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Acute Arthritis: Diagnosis And Management
Jon T Giles, M.D., M.P.H. Disclosures Acute Arthritis: Diagnosis and Management • Investigator (PI or Sub‐Investigator)‐past 5 years – Clinical Trials • Roche/IDEC • Bristol Myers Squib – Non‐interventional studies • Pfizer Jon T Giles, M.D., M.P.H. Assistant Professor of Medicine • Grant funding in past 5 years from: – NIH/NIAMS, American College of Rheumatology Research and Education Foundation, Arthritis Foundation, Arthritis National Research Foundation Division of Rheumatology Columbia University, College of Physicians & Surgeons • Acute Arthritis: Definition from the American College of Rheumatology Ad Hoc Committee on Clinical Guidelines • “Acute” – Less than 6 weeks duration • “Arthritis” – Inflammation localized to the articular structures • Swelling (synovitis and/or effusion), warmth, discomfort, redness – Distinct from arthralgia, peri‐arthritis, tendinitis, bursitis, etc… Consultant: Roche/Genentech, Regeneron Case 1 • Mr. K is a 34 y.o. man with a largely negative past medical history presenting with concern of a warm, painful, swollen knee for the past week • He denies constitutional symptoms, knee trauma or injury • He has had morning low back pain for the past 2 years that he attributes to an old mattress • He had an episode of painless eye redness that lasted for 10 days about 3 years ago that was diagnosed as viral conjunctivitis and treated with eye drops • The right knee is warm, but not hot, with a large effusion. The knee is kept in slight flexion, but can be actively extended fully with slight pain. Full knee flexion also elicits pain. • There are no lymph nodes, lymphangitic streaks, or palpable cords. Peripheral exam of the extremity is normal Case 2 Case 3 • Mr. H is an 80 y.o. man with a history of diabetes and hypothyroidism who presents with a 3 day history of right knee pain and swelling • The day prior to the onset of symptoms, a tool box fell against his knee • Mrs. T is a 50 y.o. woman with a two week history of right knee pain and swelling • No other joints are affected. She reports swelling, slight warmth, more fullness and stiffness than pain • She is otherwise healthy and takes no medications • She is an avid hiker and the back of her property abuts onto a forested area – He denies break in skin integrity, abrasion, bruising, sense of instability after the episode – Knee X‐ray was performed at an urgent care—and was negative by report • Since symptoms began, the knee is hot to the touch and pain with minimal movement is intense. He cannot weight bear. • He has never had similar symptoms before. No history of 1st MTP pain/swelling. Uric acid level is normal (5.0 mg/dL) – She denies tick exposure, travel, sick contacts Jon T Giles, M.D., M.P.H. Preliminary Points • Musculoskeletal complaints are common in the primary care setting – 1 in 7 patient visits • Acute or sub‐acute onset joint symptoms are frequently not serious and are often self‐limited • However, some can be serious, life‐threatening, or result in prolonged or permanent disability if not recognized early and treated appropriately • Primary care is the frequent first setting for musculoskeletal emergencies Achilles tendinitis Achondroplasia Acromegalic arthropathy Adhesive capsulitis Adult onset Still's disease Ankylosing spondylitis Anserine bursitis Avascular necrosis Behcet's syndrome Bicipital tendinitis Blount's disease Brucellar spondylitis Bursitis Calcaneal bursitis Calcium pyrophosphate dihydrate (CPPD) Crystal deposition disease Caplan's syndrome Carpal tunnel syndrome Chondrocalcinosis Chondromalacia patellae Chronic synovitis Chronic recurrent