APPROACH TO PATIENT APPROACH TO PATIENT WITH MONOARTHRITISWITH MONOARTHRITIS

Dr Maryum khalil HO MU1 HFH

MONOARTHRITIS

“Inflammation of a single joint”

*Acute

*Chronic

CAUSES OF ACUTE CAUSES OF ACUTE MONOARTHRITISMONOARTHRITIS

IN A PREVIOUSLY NORMAL JOINT:IN A PREVIOUSLY NORMAL JOINT: Septic arthritis Crystal synovitis

Trauma Haemarthrosis Foreign body

reaction

Monoarticular presentation of oligo- / polyarthritis

R.A

Erythema nodosum

Juvenile Idiopathic arthritis

Reactive, Psoriatic or other Seronegative spondarthritis

IN A PREVIOUSLY ABNORMAL JOINTIN A PREVIOUSLY ABNORMAL JOINT

DAMAGED JOINT:

Pseudogout in assc with O.A

Bone disease Cartilage disease Haemarthrosis Septic arthritis

EXISTING INFLAMMATORY DISEASE ( WITH OR WITHOUT DAMAGE):

Septic arthritis Exacerbation of underlying

disease

CAUSES OF CHRONIC CAUSES OF CHRONIC MONOARTHRITISMONOARTHRITIS

Foreign body Infection Ch. Sarcoidosis Enteropathic Arthritis (mainly Crohn’s) Amyloidosis Pigmented villonodular synovitis Synovial pathology (sarcoma, chondromatosis) Monoarticular presentation of oligo- / poly

articular disease

HISTORY & PHYSICAL HISTORY & PHYSICAL EXAMINATIONEXAMINATION

Acute monoarthritis can be the initial manifestation of many joint disorders. The first step in diagnosis is to verify that the source of pain is the joint, not the surrounding soft tissues. The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. A careful history and physical examination are important because diagnostic studies frequently are only supportive.

DIAGNOSTIC CLUESDIAGNOSTIC CLUES

Clues from history and physical examination

Sudden onset of pain in seconds or minutes

Onset of pain over

several hours or one to two days

Insidious onset of pain over days to weeks

Diagnoses to consider

Fracture, internal derangement, trauma,

Infection, crystal deposition disease, other inflammatory arthritic condition

Indolent infection, osteoarthritis, infiltrative disease, tumor

Intravenous drug use, immunosuppression

Previous acute attacks in any joint, with spontaneous resolution

Recent prolonged course of corticosteroid therapy

Coagulopathy, use of anticoagulants

Urethritis, conjunctivitis, diarrhea, and rash

Psoriatic patches or nail changes such as pitting

Septic arthritis

Crystal deposition disease, other inflammatory arthritic condition

Infection, avascular necrosis

Hemarthrosis

Reactive arthritis

Psoriatic arthritis

Use of diuretics, presence of tophi, history of renal stones

Eye inflammation, low back pain

Young adulthood, migratory polyarthralgias, inflammation

Hilar adenopathy, erythema nodosum

Gout

Ankylosing spondylitis

Gonococcal arthritis of the tendon sheaths of hands and feet, dermatitis

Sarcoidosis

DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES

1-SYNOVIAL FLUID EXAM: Arthrocentesis is required in most patients with

monoarthritis and is mandatory if infection is suspected. In some instances, obtaining as little as one or two drops of synovial fluid can be useful for culture and crystal analysis.

A) Cell countsB) MicroscopyC) C/S

Categorization of Synovial Categorization of Synovial FluidFluid

Noninflammatory: <2,000 WBC per mm3

Osteoarthritis Trauma Avascular necrosis Charcot's arthropathy Hemochromatosis Pigmented villonodular

synovitis

Inflammatory: >2,000 WBC per mm3

Septic arthritis Crystal-induced

monoarthritis (e.g., gout, pseudogout)

Rheumatoid arthritis Spondyloarthropathy SLE Juvenile R.A Lyme disease

MICROSCOPY:

C/S:

Synovial fluid cultures are more likely to be positive in patients with nongonococcal arthritis (90 percent) than in those with gonococcal arthritis (less than 50 percent).

2- CBC & ESR

4- BLOOD CULTURE Blood cultures should be obtained in

patients with suspected septic arthritis. Cultures are positive in about 50 percent of nongonococcal infections but are rarely positive (about 10 percent) in gonococcal infection.

Pharyngeal, urethral, cervical, and rectal swabs are necessary if gonococcal infection is suspected

5-RADIOGRAPHY: Although plain-film radiographs

often show only soft tissue swelling, they are indicated in patients with a history of trauma or patients who have had symptoms for several weeks. Occasionally, unsuspected bony lesions, such as osteomyelitis or malignancy, may be detected.

5-MRI:

Magnetic resonance imaging is superior in detecting ischemic necrosis, occult fractures, and meniscal and ligamentous injuries.

6-RADIONUCLIDE SCANS:

Radionuclide scanning can detect infection in deep-seated joints.

7- OTHERS:

Other diagnostic procedures, such as synovial biopsy or arthroscopy, may be useful to rule out deposition diseases (e.g., hemochromatosis, atypical infections) and intra-articular tumors.

SEPTIC ARTHRITISSEPTIC ARTHRITIS Bacterial Gonococcal Non-gonococcal(Staphylococcus

aureus , non group-A beta-hemolytic streptococci, gram-negative bacteria, and Streptococcus pneumoniae)

Viral – HBV, Rubella, Mumps, I.M, Parvovirus, Enterovirus, Adenovirus

Fungal

MANAGEMENTMANAGEMENT

1- Hospitalization

2- Gen. Supportive care

3- I/V Antibiotics

4- Repeated Arthrocentesis

5- Surgical Drainage

CRYSTAL INDUCED CRYSTAL INDUCED SYNOVITISSYNOVITIS

A- GOUT:

ACUTE:

NSAIDs, Glucocorticoids,Colchicine

CHRONIC:

Allopurinol, Uricosuric Drugs

B- PSEUDOGOUT: - May present as acute mono- or

oligoarthritis mimicking Gout, or as a chronic polyarhthritis mimicking R.A & O.A

- NSAIDs, Glucocorticoids, Colchicine

C- APATITE DISEASE: - May present with periarthritis or

tendinitis - Rx same as Pseudogout

QUESTIONSQUESTIONS

A 67 year old male presents with his first A 67 year old male presents with his first episode of knee pain and swelling episode of knee pain and swelling together with the following x-ray.together with the following x-ray.

Which of the following investigations is the next investigation indicated diagnostically?

(a) Thyroid function tests (b) Serum urate (c) Knee aspiration (d) Serum iron (e) Skeletal survey

The following pelvic x-ray displays The following pelvic x-ray displays radiographic features of which of the radiographic features of which of the

following rheumatic disorders?following rheumatic disorders?

(a)Rheumatoid arthritis

(b) Paget’s disease

(c) Osteonecrosis

(d) Osteoarthritis

(e) None of the above

Which of the following types of joint Which of the following types of joint involvement is not seen in psoriatic involvement is not seen in psoriatic

arthritis?arthritis?

(a) Symmetrical small joint arthropathy

(b) Jaccoud’s arthropathy

(c) Sacroiliitis

(d) Monoarthritis

(e) DIP joint arthropathy

In septic arthritis which one of the In septic arthritis which one of the following pairings is most commonly following pairings is most commonly

found in hospital practice?found in hospital practice?

(a) Ankle joint and Staph Aureus

(b) Knee joint and MRSA

(c) Wrist joint and Beta haemolytic streptococci

(d) Knee joint and Staph Aureus

(e) Hip joint and Staph Aureus

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