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Evaluating and Treating Patients with Polyarthritis …

Olyarthritis of acute or recent onset representsa diagnostic and management challenge. Poly-arthritis is generally defined as inflammation(ie, swelling, tenderness, warmth) at 5 or morejoints detected on physical examination. A patient with2 to 4 involved joints is said to have pauci- or oligoartic-ular arthritis; this finding suggests, for example, reac-tive arthritis, Lyme disease, or crystal - induced laboratory testing is indicated in many in-stances, but a thorough history and physical examina-tion should establish the diagnosis in approximately75% of Management depends on accurate diag-nosis, and Patients in whom early rheumatoid arthritis(RA) is diagnosed should receive prompt treatmentwith disease- modifying article examines Polyarthritis more fully, focus-ing on the evaluation and treatment of Patients withpolyarthritis of recent onset.

APPROACH TO DIAGNOSING POLYARTICULAR DISEASE As mentioned previously, a careful history and physi-cal examination are key to accurate diagnosis of poly-

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Transcription of Evaluating and Treating Patients with Polyarthritis …

1 Olyarthritis of acute or recent onset representsa diagnostic and management challenge. Poly-arthritis is generally defined as inflammation(ie, swelling, tenderness, warmth) at 5 or morejoints detected on physical examination. A patient with2 to 4 involved joints is said to have pauci- or oligoartic-ular arthritis; this finding suggests, for example, reac-tive arthritis, Lyme disease, or crystal - induced laboratory testing is indicated in many in-stances, but a thorough history and physical examina-tion should establish the diagnosis in approximately75% of Management depends on accurate diag-nosis, and Patients in whom early rheumatoid arthritis(RA) is diagnosed should receive prompt treatmentwith disease- modifying article examines Polyarthritis more fully, focus-ing on the evaluation and treatment of Patients withpolyarthritis of recent onset.

2 After general comments onthe epidemiology and diagnosis of Polyarthritis , specificdisorders in which Polyarthritis occurs will be discussedin detail. Table 1 lists several types of polyarthritisCHARACTERISTICS OF POLYARTICULAR DISEASEA lthough monoarthritis is widely recognized to re-quire urgent evaluation because of the risk for septicarthritis, crystal disease, and rare tumors, Patients withpolyarthritis should also receive prompt evaluation andearly intervention. Most polyarticular diseases are char-acterized by a constellation of historical and clinicalfindings. Although its actual prevalence is unknown,acute Polyarthritis is most likely very common and, insome cases, self- limited. In a population- based cohort,only 27% of Patients who presented with polyarthritisdeveloped RA by the time of follow - up 3 to 5 Signs and symptoms of early arthritis may notmatch a textbook- defined type of arthritis, so making adefinitive diagnosis can be difficult in the early days orweeks after Accurate diagnosis should still bepursued, however, because some diseases that presentwith Polyarthritis may also have major associated andtreatable systemic features.

3 Infectious arthritis, in par-ticular, can occasionally be polyarticular in nature andcan be cured if Patients receive immediate evaluationand appropriate diagnosis IN SUSPECTED POLYARTHRITISB efore discussing the different types of Polyarthritis , itis essential to distinguish between arthritis, inflamma-tion surrounding a joint (ie, periarticular inflamma-tion), and other causes of extremity pain. A necessaryinitial step is to differentiate between the joint inflamma-tion of arthritis and similar symptoms caused by periar-ticular disease. Most often, nonarthritic states do notproduce the overt joint swelling typical of Forexample, tendonitis and related disorders may mimicpolyarthritis, but the tenderness and inflammation typi-cal of these disorders are limited to the tendon sheathsand bursae on one side of the affected joint or adjacentto the joint.

4 Pain will often be greater with a specificmotion of the joint (eg, abduction of the shoulder incases of subacromial bursitis) rather than on any motionof the joint as occurs in arthritis. Similarly, diabetes mel-litus may be associated with thickening of tendons andsubcutaneous tissues that can result in painful contrac-tures, without any primary involvement of the of the spine can cause neurogenic claudica-tion, resulting in widespread aching in the legs broughton by standing or walking; however, an objective exami-nation typically reveals no joint abnormalities. Likewise,vaso - occlusive diseases (eg, Buerger s disease, athero-sclerosis) often produce diffuse pain, but no joint ab-normalities are present and pulses are decreased. Final-ly, the pain of fibromyalgia is often interpreted as jointpain, but tenderness actually occurs at the Meador is a rheumatologist, Baylor Medical Center at Garland,Garland, TX.