multifocal osteomyelitis Churg‐Strauss syndrome Cogan's syndrome Corticosteroid‐induced osteoporosis Costosternal syndrome CREST syndrome Cryoglobulinemia Degenerative joint disease Dermatomyositis Diabetic finger sclerosis Diffuse idiopathic skeletal hyperostosis Discitis Discoid lupus erythematosus Drug‐induced lupus Duchenne's muscular dystrophy Dupuytren's contracture Ehlers‐Danlos syndrome Enteropathic arthritis Epicondylitis Erosive inflammatory osteoarthritis Exercise‐induced compartment syndrome Fabry's disease Familial Mediterranean fever Farber's lipogranulomatosis Felty's syndrome Fibromyalgia Fifth's disease Flat feet Foreign body synovitis Freiberg's disease Fungal arthritis Gaucher's disease Giant cell arteritis Gonococcal arthritis Goodpasture's syndrome Gout Granulomatous arteritis Hemarthrosis Hemochromatosis Henoch‐Schonlein purpura Hepatitis B surface antigen disease Hip dysplasia Hurler syndrome Hypermobility syndrome Hypersensitivity vasculitis Hypertrophic osteoarthropathy Immune complex disease Impingement syndrome Jaccoud's arthropathy Juvenile ankylosing spondylitis Juvenile dermatomyositis Juvenile rheumatoid arthritis Kawasaki disease Kienbock's disease Legg‐Calve‐Perthes disease Lesch‐Nyhan syndrome Linear scleroderma Lipoid dermatoarthritis Lofgren's syndrome Lyme disease Malignant synovioma Marfan's syndrome Medial plica syndrome Metastatic carcinomatous arthritis Mixed connective tissue disease (MCTD) Mixed cryoglobulinemia Mucopolysaccharidosis Multicentric reticulohistiocytosis Multiple epiphyseal dysplasia Mycoplasmal arthritis Myofascial pain syndrome Neonatal lupus Neuropathic arthropathy Nodular panniculitis Ochronosis Olecranon bursitis Osgood‐Schlatter's disease Osteoarthritis Osteochondromatosis Osteogenesis imperfecta Osteomalacia Osteomyelitis Osteonecrosis Osteoporosis Overlap syndrome Pachydermoperiostosis Paget's disease of bone Palindromic rheumatism Patellofemoral pain syndrome Pellegrini‐Stieda syndrome Pigmented villonodular synovitis Piriformis syndrome Plantar fasciitis Polyarteritis nodosa Polymyalgia rheumatica Polymyositis Popliteal cysts Posterior tibial tendinitis Pott's disease Prepatellar bursitis Prosthetic joint infection Pseudoxanthoma elasticum Psoriatic arthritis Raynaud's phenomenon Reactive arthritis/Reiter's syndrome Reflex sympathetic dystrophy syndrome Relapsing polychondritis Retrocalcaneal bursitis Rheumatic fever Rheumatoid arthritis Rheumatoid vasculitis Rotator cuff tendinitis Sacroiliitis Salmonella osteomyelitis Sarcoidosis Saturnine gout Scheuermann's osteochondritis Scleroderma Septic arthritis Seronegative arthritis Shigella arthritis Shoulder‐hand syndrome Partial List of Diseases which can Present with Musculoskeletal Complaints Sickle cell arthropathy Sjogren's syndrome Slipped capital femoral epiphysis Spinal stenosis Spondylolysis Staphylococcus arthritis Stickler syndrome Subacute cutaneous lupus Sweet's syndrome Sydenham's chorea Syphilitic arthritis Systemic lupus erythematosus (SLE) Takayasu's arteritis Tarsal tunnel syndrome Tennis elbow Tietse's syndrome Transient osteoporosis Traumatic arthritis Trochanteric bursitis Tuberculosis arthritis Arthritis of Ulcerative colitis Undifferentiated connective tissue syndrome(UCTS) Urticarial vasculitis Viral arthritis Wegener's granulomatosis Whipple's disease Wilson's disease Yersinial arthritis Musculoskeletal Emergencies • Infection – septic arthritis, septic emboli, osteomyelitis • • • • • • • With few exceptions, the differential diagnosis for most presentations of acute arthritis can be isolated to only a few possibilities by obtaining a history and performing a physical examination Fracture Operable