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Polyarthritis


Essentials

  • 1

    Polyarthritis is a common adult rheumatological presentation with a wide differential diagnosis.

  • 2

    Recording articular and extra-articular involvement facilitates decision making, particularly with regards to patient admission.

  • 3

    Joint aspiration is paramount for both diagnosis and excluding a septic arthritis.

  • 4

    Early rheumatological consultation is essential to ensure appropriate and timely diagnosis and treatment for inflammatory arthritis to prevent joint damage and maintain joint function.

  • 5

    Early rheumatological consultation or admission is essential in the presence of extra-articular or systemic inflammatory response features.

  • 6

    Emergency management is with anti-inflammatory medication that may include systemic or intra-articular corticosteroids.

Introduction

Polyarthritis is a frequent rheumatological presentation to the emergency department in adults. This chapter focuses on the initial assessment, management and most appropriate follow-up of the more common conditions encountered. These include rheumatoid arthritis (RA), seronegative spondyloarthritis including psoriatic arthritis, reactive arthritis with reference to arthritides occurring in association with enteric and urogenital infections, and infectious arthritis including viral arthritis and rheumatic fever. Management principles include establishing the diagnosis, treating the acute problem and arranging appropriate follow-up.

Acute Polyarthritis

Polyarthritis syndromes may be difficult to diagnose accurately due to the wide range of differential diagnoses, as seen in Box 14.3.1 . Important principles include:

  • 1.

    Exclude infection.

  • 2.

    Consider relevant differential diagnosis, such as early presentation of inflammatory arthritis.

  • 3.

    Document extra-articular involvement.

Box 14.3.1
Differential diagnosis of polyarthritis syndromes

Inflammatory

  • Rheumatoid arthritis

  • Inflammatory osteoarthritis

  • Systemic connective tissue disease, including SLE, vasculitis, Behçet disease, relapsing polychondritis

  • Seronegative spondyloarthropathies, commonly psoriatic arthropathy

  • Gout

  • Pseudogout (calcium pyrophosphate arthropathy)

  • Drug induced, including lupus syndromes

  • Infectious arthritis—bacterial including mycobacteria, endocarditis, protozoal, viral

  • Reactive or post-infectious arthritis including rheumatic fever

Non-inflammatory

  • Neoplastic/paraneoplastic disease, including hypertrophic pulmonary osteoarthropathy

  • Sarcoidosis

  • Endocrine disease, such as haemochromatosis, acromegaly

  • Haematological disease, such as haemophilia, leukaemia

SLE , Systemic lupus erythematosus.

Clinical features and diagnosis

History

Take a focused history to include the following:

Mode of onset

  • Acute (less than 6 weeks): gonococcal, viral including human immunodeficiency virus (HIV), reactive arthritis, rheumatic fever, crystal arthritis (gout or pseudogout)

  • Chronic (longer than 6 weeks): RA, psoriatic arthropathy, systemic lupus erythematosus (SLE), systemic sclerosis, dermatomyositis, other autoimmune diseases, crystal arthritis (gout or pseudogout)

Distribution

  • Symmetric or asymmetric

  • Large or small joint involvement

Course

  • Progressive, intermittent or migratory

Constitutional symptoms

  • Fever, night sweats, fatigue, significant weight loss >10%

Rheumatological systems review

  • Symptoms suggestive of an inflammatory arthritis: early morning stiffness, joint swelling, uveitis, scleritis, urethritis, cervicitis, chronic bowel symptoms

  • Symptoms suggestive of a connective tissue disorder: Raynaud phenomenon, sclerodactyly, sicca syndrome, oral, nasal, digital or genital ulcers, rash, alopecia, and serositis with pleuritis or pericarditis

  • Symptoms suggestive of vasculitis: haemoptysis, haematuria, hypertension, symptomatic peripheral neuropathy

  • Many of these symptoms may overlap in rheumatological conditions.

Extra-articular organ involvement

  • Cough, dyspnoea, hypertension, haematuria, symptomatic peripheral neuropathy

Other history

History of recent sore throat, febrile illness, new sexual contact, features of a sexually transmitted disease, diarrhoea, rash or uveitis, suggesting reactive arthritis

Past medical history of psoriasis, gout, rheumatic fever, inflammatory bowel disease (IBD), malignancy and juvenile polyarthritis

Family history of gout, psoriasis, IBD, uveitis or chronic back pain suggesting ankylosing spondylitis (AS) and other seronegative arthritis

Examination

Perform a detailed physical examination and document:

  • vital signs

  • painful joints and soft-tissue swelling and their distribution

  • cutaneous stigmata of underlying diseases, such as nail changes (psoriatic), rash and subcutaneous nodules, oral, genital or digital ulceration

  • features of organ involvement, such as a pleural or pericardial rub, cardiac murmur or pulmonary crackles

  • lumbosacral spine and pelvis including sacroiliac joints

Investigations

Laboratory studies

Send blood for full blood count (FBC), urea, electrolytes and liver function tests (ELFTs) and inflammatory markers, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

Exclude infection by sending blood cultures, urine microscopy and chest x-ray.

