Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2] , Mehrian Jafarizade, M.D [3] , Eiman Ghaffarpasand, M.D. [4]
Overview
Psoriatic arthritis must be differentiated from other arthritides including rheumatoid arthritis , reactive arthritis , ankylosing spondylitis , arthritis associated with inflammatory bowel disease , osteoarthritis , gout , and Pseudogout .
Differentiating psoriatic arthritis from other Diseases
Psoriatic arthritis must be differentiated from other arthritides including[1] [2] [3] [4]
Differential Diagnosis of Diseases That Cause Polyarthritis
Diseases
Clinical manifestations
Para-clinical findings
Gold standard
Additional findings
Symptoms
Physical examination
Lab Findings
Imaging
Histopathology
Joint Swelling
Fever
Weight loss
Claudication
Morning stiffness
Local erythema
Skin manifestation
CBC
ESR
Synovial fluid
Other
X-ray
CT scan
Other
Polyarthritis
Infectious arthritis
Lyme disease [5]
+
+
+/-
+/-
-
-
Erythema migrans
Leukopenia , Thrombocytopenia
-
Cell counts 500-98,000/µL
Microscopic hematuria , Proteinuria , ↑ALT or AST
-
-
-
Fibrosis of the deeper dermis and hyalinization of collagen bundles
Serologic tests
Erythema migrans
Bacterial endocarditis [6]
+
+
+
-
-
+/-
Janeway lesions , Osler nodes , Roth spots
Normochromic-normocytic anemia
↑
↑WBC , S. aureus in culture
Hyperglobulinemia , Cryoglobulinemia
Joint erosion and effusion
-
-
Vegetation or intracardiac abscess demonstrating active endocarditis
Echocardiography (TTE )
Vertebral osteomyelitis
Postinfectious (reactive) arthritis
Rheumatic fever [7]
+
+
-
-
-
+/-
Erythema marginatum rheumaticum
Leukocytosis
↑
Sterile inflammatory reaction with cells<20,000/μL
Streptococcal antibody titer
Cardiomegaly
Valvular or pericardial calcification
Echocardiographic changes in heart valves
Edema , Fibrinoid necrosis , Mononuclear cell infiltrate
Echocardiography
Chorea, Carditis
Reactive arthritis [8]
+/-
+/-
-
-
-
-
Genital ulceration
Normocytic normochromic anemia
↑
High WBC count (10,000-40,000/µL)
HLA-B27 test
Periosteal reaction and proliferation of tendon insertion site
Sacroiliitis
Enthesitis in ultrasonography
Keratoderma blennorrhagicum , Balanitis circinata
Spondyloarthritis and unequivocal demonstration of preceding infection
Conjunctivitis , Uveitis
Enteric infection [9]
-
+
-
-
-
-
Keratoderma and psoriaform lesions, Erythema nodosum
Neutrophilia
↑
PCR of causative organism
Stool exam and culture
-
-
-
Neutrophilic infiltration in synovial tissues
PCR of causative organism in synovial fluid
Diarrhea , Enthesopathy
Other seronegative spondyloarthritides
Ankylosing spondylitis [10]
+
-
+/-
+/-
+
-
Dactylitis (sausage digit)
Normocytic normochromic anemia
↑
High WBC count (lymphocyte predominance)
↑Alkaline phosphatase (ALP)
Bony erosions and sclerosis of the joints
Early sacroiliitis , erosions , and enthesitis
Possible cauda equina syndrome secondary to spinal stenosis in MRI
Chronic inflammation with CD4+ and CD8+ T lymphocytes and macrophages
Plain x-rays
Peripheral enthesitis , Uveitis
Psoriatic arthritis [11]
+
-
-
-
-
+
Scaly erythematous plaques ,
Guttate lesions , Lakes of pus ,
Erythroderma
Normal
↑
High WBC count (5000-15,000/µL) with >50% of PMN leukocytes
↑RF , ANA , IgA
Joint -space narrowing, Fluffy periostitis
Pencil-in-cup deformity, Early signs of synovitis
Sacroiliitic synovitis , Enthesitis in MRI
Lack of intrasynovial Ig and RF , Greater propensity for fibrous ankylosis , osseous resorption , and heterotopic bone formation
Clinical findings
Onycholysis , Splinter hemorrhages
Inflammatory bowel disease [12]
+
+
-
-
+
+/-
Pyoderma gangrenosum (ulcerative colitis ), Erythema nodosum (Crohn disease )
Iron deficiency anemia , Leukocytosis , Thrombocytosis
↑
Mild to moderate inflammatory fluid , PMN predominance
↑RF , Antiendomysial Ab , Antitransglutaminase Ab
Bilateral sacroiliitis , Syndesmophytes and apophyseal joint involvement in spine
-
Early detection of spinal and sacroiliac lesions in MRI
-