full/partial tendon/ligament tears Compartment syndrome Entrapment neuropathy/mononeuritis multiplex Myelopathy/myelitis Primary and secondary bone tumors Vascular – Deep venous thrombosis or arterial insufficiency A Misguided Approach Doctor, my right knee has been swollen and painful for the last 3 days OK, I’m going to call you in a prescription for some Percocet and I want you to get an MRI of your knee. I’m also going to send you to the lab to get a rheumatoid factor and an antinuclear antibody test Goals of the Initial Evaluation of Acute Joint Complaints Distinguish articular vs. non‐articular pathology Determine inflammatory vs. non‐inflammatory features Identify and triage musculoskeletal emergencies appropriately Assess whether history, current symptoms, and exam are consistent with a specific systemic rheumatic disease • Obtain appropriate additional testing • • • • – i.e. imaging, labs, others • Establish a short and long term treatment plan Jon T Giles, M.D., M.P.H. • Timing of symptoms – – – – Rapid onset vs. slow/insidious AM vs. PM worse with activity or rest Time from no symptoms to maximal intensity • • • Confined to joints or inter‐articular mono vs. oligo vs. polyarticular Pattern of joints affected • • • Recent trauma Warmth and swelling Intensity and quality of symptoms – – – • • • • • Important Historical Elements History • Timing of symptoms – Rapid onset vs. slow/insidious • Rapid: Trauma, Septic, Crystalline • Slow: systemic rheumatic disease or non‐inflammatory process (osteoarthritis) small joint peripheral vs. large joint vs. axial involvement 0‐10 pain scale, “touch‐me‐not” sore vs. ache vs. stiff vs. stabbing/lancinating vs. burning vs. numbness/tingling Symmetry Constitutional /prodromal symptoms Prior similar episodes Sick contacts, travel, pets/exposures, recent infections, comorbidities, sexual history, injection drug use, immunocompromised state Specific indicators of systemic rheumatic diseases History – AM vs. PM1 • AM: prolonged in systemic rheumatic diseases • PM: sprain/strain/non‐inflammatory processes – worse with activity or rest • Worse with activity: tendinitis/bursitis/non‐inflammatory processes • Worse with rest: systemic rheumatic diseases – Time from no symptoms to maximal intensity • Rapid: Trauma, Septic, Crystalline 1. Hazes JMH. J Rheumatol 1993; 20: 1138‐1142. History • Recent trauma • Confined to joints or inter‐articular – Localized to joints: arthritis or arthralgia – Inter‐articular: diffuse pain syndromes • mono vs. oligo vs. polyarticular – Polyarticular less likely to be septic arthritis • However, polyarticular septic arthritis is still possible – Monoarticular can still be an early presentation of a systemic rheumatic disease • Pattern of joints affected – small joint peripheral vs. large joint vs. axial involvement • Clues to type of systemic rheumatic disease if presentation is polyarticular History • Symmetry – certain systemic rheumatic diseases • Constitutional /prodromal symptoms – Infection or systemic rheumatic diseases, occasionally crystalline • Prior similar episodes – Less likely to be infectious – Intercritical return to complete normality: crystalline arthritis – Possible fracture, sprain, strain, tendon/ligamentous rupture, etc.. – Acute attacks of CPPD often preceded by traums • Warmth and swelling – Hot to touch: Septic or crystalline – Cool: non‐inflammatory • Intensity and quality of symptoms – 0‐10 pain scale, “touch‐me‐not” • Highest often in septic or crystalline – sore vs. ache vs. stiff vs. stabbing/lancinating vs. burning vs. numbness/tingling • Stiffness>pain: systemic rheumatic diseases • Vague, deep ache: Hyperparathyroidism, osteomalacia, bone lesions (night pain) • Burning/numbness/tingling: neurogenic • Claudication: vascular vs. spinal stenosis History • Sick contacts, travel, pets/exposures, recent infections, comorbidities, sexual history, injection drug use, immunocompromised state • Specific indicators of systemic rheumatic diseases – Cutaneous manifestations • – – – – – – – – – – psoriasis, photosensitivity, purpura, skin thickening, erythema nodosum, nodules, etc…. Swollen glands Raynaud’s Oral/nasal ulcers Pleurisy/pericarditis Eye inflammation Nail changes Dry eyes/mouth Proximal muscle weakness Sinusitis Hearing loss Jon T Giles, M.D., M.P.H. Physical Examination Distinguishing Exam Features • Articular Sign – Inspection – Range of motion – Palpation • warmth, erythema, swelling, effusion, tenderness, deformity, crepitus, stability • Extra‐articular – Requires multi‐system examination Tendinitis/Bursitis Non‐inflammatory Symmetry Uncommon Occasional Common Inflammation Over tendon/bursa Unusual Common Tenderness Focal Unusual (variable) Over entire joint space Instability Uncommon Occasional Uncommon* Locking Unusual expect with tears Possible—implies loose body or internal derangement Uncommon Multi‐system disease No No Often ACR Guidelines. Arthritis Rheum 1996; 39(1): 1‐8. Effusion Testing for Knee Effusion http://therapyprotocols.webs.com Synovitis Systemic Rheumatic Disease MCP/MTP Squeeze Test Jon T Giles, M.D., M.P.H. Rotator Cuff Tendinitis/Subacromial Bursitis DeQuervain’s Tenosynovitis‐Finkelstein Test http://physioworks.com Trochanteric Bursitis/ Anserine Bursitis McMurray Test for Medial Meniscal Instability Acute Monoarthritis: Common Etiologies • Infection – Bacteria • Gonococcal vs. non‐Gonococcal Mono/Oligoarthritis – Viruses (often polyarticular) – Fungi/Spirochetes/Mycobacteria • Coccidiodomycosis, Spirotrichosis, Blastomycosis, Lyme, M. Marinum • Crystal induced – Gout, Pseudogout (Calcium Pyrophosphate Deposition Disease‐CPPD) • • • • Trauma Hemarthrosis Osteonecrosis Early monoarticular presentations of polyarticular diseases Jon T Giles, M.D., M.P.H. Joint Aspiration Synovial Fluid Tests for Monoarthritis Imperative to perform if septic joint suspected Gout is a risk factor for septic arthritis “If you think of it…do it” Gram stain and culture should be performed prior to antibiotics • Warfarin is not a contraindication • Cell count + differential • • • • Inflammatory vs. Non‐inflammatory Joint Fluid – Inflammatory WBC>2,000 or >75% PMN – Septic and crystal arthritis often much higher • Gram stain + culture – Negative studies do not absolutely rule out septic joint – aerobe, anaerobe…fungal, AFB and mycobacterial if clinically indicated • Crystal assessment using polarized light microscopy • Glucose, LDH, protein not very helpful Additional Testing • CBC, blood cultures, coagulation studies • Plain radiographs • Elevated uric acid level does not exclude septic arthritis • CT or MRI in specific situations – suspect osteomyelitis as focus, or soft‐tissue abscess • Specialized testing for specific pathogens – Typically not sent initially From Phillips et al. Am J Med 1997; 103(6A): 7s‐11s. Bacterial Septic Arthritis • Musculoskeletal emergency – Associated with sepsis, extensive joint damage, mortality • Mortality ~ 10% overall 1 – 19‐33% in elderly or with comorbidities • 40% with permanent loss of joint function • Gonococcal vs. non‐Gonococcal – Gonococcal2 • • • • Incidence decreasing over past 2 decades Typically, sexually active young adults Female > Male Other clinical features may be present, but these may be absent – – – – Polyarthralgia can precede—but monoarthritis in 50% Constitutional symptoms tenosynovitis, especially wrist (68%) Skin lesions (75%)—erythematous papules progress to vesicles or pustules on extremities and trunk • Anogenital infection often assymtomatic 1. 