Rapid onset joint pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Information from the American College of Rheumatology
Of all the problems in rheumatology, this is one of the most important... diagnosing the patient who presents with rapid onset of joint pain.
When evaluating the patient with joint pain, I find it useful to consider six important concepts during the history and physical examination that help me narrow my choices.
• Is the joint pain really arthritis?
• Is the condition acute or chronic?
• Is the problem inflammatory or non-inflammatory?
• What is the pattern of joint involvement?
• Are there associated systemic features?
• What are the demographics of the patient that might make one diagnosis more tenable?
There are a variety of structures that can become painful and might be interpreted as arthritis by patients. Causes of joint pain from outside the joint (structures inside the joint capsule) can be from “periarticular” (near the joint) structures. The following is a list of structures around a joint that might present as joint pain.
Periarticular causes of joint pain
4. Ligament Injury
There are also a variety of non-articular (non-joint) abnormalities affecting bone, nerve, or blood vessels that may present as joint pain. Below is a list of such causes.
Nonarticular causes of joint pain
1. Tumors of bone
5. Nerve entrapment
Differentiation of these problems from arthritis requires careful physical examination which should include:
1. Inspection of the joint area for evidence of swelling or redness
2. Passive range of motion of the joint in the area noting pain, reduction of motion, or instability
3. Active range of motion of the joint in the area noting pain that was not there when the joint were passively moved
4. Resisted range of motion of the joint in the area again noting pain
5. Palpation of the joint line and surrounding structures noting tenderness, joint effusion, and bony changes.
These physical exam features are helpful for the following reasons: Most soft tissue problems do not hurt with passive motion while most forms of arthritis do. Tendonitis is typically painful with active or resisted motion. Bursitis is usually painful only with palpation. Myofacial pain is also painful to palpation and may be widespread.
Acute refers to conditions lasting less than 8 weeks while chronic signifies conditions that persist for a longer period of time. Acute also suggests a rapid onset. Many acute disorders are also self-limited... they go away on their own.
Distinguishing between inflammatory vs. non-inflammatory diseases is important. Inflammatory disorders usually present with morning stiffness that lasts longer than 30-40 minutes, stiffness that increases with rest, relief of symptoms with exercise, some degree of swelling, and a synovial fluid WBC that is above 2000/mm3.
Noninflammatory disorders usually present with only limited morning stiffness (< 15 minutes), pain with use, relief of pain with rest, swelling may or may not be present, and synovial fluid WBC is typically less than 2000/mm3.
Is the problem in one joint only? If inflammatory, this suggests:
• Infection (gonorrhea, fungus, tuberculosis, Lyme, endocarditis)
• Crystals (gout, pseudogout)
• Spondyloarthopathy (Reiter’s, ankylosing spondylitis, psoriatic arthritis)
• Palindromic rheumatism
If non-inflammatory, it suggests:
• Osteoarthritis (although it is clear that this is truly an inflammatory condition)
• Avascular necrosis (dead bone/cartilage)
Nongonococcal septic arthritis is the most serious cause of monoarthritis. Sometimes a few joints (2-3... this is called pauciarticular) may be affected. The presentation is that of an acute or subacute onset of mono-arthritis. Large joints are usually affected especially knees. Patients most often look very ill and have fever, chills, and will have an elevated WBC and ESR.
Patients with underlying arthritis especially rheumatoid arthritis are at increased risk of septic arthritis and may not have the usual symptoms due to anti-inflammatory medications. The most common organisms are Staphylococcus aureus, Streptococcus species and much less common are gram negatives but think of the latter in the immunosuppressed or in IV drug users. The initial evaluation should include arthrocentesis for gram stain and culture and WBC, blood cultures, as well as an ESR. The patient should be admitted and IV antibiotics started while waiting for culture results. If there is any concern for a septic joint, one must perform an arthrocentesis!
Gonococcal arthritis is seen in sexually active young adults and only 25% have local genitourinary symptoms. Patients are usually systemically ill and have dermatitis, tenosynovitis, and migratory arthritis. Blood cultures are positive in only 5%, GU cultures in 80%, and synovial fluid cultures in 30%. One often resorts to treatment of presumptive gonococcal arthritis. usually most strains that cause gonococcal arthritis are penicillin sensitive although, resistant strains are emerging. Initial evaluation should include the above cultures plus consideration of pharyngeal and rectal cultures. Patients often need a few days of hospitalization then can be treated as an outpatient.
Endocarditis (infection of the heart valves) causes musculoskeletal symptoms in up to 40% of affected patients. Inflammatory low back pain is common as is mono- or pauciarthritis. It is interesting to note that the fluid while inflammatory is usually sterile. This is thought to be due to immune complex deposition in the synovium. Other peripheral signs of immune complex deposition are cutaneous vasculitis and painful nodules. Patients may have a heart murmur. It’s important to check an ESR, blood cultures, CBC, cultures of synovial fluid, and if endocarditis is likely, admit the patient and begin antibiotics. Of note, rheumatoid factor is frequently positive in these patients.
