout tophi
Rash: psoriasis, lupus, Still’s, viral etc
Inability to bear weight
Sepsis
Fracture
Crystal arthritis
Neurologic

39. Signs of inflammation Range of motion Synovitis (soft tissue swelling)
Local heat
Effusion
Range of motion
 Active, N Passive: soft tissue eg bursitis, tendinitis, muscle
 Active,  Passive: contracture, synovitis, structural abnormality

40. Investigations

41. Monoarthritis Synovial fluid analysis.:
Most useful diagnostic study in the initial evaluation of monoarthritis

42. Almost always indicated
1. Radiograph of the joint: may reveal:
Normal, OR unsuspected fracture,
Osteonecrosis, OA, or
Juxta-articular bone tumor.
Chondrocalcinosis, a radiologic feature of CPPD
Chronic fungal or mycobacterial infection.
Contralateral joint radiograph for comparison.
2. Complete blood count.
Leukocytosis + possibility of inf.

43. Indicated in selected patients
Cultures of blood, urine:
Mandatory in septic joint.
2. PT & PTT: when anticoagulation or coagulation disorder is suspected.
3. ESR, CRP: nonspecific;
significant elevation = inflammation.

44. Ask for further investigations in chronic cases:
Radiograph of sacroiliac joints:
asymptomatic sacroiliitis in young males (spondyloarthropathy).
Chest radiograph:
pulmonary TB or sarcoidosis.
Tuberculin test:
negative test in excluding TB?.
Serologic tests: Lyme disease (Borrelia burgdorferi), RF, ANA, and HLA-B27.

45. Polyarthritis X-ray Laboratory testing CBC Serum uric acid THS
Iron studies
Liver enzymes
Serum creatinine
Urinalysis

46. ESR
ANA RF
HLA-B27 antigen
Synovial fluid analysis

47. Conclusion

48. Acute monoarthritis = joint aspiration to exclude septic & crystal- induced arthritis.
Chronic monoarthritis > 6 weeks of unknown cause needs synovial biopsy.
Gout does not occur in premenopausal females or in joints close to spine.

49. Take your time for final diagnosis!
Because many chronic polyarticular diseases require months or years to diagnose, patience is often required.
Many diseases present insidiously with few objective findings for prolonged times.
Many diseases initially represent others before finally take their usual pattern.
RA, for example, can present as a monoarthritis before assuming its more typical polyarticular course.

50. Take your time for final diagnosis! (cont.)
Characteristic laboratory abnormalities may require months or years to develop.
The joint symptoms precede the extra-articular features by months or years.
Joint radiographs may not show characteristic changes of the arthritis for months or years.
Not all pts. with +ve RF=RA, nor +ve. ANA = SLE .
Remember nothing is 100%

51. Musculoskeletal complaint1
Musculoskeletal complaint
History & Examination?
Articular or non
Acute or chr.
Inflammatory or non.
Number & distribution
Non articular
Fibromyalgia R
Hypermobility S
Articular?
Acute or Chronic ?
Acute<6 W.
Chronic>6W.
Acute arthritis:
Infectious
Crystal-induced
Reiter’s
Presentation of Chr. Arth.
Inflammatory or non-infl.

52. - + + 2 Inflammatory or non-inflam. Chronic inflammatory arthritis=
MS>1hr, synovial swelling,
warm, tender Joint, +syst.
manifes., CRP, ESR
Chronic non-inflammatory
arthritis
>4 J = polyarthritis
1=mono,
2-4=oligo
arthritis:
PA- RS- PJA
Affects Wt. Br. J.
(H & k), DIP, CMC
Symetrical _ +
PA, RS
PIP, MCP, MTP OA
Osteonecrosis
Charcot arthritis - +
SLE, SSc, PM RA

53. THANK YOU