Acute monoarthritis
Classification of arthritis by numberof joints involved
| 1: Monoarthritis |
2-3: Oligoarthritis |
>3: Polyarthritis |
Causes of migratory arthritis |
- Trauma
- Infection
- Crystal arthropathy
- Acute osteoarthritis
- Reactive arthritis
- Lyme disease
- Avascular necrosis
- Tumour
|
- Lyme disease
- Reiter’s syndrome
- Ankylosing spondylitis
- Gonococcal arthritis
- Rheumatic fever
|
- Rheumatoid arthritis
- SLE
- Viral arthritis
- Chronic osteoarthritis
|
- Rheumatic fever
- Infective endocarditis
- Henoch Schonlein purpura
- Serum sickness ( esp cefaclor sensitivity )
- Viral arthritis
- Septicaemia: staph, strep, mening/gonococcal
- Pulmonary infection: mycoplasma, histoplasmosis
- Lyme disease
|
Assessing monoarthritis
History:
- Trauma?
- Night pain, morning stiffness, systemic symptoms, recent non-articular infections
- Sexual history, previous episodes (back pain), rash
Examination
- Joint line tenderness, movements, erythema, local increases in temperature, swelling, loss of joint function, muscle wasting.
- General examination for peripheral stigmata ( eg occular inflammation, mouth ulcers, psoriasis, erythema nodosum, vasculitic lesions )
Labs
- FBC
- ESR, urate,
- Renal and liver function ± blood culture ± serum for strep titres
- Urine culture
- Cultures for STDs if indicated
- Arthrocentesis- sterile technique, samples:
- Direct microscopy
- C & S samples
- Samples into blood culture media
- Fluid in FBC bottle for WCC etc
- x-rays normal for >2 weeks even in septic
| |
Normal |
Noninflammatory |
Inflammatory |
Septic |
Clarity |
Transparent |
Transparent |
Cloudy |
Cloudy |
Colour |
Clear |
Yellow |
Yellow |
Yellow |
WBC |
<200 |
200-2000 |
200-50000 |
>50000 |
PMNs |
<25% |
<25% |
>50% |
>50% |
Culture |
Neg |
Neg |
Neg |
>50% +ve |
Crystals |
None |
None |
Possibly |
None |
Associated |
|
OA, trauma, ARF |
Gout, pseudogout, spondyloarthropathies, RA, Lyme disease |
Gonococcal and non-gonococcal sepsis, SLE |
Gonococcal septic arthritis
- Young adults, F > M
- From disseminated gonococcal infection
- Complicates 1-3% of all cases of gonnorhoea.
- May haave preceding migratory tendonitis or arthritis.
- ± vesiculopustular lesions, (esp. hands)
- ± multiple painless macules on limbs and trunk
- Generally large joints.
- Synovial fluid cultures are often negative
- …. the gonococcus has to be grown from elsewhere
- Note that reactive arthritis secondary to gonococcal infection is a separate entity.
- Treatment: Ceftriaxone or cefotaxime
Non-gonococcal septic arthritis
- Extreme of age and immunocompromised.
- NB prosthetic joints and rheumatoid arthritis.
- Irreversible loss of joint function in 25%
- Fatality rate is 10% (higher in rheumatoid)
- Large joints (textbook is knee)
- 10% SIJ, 10% are polyarticular.
- Haematogenous or local spread
- May not be systemically unwell
- Staph > streptococcus
- G-ve and mycobacterium in immonocompromised
- Joint aspirate more sensitive than blood cultures
- Treatment: beta-lactam and an aminoglycoside / 2nd generation quinolone until sensitivities known
Crystal arthropathies
More on the Gout / Pseudogout page
Lyme disease
- Delayed from the time of spirochete infection.
- A history of tick bite, followed the rash of erythema chronicum migrans, is diagnostic.
- Arthritis typically an asymmetric mono- or oligoarthritis, affecting large joints.
- May be migratory.
Reiters syndrome
More on the Reiter's syndroms page
Other causes of monoarthritis incude:
- Ankylosing spondylitis
- Tumours ( local, metastatic, haematological, or as part of a paraneoplastic syndrome)
- Rheumatoid arthritis
- Osteoarthritis
Reactive arthritis
- A sterile joint inflammation that may be related to a distant infection.
Infectious agents include:
- Salmonella
- Shigella
- Yersinia
- Campylobacter
- Chlamydia
- Streptococcus
- Viruses such as
- rubella, Hep B, parvovirus,
- EBV, CMV, HIV, mumps
Disposal
| Symptoms |
Diagnosis |
Action |
Clear cut septic joint
or
Septic infected joint |
|
Urgent orthopaedic referral |
Skin rash
Swollen joint
Unwell |
Sepsis
Consider :psoriasis, viral, connective tissue disorders |
Referral rheumatology SpR or on-take medical SpR |
Very painful joint swelling
No trauma |
Gout / Pseudgout |
Uric acid level
Diagnostic joint aspirate
NSAIDs (See gout)
GP follow up in next week
Admit if intractable pain or Dx unclear |
Iritis
Non-specific urethritis
Diarrhoea &
Joint pain |
Reactive arthritis |
OPD follow up
Local "Early arthritis" referral policy |
Early morning stiffness, joint pains
Swelling of hand, wrist, MTP or MCPs |
? Early rheumatoid arthritis |
OPD follow up
Local "Early arthritis" referral policy |
Patient well
Background of OA
Mild trauma
Age > 50 |
Probable osteo-arthritis |
NSAIDs
GP follow up |
Links
Content by Dr Íomhar O' Sullivan 29/12/2010. Last updated Dr ÍOS 16/12/19.