Crystals causing arthritis include urate, calcium pyrophosphate, and appatite. Urate gout is probably the most common cause of acute inflammatory monoarthritis. Inflammation is usually intense and the patient will relate a history of previous self-limited attacks. The first metatarsophalangeal joint (big toe joint) is a common site for urate gout and knee for calcium pyrophosphate. Young women can have hydroxyappatite pseudopodagra affecting the great toe joint. Patients can have a pauciarticular presentation with urate and pyrophosphate.
For urate gout, a history of alcohol use, history of kidney stones, or a family history of urate gout is helpful. Females rarely get urate gout before menopause. There are some distinctive X-ray findings for calcium pyrophosphate and appatite arthritis (chondrocalcinosis and calcification respectively) On examination, look for tophi and synovial fluid analysis is very helpful in the definitive diagnosis of all but hydroxyappatite. A useful hint to remember is that bugs, blood, and crystals (BBC) cause the most intense joint pain.
Palindromic rheumatism is an episodic condition usually affecting one joint at a time. The attacks can be fairly intense and the fluid can be quite inflammatory. Attacks usually last several days and resolve. With time, many individuals progress on to frank rheumatoid arthritis.
Tuberculosis and fungi are relatively rare but any chronic monoarthritis without a diagnosis should be considered for synovial biopsy and granulomatous synovitis considered.
Osteoarthritis is probably the overall most common cause of monoarthritis and trauma/internal derangement of the knee is not far behind. Meniscal tears can cause chronic non-inflammatory type pain and may give symptoms of knee locking or giveway.
Avascular necrosis is caused by trauma, alcohol abuse, steroid use, divers, and in patients with blood disorders. Pain is initially out of proportion to X-rays. Hips, knees and shoulders are usually involved. Early diagnosis is by MRI scan.
Synovial neoplasms (tumors) can cause acute onset of joint pain. One particularly common one is pigmented villonodular synovitis. It can cause dark bloody effusions and is diagnosed by MRI/arthroscopy.
Pauciarticular arthritis- again referring to arthritis affecting fewer than 4 joints, has a number of causes including:
Infection due to gonorrhea, rheumatic fever, Lyme disease ansd endocarditis
Gonorrhea affects young sexually active adults. Typically, a pauciarticular disease is also accompanied by tendon inflammation and pustular skin lesions. A high index of suspicion helps with the diagnosis.
Rheumatic fever - In many of these conditions systemic features play an important role in the differential diagnosis. Rheumatic fever is certainly one of these although most adults with rheumatic fever present with only arthritis. The pain is usually out of proportion to the swelling and the symptoms tend to be migratory. Other Jones criteria include carditis, erythema marginatum, chorea, and subcutaneous nodules. Be sure to listen for a murmur and check ASO/streptozyme. The ASO should be followed serially and remember that a positive test still does not prove rheumatic fever. Throat cultures are usually negative by the time rheumatic fever occurs. One often spends time ruling out other diseases even with a suspicion for rheumatic fever due to the lack of definitive diagnostic testing. The presence of carditis though, is almost diagnostic and can be made by echocardiogram.
Lyme arthritis is a late manifestation of Lyme disease and usually presents with recurrent attacks of mono- or pauciarthritis especially including the knee. In this condition, the swelling is often out of proportion to the pain! A history of exposure and the characteristic rash of Lyme disease are important. By time the arthritis is present, the vast majority of patients have a positive Lyme antibody test. One may have to treat presumptively for at least one course of antibiotics in some marginal cases.
Spondyloarthropathies are characterized by their association with the HLA-B27 gene. Features of these illness that are helpful in the diagnosis include inflammatory low back pain, history of inflammatory eye disease (uveitis, iritis, conjunctivitis), urethritis, cervicitis, diarrhea, a variety of hyperkeratotic rashes, and diffuse swelling of digits called sausage digits. Joints most often affected are the large joints of the lower extremities. Up to 7% of patients with psoriasis will have arthritis.
Sarcoidosis frequently presents with pauciarthritis. One typical presentation is called Lofgren’s syndrome and consists of erythema nodosum, hilar adenopathy, and pauciarthritis usually affecting the large joints of the lower extremities. A chronic destructive form also exists and is often seen along with extensive bone cysts on X-ray. Other important features include uveitis and skin lesions.
Crystal induced arthritis such as gout and pseudogout
Polymyalgia rheumatica, a type of inflammatory arthritis that affects the neck, shoulders, and hips usually in people over the age of 50.
