1. APPROACH TO PATIENT WITH MONOARTHRITIS
Dr Maryum khalil
HO MU1 HFH

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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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).

13. 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

14. 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.

17. 5-MRI:
Magnetic resonance imaging is superior in detecting ischemic necrosis, occult fractures, and meniscal and ligamentous injuries.

18. 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.

20. 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

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

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

23. - 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

24. QUESTIONS

25. 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

26. 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

27. 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

28. 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

29. TAKE HOME MESSAGE