5 Dr. Schumacher is the Director, Arthritis -ImmunologyCenter, VA Medical Center, Philadelphia, PA; and a Professor of Medicine,University of Pennsylvania School of Medicine, Philadelphia, - Physician March 200337 Clinical Review ArticleEvaluating and Treating Patients withPolyarthritis of Recent OnsetRobert Meador, MDH. Ralph Schumacher, MDAPPROACH TO DIAGNOSING POLYARTICULAR DISEASEAs mentioned previously, a careful history and physi-cal examination are key to accurate diagnosis of poly-arthritis. Whereas a single descriptive finding may beessentially diagnostic for a few types of Polyarthritis (eg,a positive culture in cases of gonococcal Polyarthritis ,the rash of psoriasis in cases of psoriatic arthritis), mostpolyarthritides are identified by a collection of clinicalfindings. In Patients with objective findings at multiplejoints, a crucial step is to determine whether the diseaseprocess is overtly inflammatory or more subtly inflam-matory (as in cases of osteoarthritis [OA]).

6 Diseasecourse and treatment obviously differ radically based onthe presence and severity of inflammation. Historicalsuggestions of inflammatory disease include severemorning stiffness, weight loss, fever, and spontaneousjoint In Patients with inflammatory arthritis(eg, RA), morning stiffness generally lasts longer thanan hour; in contrast, most Patients with OA take consid-erably less time to become limber. The presence offever can signify infectious arthritis, systemic lupus ery-thematosus (SLE), or crystal - induced examination features of RA and other in-flammatory arthritides include synovial thickening andjoint effusions with local warmth. However, swellingand effusion may also occur in types of arthritis that arenot primarily inflammatory, making analysis of jointfluid essential for differentiation.

7 In cases of OA, kneeeffusions can occur either abruptly or gradually, andthe knees may feel warm. However, bony enlargementis more common in mechanical disorders such as can be found in Patients with RA, gono-coccal arthritis, fungal arthritis, or possibilities for the polyarthritides can benarrowed by several considerations; it should be noted,however, that more than one disease can coexist (eg,OA and gout), and specific clues to the diagnosis maynot be evident early in the course of the disease. Thesequence of early joint manifestations is revealing. Asindividual joints become involved, the process may bemigratory or additive. The term migratory arthritisimplies that previously involved joints become asymp-tomatic as new joints become inflamed; thus, the dis-ease appears to migrate from joint to joint.

8 Diseasesthat typically present with migratory, additive, or inter-mittent patterns are listed in Table , determining patterns of joint involve-ment may prove helpful. For example, both RA andOA can affect proximal interphalangeal joints, but RAinvolves metacarpophalangeal joints as well. Moreover,in RA and other inflammatory types of Polyarthritis ,38 Hospital PhysicianMarch - & Schumacher : Polyarthritis of Recent Onset : pp. 37 45 Table Typical Patterns of Joint Involvement PatternExamplesMigratory (symptoms are present in certain joints for a few days and then remit, only to reappear in other joints)Additive (symptoms begin in some joints and persist, with subsequent involve-ment of other joints.)Intermittent (repetitive attacks of acute poly-arthritis [or often oligo-arthritis] with complete remission between attacks)Early phase of Lyme disease,rheumatic fever, gonococcalarthritis, Whipple s disease,palindromic onset ofrheumatoid arthritisSystemic lupus erythemato-sus, rheumatoid arthritis,osteoarthritisPolyarticular gout, pseudo-gout, reactive arthritisTable 1.

9 Some Types of PolyarthritisSystemic rheumatic diseasesRheumatoid arthritisSystemic lupus erythematosusStill s diseaseSclerodermaPsoriatic arthritisSarcoidosisInfectious arthritidesViral arthritisNongonococcal septic arthritisGonococcal arthritisCrystal-induced arthritidesGoutPseudogoutLess common systemic diseasesPoststreptococcal reactive arthritisMulticentric reticulohistiocytosisRelapsing polychondritisWhipple s diseaseMalignancyLess inflammatory diseasesPrimary osteoarthritisOsteoarthritis secondary to metabolic diseaseAmyloidosislaboratory markers of inflammation (eg, erythrocytesedimentation rate, C - reactive protein level) are oftenincreased, and thrombocytosis is frequently fluid analysis must be performed immedi-ately in Patients with Polyarthritis who are febrile oracutely ill; it is best performed at least once in anypatient with a swollen joint.

10 The analysis may be diag-nostic in Patients with bacterial infections or crystal -induced synovitis. In Patients with other polyarthri-tides, synovial fluid analysis may permit the examinerto determine whether the arthritis is inflammatory ornot. Synovial fluid leukocyte counts in Patients withmost inflammatory arthritides are seldom less than 2 103 In contrast, joint swelling that is part of amechanical problem (eg, OA) produces clear fluidwith fewer leukocytes (virtually always < 103/mm3). Yet, this latter amount is still greater thanoccurs normally, indicating that there is, in fact, somemild inflammation. Moreover, even in clearcut cases ofinflammation, there are times when standard guide-lines do not apply. For example, inactive or less activejoints in Patients with RA will produce fewer leuko-cytes; similarly, some effusions in cases of SLE arthritiscontain few of the synovium or other tissues may be necessary to confirm or establish a diagnosis in lesscommon diseases presenting with Polyarthritis (eg,mycobacterial or fungal infections, Whipple s disease,vasculitis).


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