ARTHRITIS     

We will attempt to classify  the rheumatological entities (with regard to the ER physician) based on how the  pt  presents. They  usually  c/o joint pain. These can be limited to joint/s only or be manifestation of a systemic disease. The classification is purely to facilitate in differentiating between various entities and are not strict or rigid formulas.

MONOARTICULAR	POLYARTICULAR	SYSTEMIC
•  Septic Joint	- Hepatitis	-PMR
•  Gout/Pseudogout	- Serum Sickness	- Poly/Dermatomysitis
•  TB Spondylitis	- RA	- Ankylosing
•  Bursitis/Tendinitis	- SLE	- Fibronmyalgia
•  Trauma	- RF	- Lyme
•  Osteoarthritis	- Psoriasis	- Sarcoidos
	- Endocarditis
	- IBD
	- Reiter's

 

The diagnosis is commonly  established by aspiration and specific blood tests. If aspiration is a consideration and the site over the joint is infected (e.g. cellulitis), aspiration is contraindicated. Also remember that pt may c/o pain to one joint while the pathology may involve an adjacent joint (referred pain).

1. Ankylosing Spondylitis
    
1. Inflammatory process with ossification of spine, hip, shoulder, joints.
    
2. Inflammation of periarticular tissue; i.e. tendons and ligaments
    
3. Back pain in young man in morning hrs and improves during the day
    
2. Bursitis/Tendinitis
    
1. Soft tissue inflammation around joints that are generally involved in repeat motion (elbow, knee, shoulder, thumb).
    
3. Fibromyalgia
    
1. Not a real joint problem but certainly included in differential. It is a non-inflammatory, painful musculoskeletal disorder. The ACRA defines this disorder  as a constellation of pain and tenderness in more than 11-18 specific sites (see specialized books).
    
2. Pt generally has sleeping disorder , HA, malaise, poorly localized pain in SCM, trapezoid, costovertebral, cervical spine with possible signs of radiculopathy, hip.
    
3. Pts generally respond to TCA's, SSRI, psych and physical  therapy.
    
4. IBD
    
1. Pt with hx of Crohn's, UC, Intestinal bypass.
    
2. Usually joint involvement is symmetrical and commonly present with spondylitis, sacroilitis, ankle/knee arthritis.
    
5. Gout/Pseudogout
    
1. Pt generally c/o pain to big toe, ankle (Gout), knee, wrist (pseudogout). Aspiration will revealmneedle shaped , negatively  birefringent crystals (Gout) or rhomboid shaped, weakly positively birefringent crystals (Pseudogout).
    
2. Treatment c/o NSAIDs (Indomethacin 50 mg PO q6) and Colchicine IV or PO (PO is 0.6 mg repeat q 2 hr. until GI symptoms, resolution of pain or total of 6 mg given in 24 hr. Renal and liver impairment warrant dose adjustment).  Steroids (prednisone 20-30 mg with rapid taper) are given if above treatment is with no yield or NSAID and Colchicine are contraindicated.   Allopurinol is contraindicated in acute attack.
   
    
6. Lyme
1. See in "Infectious Disease" section.
    
7. Osteoarthritis
    
1. Aging process, obesity, h/o trauma
    
2. Pain occurs after normal joint use and initially  is relived by rest. As the disease progresses, rest pain develops. Minimal morning stiffness, typically lasting < than ½ hr
    
3. On hands pt has nodes on DIP (Heberden) and PIP (Bouchard).
    
4. X-ray will show typical changes (joint space narrowing, osteophytes,  formation of subchondral bone cysts)
    
5. Therapy c/w:
1. Joint rest with cane, crutches, walker
    
2. Wgt loss
    
3. Occupational change
    
4. PT
    
5. Acetaminophen,  NSAIDs. If GI risks of PUD or pt on warfarin, consider Cox-2 inhibitors (have less GI effects and no anti-platelet effect).
    