Clinical findings and history
Acute anterior uveitis
Rheumatoid arthritis [13]
+
-
+
+
+
-
Rheumatoid nodules
Anemia , Thrombocytosis
↑
WBC count >2000/µL (generally 5000-50,000/µL), with neutrophil predominance (60-80%)
Anti-CCP Ab , Hyperuricemia
Joint -space narrowing
Microfractures
Synovitis in MRI
Influx of inflammatory cells into the synovial membrane , with angiogenesis
Clinical findings coupled anti-CCP antibody
Rheumatoid nodules
Crystal-induced arthritis [14]
+
+/-
-
-
-
+
Joint erythema
Leukocytosis
↑
Needle shaped urate crystals, WBC count > 2000/µL
Urinary uric acid (>1100 mg in 24h)
Punched-out erosions or lytic areas with overhanging edges
Complementary for recognizing erosions
Tophi or edema in MRI
Large pale pink acellular areas (urate crystals ), surrounded by histiocytes and multinucleated giant cells
Synovial fluid assay
Conjunctival nodules
Systemic rheumatic illnesses
Systemic lupus erythematosus [15]
+
-
+/-
-
-
+
Malar rash , Photosensitivity , Discoid lupus
Leukopenia , Lymphopenia , Anemia , Thrombocytopenia
↑
Cell count from < 25% PMNs (non-inflammatory effusions) to > 50% PMNs (inflammatory effusions)
Creatine kinase , LFT , ANA , Anti-dsDNA , Anti-Sm , Lupus anticoagulant
Periarticular osteopenia and soft-tissue swelling without erosions
Interstitial lung disease , Pneumonitis , Pulmonary emboli , Alveolar hemorrhage
Pericardial effusion , Pulmonary hypertension , Verrucous Libman-Sacks endocarditis in echocardiography
Inflammatory infiltrates at the dermoepidermal junction and vacuolar change in the basal columnar cells
Anti-dsDNA
Rheumatoid arthritis , Serositis , Oral ulcers
Systemic vasculitis [16]
-
-
+/-
+
-
-
Petechia , Purpura
Anemia , Thrombocytosis
↑
-
P-ANCA , C-ANCA , ANA
Soft tissue swelling with mild erosions
Focal regions of infarction or hemorrhage
Multiple microaneurysms ,Hemorrhage due to focal rupture , Occlusion in angiography
Acute destruction of the media by neutrophils , with loss of elastic fibers
Angiography
Peripheral neuropathy , Livedo reticularis
Systemic sclerosis [17]
-
-
+/-
-
-
-
3 phases of (1) Edematous , (2) Indurative , and (3) Atrophic
Thrombocytopenia
↑
Cell count < 25% PMNs (non-inflammatory )
Hypergammaglobulinemia ,
Creatine phosphokinase
Juxta-articular osteoporosis , Joint space narrowing, Frank erosions
Synovial inflammation
Synovial vascularity in doppler ultrasonography
Epidermal skin appendages atrophy , Broad and hyalinized collagen fibers in the reticular dermis
Histopathology
Raynaud phenomenon , Tendon friction rubs
Polymyositis /dermatomyositis [18]
-
-
+/-
-
-
+
Heliotrope rash , Gottron papules , Poikiloderma
Normocytic normochromic anemia
↑
Predominantly mononuclear cells and large macrophage-like cells
Anti–Mi-2 antibodies, Anti–Jo-1 antibodies, Creatine kinase , ANA
Marginal erosions and periarticular calcification
-
-
Vacuolar changes of the columnar epithelium and lymphocytic infiltrates
Muscle biopsy
Dysphagia
Still's disease [19]
-
-
+/-
-
+/-
+
Mild papules and nodules
Anemia , Thrombocytosis
↑
High WBC count (5000-15,000/µL) with >50% of PMN leukocytes
ANA , RF
Soft tissue swelling,
Osteopenia ,
Joint-space narrowing
Synovial inflammation
Inflamed synovium in ultrasonography
Inflammatory infiltration in synovium
Clinical findings and synovial fluid analysis
Ocular involvement
Behçet's syndrome [20]
+
-
-
-
-
-
Erythema nodosum
Normocytic normochromic anemia
↑
Cell count < 25% PMNs (non-inflammatory )
Serum complement levels, Human leukocyte antigen (HLA)-B51
Soft tissue swelling
Non-erosive synovitis
-
Dermal vessels infiltration with lymphocytes and plasma cells, Immune deposits of immunoglobulin M (IgM) and C3
Clinical findings
Oral ulcer , Mucosal erosion
Relapsing polychondritis [21]
+
-
-
-
-
-
-
Leukocytosis , Anemia
-
Cell count < 25% PMNs (non-inflammatory )
Cryoglobulins , ANA , C-ANCA
Tracheal stenosis in CXR
Calcification of cartilaginous structures
Aortic root dilatation and degree of aortic regurgitation in echocardiography