Send serum antibody or antigen tests as indicated by the history for infectious exposure, such as hepatitis B and C serology, HIV serology, syphilis serology, chlamydia and gonorrhoea urine polymerase chain reaction (PCR), streptococcal antigen test (ASO titre) and an autoantibody panel including antinuclear antibody (ANA), extractable nuclear antigen antibodies (ENA), double stranded DNA, rheumatoid factor (RF) and antibodies against citrullinated peptides (ACPA), usually ordered as anticyclic citrullinated peptide (anti-CCP). Antibody tests in particular should be interpreted with caution and in the context of each individual patient, due to their varying sensitivity and specificity.

Joint aspiration

Joint aspiration and analysis of synovial fluid are essential to diagnose septic arthritis and crystal arthropathy (see Chapter 14.2 ).

Imaging studies

Imaging studies, such as plain x-rays, may demonstrate diagnostic features in erosive arthropathy, but these do not occur for some time after the acute onset. They may also demonstrate chondrocalcinosis, which may suggest a diagnosis of pseudogout.

Rheumatoid Arthritis

RA is a chronic systemic inflammatory disorder characterized by symmetric synovitis, erosive polyarthritis and numerous extra-articular manifestations. The onset is often indolent and may lack the characteristic symmetrical joint involvement. Joint destruction may begin within a few weeks of symptom onset and is irreversible. A window of opportunity exists to initiate early treatment that will alter the course of the disease; early referral to rheumatology is important.

Diagnosis

The diagnosis in adults is guided by the American College of Rheumatology/European League Against Rheumatism Criteria. These criteria were revised in 2010 to identify features predictive of erosive disease earlier in the illness. Constitutional features, such as malaise and fatigue, are common.

‘Definite RA’ is based on the confirmed presence of:

  • synovitis in at least one joint

  • absence of an alternative diagnosis that better explains the synovitis

  • a total score of 6 or greater (of a possible 10) from individual scores in four domains: number and site of involved joints (score range 0 to 5); serological abnormality (score range 0 to 3); elevated acute-phase response (score range 0 to 1) and symptom duration (2 levels; range 0 to 1) ( Box 14.3.2

    Box 14.3.2
    Classification criteria for rheumatoid arthritis
    (Adapted from Kay J, Upchurch KS. ACR/EULAR 2010 rheumatoid arthritis classification criteria. Rheumatology (Oxford) . 2012;51(6):vi5–vi9.)

    • A.

      Joint involvement

      • 1 large joint—0 pts

      • 2–10 large joints—1 pt

      • 1–3 small joints (with or without involvement of large joints)—2 pts

      • 4–10 small joints (with or without involvement of large joints)—3 pts

      • >10 joints (at least 1 small joint)—5 pts

    • B.

      Serology (at least 1 test result is needed for classification)

      • Negative RF and negative ACPA—0 pts

      • Low-positive (<3 × ULN) RF or low-positive ACPA—2 pts

      • High-positive (≥3 × ULN) RF or high-positive ACPA—3 pts

    • C.

      Acute-phase reactants (at least 1 test result is needed for classification)

      • Normal CRP and normal ESR—0 pts

      • Abnormal CRP or abnormal ESR—1 pt

    • D.

      Duration of symptoms

      • <6 weeks—0 pts

      • ≥6 weeks—1 pt

      • Add score of categories A–D: a score of >6/10 classifies a patient as having definite RA

    ACPA , Antibodies against citrullinated peptides; CRP , C-reactive protein; ESR , erythrocyte sedimentation rate; RA , rheumatoid arthritis; RF , rheumatoid factor; ULN , upper limit normal.

Morning stiffness, symmetric involvement and radiographic erosions are no longer included in the diagnostic criteria; however, they are also suggestive of RA.

Clinical features

Characteristic presentations in RA include the following:

Cervical spine

Degeneration of the transverse ligament of the C1 vertebra produces C1 to C2 instability in patients and can result in cervical cord compression or vertebral artery insufficiency. In addition, decreased motion and myelopathy may result from long-standing joint involvement (see Chapter 14.1 ).

Upper limb

The wrist, metacarpophalangeal and proximal interphalangeal joints are typically affected, with sparing of the distal interphalangeal joints. Swan-necking and boutonnière deformities are common, together with ulnar deviation at the metacarpophalangeal joints. Fixed flexion deformities may result in entrapment neuropathies, in particular, carpal tunnel syndrome with median nerve involvement. Tenosynovitis may lead to tendon rupture, particularly of the extensor pollicis longus, or degenerative changes in the long extensors of the middle, ring and the little fingers with rupture of these tendons.

Lower limb

The hip and knee are frequently involved. Metatarsophalangeal joint subluxation may occur. Talonavicular joint inflammation causes pronation and eversion deformity, with overlying muscle spasm. A Baker cyst due to posterior herniation of the joint capsule of the knee joint may occur and require differentiation from a deep vein thrombosis by Doppler ultrasound. Entrapment of the posterior tibial nerve causes burning paraesthesiae on the sole of the foot.

Extra-articular manifestations

The extra-articular manifestations of RA are protean and may involve any organ system due to local inflammation causing functional or neurological deficits, rheumatoid vasculitis or distant inflammation (see Chapter 14.1 ). Patients may also present with the side effects of the treatment, including sepsis related to immunosuppression. Sepsis with encapsulated organisms is of particular concern in patients with the Felty syndrome of RA with splenomegaly and neutropenia.

Investigations

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