6. Intraarticular steroids
    
7. Surgery
    
8. Psoriasis
    
1. Asymmetric or symmetric, oligo or polyarticular joint (usually DIP) involvement.
    
2. Usually psoriatic rash  precedes.
   
    
9. PMR
    
1. Symmetric aching and stiffness to trunk, proximal muscles, shoulders.
    
2. Most prominent pain is in shoulder and pelvic girdle
    
3. Most pts are  > 50 y.o.
    
4. Symptoms are worse in AM.
    
5. Constitutional S & S (fatigue, malaise, low grade temperatures are common).
6. ESR and chronic anemia on labs
    
7. 30-40%  of pts develop  T.A., thus ask about HA, jaw claudication, visual changes
    
8. Rapid and dramatic response (in 2-3 days) to 10-15 mg/day of prednisone
    
10. Poly/Dermatomyositis
     
1. Inflammatory process of muscles that presents with proximal weakness and pain.
    
2. In dermatomyositis rash is also present (eyelids, extensor surface, face, neck, legs). Violet in color.
    
3. On labs  in CPK, Aldolase, SGOT. Muscular fibrosis on muscle biopsy.
    
11. RA
1. 20-45 y.o. F.
    
2. Symmetrical morning stiffness of MCP, MTP, PIP, wrist, knees, ankles, elbows, shoulders
    
3. On hands one can  observe, in advanced stage, deformity caused by hyperextension of PIP and flexion of DIP (swan neck deformity) or  flexion of  PIP and extension of  DIP (Boutoniere's deformity).
    
4. Systemic features such as fatigue, wgt loss and anemia are common
    
5. Pulmonary (pleuritic chest pain, nodules) and cardiac (pericarditis, arrhythmia) involvement, nodules on bony prominence, vasculitis, are less common.
    
6. RF on  blood test is generally (+)ve but is not specific for dx.
    
7. X-ray shows typical changes (articular erosions, periarticular osteopenia).
   
    
12. Reiter's Syndrome (RS) or Reactive Arthritis
     
1. Oligoarthritis, non-bacterial urethritis/cervicitis, conjunctivitis is the triad
    Dermatitis topalm/soles, genital and oral  mucosa can be present.
    
2. RS is 2ry  to STD (Chlamydia), Dysentery (Shigella, Salmonella, Yersenia), AIDS. Generally occurs 1-2 wks. after STD  or  entheropathy.
    
3. High incidence of HLA-B27.
    
4. Treatment c/o tetracycline or  erythro  if  hx  of STD and NSAIDs for arthritis.
    
5. Ophtalmological  referral is prudent if  uveitis is present
   
    
13. RF
1. Jone's criteria needed for dx (see elsewhere).
   
    
14. Septic joint
1. 2ry to trauma, s/p surgery, prosthesis, STD or hematogenous seeding
    
2. Area is hot. Aspiration is generally diagnostic.
    
3. Treatment c/o antbx and possible orthopedic intervention  to "wash out".
    
15. Serum Sickness
    Fever, adenopathy, rash and arthritis 1-3 wks. after  exposure to drugs, viruses.
     
16. SLE
     
1. Rash,  renal function, hematologic abnormalities, pulmonary and cardiac involvement (pleuritic chest pain, pericarditis, pleural effusion, P.E.), signs of,peritoneal inflammation, SZ, constitutional symptoms, arthralgias, ANA (+), DVT and/or PE.
    
17. Sarcoidosis
     
1. Affects mainly africanamericans female 20-45 y.o.
    
2. It is multisystem disease and lung involvement is most evident
    
3. Pulmonary manifestations usually precede arthritis.
    
4. Constitutional  S & S are present. Almost all  organs are involved (arrhythmia, rash, ocular, CNS, LFT).
    
5. Lofgren  syndrome: Hilar adenopathy, oligoarthritis, erythema nodosa
   
    

Synovial Fluid interpretation after Arthrocentesis:

Color	WBC	PMN	Clinical Entity
Straw	<200	<25%	Normal
Yellow	200-2K	<25%	OA/DJA, Trauma (bloody), AVN, SLE
Yellow	2K-50K	25-75%	Gout, RA, RF, Psoriasis, etc
Torbid	10K-100K	>75%	Septic

 

Note!  The WBC  count overlaps  in  various entities and there is no perfect WBC which can be labeled as inflammatory  vs. infectious. Thus, in addition to WBC, white count differential and proper clinical setting must be taken into account.

[BACK]