Non-inflammatory pauciarticular arthritis is best represented by osteoarthritis.
Polyarticular arthritis has a number of causes including:
Viruses are a common cause of acute self limited arthritis. The ones to remember include hepatitis B, parvovirus B19, and rubella. HIV can cause a variety of rheumatologic syndromes but polyarthritis is unusual. Viral arthridities are usually symetrical and cause more pain than swelling. They usually are self limited and are associated with rash. The prodrome of hepatitis B can be polyarthritis even before liver function tests are abnormal. Be sure to check for hepatitis B surface antigen. The arthritis usually goes away by the time the patient has clinical hepatitis. Hepatitis C is being recognized as a common infection. It can cause a symmetric polyarthritis that is often accompanied by a positive rheumatoid factor thus being confused with rheumatoid arthritis. There are no nodules with hepatitis C nor does it cause erosive joint changes.
Rheumatoid arthritis is a relatively common disease affecting 1-2% of the US population. Remember that rheumatoid factor is seen in only 70% of patients and may not appear for 1 year. RA is a symmetric arthritis and almost always affects the small joints of the hands and feet.
Systemic lupus erythematosus is often accompanied by a positive ANA test. A negative ANA plus a negative anti-SSA antibody and anti-DNA virtually excludes SLE. On the other hand, a positive ANA does not mean SLE. One has to look for other features to go along with the positive ANA not just fatigue and arthralgias. An ANA of less than 1:160 is not particularly alarming. Evaluation for the presence of other auto-antibodies as well as objective evidence of inflammation on laboratory testing and examination is helpful. Urgent cases of SLE include those with new onset or exacerbation of nephritis or cerebritis.
Secondary causes of osteoarthritis especially metabolic causes, are conditions to think of in a patient with clinical osteoarthritis in a symmetric pattern but in places atypical for primary OA. These include the shoulders, elbows, wrists, and MCP joints. The most important cause is idiopathic calcium pyrophosphate disease and less common, but with more significant implications, is hemachromatosis.
Serum sickness is a reaction to drugs. Symptoms include rash often uriticarial, and inflammatory arthritis affecting large joints. Fever is common and laboratory abnormalities include mild hypocompletemia and normal eosinophil count. The process is self limited resolving in 1-3 weeks after exposure. Typical causes of serum sickness-like reactions are antibiotics especially penicillins and sulfa drugs.
There are a variety of systemic features that can help in the differential diagnosis of joint pain/arthritis. Finding these requires a complete review of systems and a good general examination with emphasis on the skin, eyes, heart, lungs, GI, GU, and nervous system.
There are features of the history that can help you focus the differential diagnosis. Knowing which diseases are more common in certain patient groups may move certain conditions to the top of your list.
Parvovirus arthropathy is a recently recognized cause of acute and chronic joint symptoms. In 1975, the parvovirus was isolated from human tissue. The virus is a small, single stranded DNA virus that grows in erythrocyte precursor cells. Presently, detection of infection depends on serologic confirmation of an IgM response to the virus and one need to check for infection within the first 8 weeks. Newer methods of detection are being developed as is a method for culture.
The acute arthropathy consists of polyarthralgias/polyarthritis that may come on over night. There is usually significant stiffness and pain and only mild synovitis. Joint symptoms are much more common in adult women than men and the characteristic rash of childhood Fifth disease is unusual in adults but a fine evanescent macular is frequently present on the extremities and trunk. The symptoms last 1-3 weeks and in most cases disappear without sequelae. In up to 1/3 of affected females the symptoms may continue or recur at various intervals. Symptoms have been recorded up to 4 years to date. One can usually treat the symptoms with NSAIDs. It is important to ask individuals with chronic or recurring inflammatory sounding arthralgias about possible exposure to the virus ie., exposure to Fifth disease. There is some interest in the parvovirus as a possible trigger of rheumatoid arthritis or systemic lupus erythematosus.
Polymyalgia rheumatica with synovitis or seronegative rheumatoid arthritis is a diagnostic puzzle. In recent years, it has become evident that there is a group of individuals over the age of 60 who present with symmetrical polyarthritis, are seronegative for rheumatoid factor, and present with considerable shoulder and hip stiffness. This group has an excellent response to low dose steroids and do not show the progressive destructive course so common of true rheumatoid arthritis. Their symptoms resemble more the course of polymyalgia rheumatica (PMR). It is well recognized that PMR can have have coexisting joint effusions often pauciarticular, but this group who are between RA and PMR, have a polyarticular presentation. The response to low dose steroids is as dramatic as that for PMR and relapses can occur as well as actual temporal arteritis. Besides the absence of rheumatoid factor, another clue to help distinguish this syndrome from RA is the lack of involvement of the MTP joints of the foot.
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