2. Ross JJ. Infect Dis Clin North Am 2005; 19: 799‐817. Cucurull E. Rheum Dis Clin North Am 1998; 2(4): 305‐22. Disseminated Gonococcal Infection: Skin Lesions Jon T Giles, M.D., M.P.H. Bacterial Septic Arthritis Crystal Arthritis • Non‐Gonococcal • Gout – Gram positive anaerobes in most cases (80%) • S Aureus predominates (60%) – Gram negatives in 10‐20% • E. coli, Proteus, Klebsiella, Enterobacter • Very young, elderly, injection drug use, immunocompromised – Anaerobes uncommon, diabetes a risk factor – Prodrome of malaise and fever • Fever often mild • Only 30‐40% with temperature > 39C2 – Large joint predilection (knees/hips > shoulders > wrist/ankles) – Requires aggressive management • Serial aspiration to dryness vs. open surgical drainage with lavage • Parenteral antibiotics • Splinting and physical therapy to prevent contractures and muscle atrophy 1. 2. – – – – Intense Articular Inflammation “Touch‐me‐not” tenderness Minimal to no prodrome Joint predilection • 1st metatarsophalangeal, midfoot, ankle, knee, wrist, elbow, distal interphalangeal – Inter‐critical resolution of symptoms • Calcium Pyrophosphate Deposition (CPPD) – – – – Can be mono‐, oligo‐, polyarticular Knee most commonly affected, followed by wrist, MTP uncommon Preceding minor joint trauma often reported Associated with hemochromatosis, hyperparathyroidism; hypophosphatasia, hypomagnesemia Ross JJ. Rheumatology 2005; 44: 1197‐8. Smith JW. Clin Microbiol 2006; 12: 309‐14. Synovial Fluid in Acute Gout CPPD: Chondrocalcinosis Acute inflammation dependent on a number of factors Tissue concentration of urate pH and temperature Other solute concentrations Often occur in joints with damage (osteoarthritis) Hallmark crystal finding: Needle shaped Intracellular Negative birefringence with polarized light microscopy Pascual E et al. Curr Opin Rheumatol 2011; 23: 161‐169. Algorithm for Mono‐ or Oligoarthralgia Lyme Arthritis • Features dependent on phase of disease – Early disseminated Lyme • poly‐arthralgia – Late Lyme • • • • ACR Guidelines. Arthritis Rheum 1996; 39(1): 1‐8. weeks to months after primary infection Mono, oligo, occasionally poly‐arthritis Tends to be assymetric, large/medium joint Large effusion in a single knee in most Jon T Giles, M.D., M.P.H. Polyarthritis: Differential • Infection – – – – – – Polyarthritis • Systemic Rheumatic Gonococcal Meningococcal Lyme disease Rheumatic fever Bacterial endocarditis Viral • rubella, parvovirus, HBV, HCV – – – – – – RA SLE Reactive arthritis Psoriatic arthritis Polyarticular gout Sarcoid arthritis – Fungal • Histoplasmosis, Disseminated Coccidiodomycosis – Mycobacterial Polyarthritis: Differential Temporal Patterns in Polyarthritis • Infection • Migratory pattern – – – – – – Gonococcal Meningococcal Lyme disease Rheumatic fever Bacterial endocarditis Viral • rubella, parvovirus, HBV, HCV • Systemic Rheumatic – – – – – – RA (Bathon) SLE (Geraldino) Reactive arthritis Psoriatic arthritis Polyarticular gout (Pappas) Sarcoid arthritis – Rheumatic fever – Gonococcal (disseminated gonococcemia) – Early phase of Lyme disease • Additive pattern – RA, SLE, psoriasis • Intermittent – Fungal – Gout, reactive arthritis • Histoplasmosis, Disseminated Coccidiodomycosis – Mycobacterial Algorithm for polyarthralgia Reactive Arthritis • Infection‐induced systemic disease – inflammatory synovitis present – viable organisms cannot be cultured – Enteropathic and genitourinary pathogens implicated • Association with HLA B‐27 • Asymmetric, oligoarticular – knees, ankles, feet • 40% have axial (spinal) disease • Enthesitis – inflammation of tendon‐bone junction (Achilles tendon, dactylitis) • Extra‐articular – psoriasis, nail dystrophy and onycholysis, eye involvement ACR Guidelines. Arthritis Rheum 1996; 39(1): 1‐8. Jon T Giles, M.D., M.P.H. Psoriatic Arthritis Reactive Arthritis and Psoriatic Arthritis: Extra‐Articular Features Enthesitis Keratoderma Blenorrhagicum • Prevalence of arthritis in Psoriasis 5‐7% Circinate Balanitis – Psoriasis often minimal or “hidden” • Dactilytis (“sausage digits”), nail changes • Subtypes: – Asymmetric, oligoarticular • Associated with dactylitis • Predominant DIP involvement • Often with nail changes Conjuctivitis Dactylitis and Onycholysis – Polyarthritis “RA‐like” – Arthritis mutilans • destructive erosive hands/feet – Axial involvement • 50% HLAB27 (+) – HIV‐associated – more severe Case 1 Sarcoid Arthritis • 15‐20% of patients with sarcoidosis – Lofgren’s syndrome • triad of acute arthritis, erythema nodosum, hilar adenopathy • Joint predilection – Wrists, PIPs, ankles, knees – Isolated symmetric ankle arthritis • Cutaneous manifestations – Erythema nodosum, lupus pernio • Mr. K is a 34 y.o. man with a largely negative past medical history presenting with concern of a warm, painful, swollen knee for the past week • He denies constitutional symptoms, knee trauma or injury • He has had morning low back pain for the past 2 years that he attributes to an old mattress • He had an episode of painless eye redness that lasted for 10 days about 3 years ago that was diagnosed as viral conjunctivitis and treated with eye drops • The right knee is warm, but not hot, with a large effusion. The knee is kept in slight flexion, but can be actively extended fully with slight pain. Full knee flexion also elicits pain. • There are no lymph nodes, lymphangitic streaks, or palpable cords. Peripheral exam of the extremity is normal Case 2 Case 3 • Mr. H is an 80 y.o. man with a history of diabetes and hypothyroidism who presents with a 3 day history of right knee pain and swelling • The day prior to the onset of symptoms, a tool box fell against his knee • Mrs. T is a 50 y.o. woman with a two week history of right knee pain and swelling • No other joints are affected. She reports swelling, slight warmth, more fullness and stiffness than pain • She is otherwise healthy and takes no medications • She is an avid hiker and the back of her property abuts onto a forested area – He denies break in skin integrity, abrasion, bruising, sense of instability after the episode – Knee X‐ray was performed at an urgent care—and was negative by report • Since symptoms began, the knee is hot to the touch and pain with minimal movement is intense. He cannot weight bear. • He has never had similar symptoms before. No history of 1st MTP pain/swelling. Uric acid level is normal (5.0 mg/dL) – She denies tick exposure, travel, sick contacts Jon T Giles, M.D., M.P.H. When to Refer Conclusions • Acute arthritis is a common presentation in the primary care setting • Separating out articular from non‐articular processes essential • Identifying inflammatory vs. non‐inflammatory components helpful in formulating differential diagnosis • Rapid assessment and referral of musculoskeletal emergencies is required to prevent morbidity/morbidity • The differential for acute mono‐ and oligo‐ articular arthritis is infection, trauma, and crystal arthritis – History and exam usually all that is required – High suspicion for septic arthritis • ACR Guidelines. Arthritis Rheum 1996; 39(1): 1‐8. The differential for acute polyarthritis is infection and systemic rheumatic diseases – Patterns of joint involvement and extra‐articular features helpful in establishing the diagnosis