Chondrolysis, Chondritis , Perichondritis
Clinical findings coupled with imaging
Ear pain and redness, Polyarthritis
Other systemic illnesses
Sarcoidosis [22]
+
-
-
-
-
-
Mild papules and nodules
Mild anemia
↑
Cell count < 25% PMNs (non-inflammatory )
IL-2 and IFN-γ , ↑ACE , ↑1, 25-dihydroxyvitamin D
Bilateral hilar adenopathy
Active alveolitis or fibrosis
Hepatosplenomegaly in ultrasonography
Noncaseating granulomas (NCGs)
Histological confirmation
Heart block , Ocular lesion
Palindromic rheumatism [23]
+
-
-
+/-
+
-
Rheumatoid nodules
Anemia
↑
High WBC count (5000-15,000/µL) with >50% of PMN leukocytes
RF , Anti-CCP antibody , ↑Cr or BUN ,
↑ALT or AST , ANA
Effusions in joints
Microfractures
Basilar invagination with cranial migration of an eroded odontoid peg in MRI
Influx of inflammatory cells into the synovial membrane , withangiogenesis , proliferation of chronic inflammatory cells
Clinical findings coupled anti-CCP antibody
Rheumatoid nodules
Familial Mediterranean fever [24]
-
+
-
-
-
-
A well-demarcated, erythematous , warm rash , particularly below the knee
Leukocytosis
↑
Cell counts as high as 100,000/µL
CRP , Amyloid A protein , Fibrinogen
Synovial effusions
Pleural effusions
Air-fluid levels in MRI
Massive amyloid infiltration of the blood vessels and endothelial side of the glomerular basement membrane
Clinical findings
Abdominal pain , Severe myalgia , Scrotal attacks
Hyperlipoproteinemias [25]
-
-
-
-
-
-
Xanthelasma
Leukocytosis
↑
Xanthochromic fluid with mononuclear cells predominance
CRP , Hyperlipidemia
Joint space narrowing
Achilles tendon enthesitis
Retrocalcaneal bursitis and ill-defined edema in posterosuperior corner of the calcaneus
Inflammatory infiltration
Laboratory findings
Atherosclerosis
Polyarticular pain
Viral arthritis
Hepatitis B and C [26]
-
+
+
-
-
-
Urticarial and maculopapular eruptions
Leukocytosis
↑
Cell counts < 100,000/µL
LFT , HBsAg
Joint space narrowing
-
-
Deposition of immune complexes , Cryoprecipitates containing HBsAg and complements
HBsAg
Liver failure , Icterus
Rubella [27]
-
+
+/-
-
-
-
Acute maculopapular rash
Leukocytosis
↑
Rubella virus antigen
LFT , CRP
Joint space narrowing
-
-
proliferation of the synovial lining cells , without inflammatory
cells
Serological evidence
Headache , Malaise
Parvovirus [28]
+
+
+/-
-
-
-
Fifth disease / Erythema infectiosum
Aplastic crisis
↑
Normal
ANA , RF , CRP
Joint swelling
-
-
Immune complex deposition
Parvovirus IgM antibody
Transient aplastic crisis , Fetal infection
Fibromyalgia [29]
-
-
-
+/-
+/-
-
Maculopapular rash
Normal
-
Normal
-
-
-
-
Mild inflammation
Clinical findings
Muscle pain
Soft tissue abnormalities
+
-
-
-
-
+/-
Maculopapular rash
Normal
-
Cell count < 25% PMNs (non-inflammatory )
CRP , Ca
Joint swelling
Synovial edema and thickness
Mild joint effusion in ultrasonography
Mild inflammation
Clinical findings
Mucositis , Enthesitis
Hypothyroidism [30]
-
-
-
-
-
-
Dry and coarse skin
Anemia
-
Clear yellow fluid with normal cell counts
TSH , T4 , T3
Peri-articular demineralization
Destructive changes in the cartilage and bone
High-signal fluid in the joint space in MRI
Physeal growth plate with little evidence of cartilage cellular proliferation
TSH , T4 , T3
Decreased DTR , Fatigue
Neuropathic pain [31]
-
-
-
-
-
-
Livedo reticularis
Normal
-
Normal
Hyperglycemia , Hypokalemia , Hypocalcemia
-
-
-
-
Neurologic examination
Paresthesia , Dysesthesia
Metabolic bone disease[32]
-
-
-
-
-
-
Hyperpigmentation
Mild anemia
↑
Cell count < 25% PMNs (non-inflammatory )
Vitamin D , PTH
Peri-articular demineralization
Microfractures
Subperiosteal reaction
Decrease mineralization of bone matrix
Laboratory findings
Bone pain , Constipation
Depression [33]
-
-
+
-
-
-
-
Normal
-
Normal
Normal
-
-
-
-
Psychological interview
Slow psychomotor , Muscle pain
References
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↑ Helliwell PS, Hickling P, Wright V (March 1998). "Do the radiological changes of classic ankylosing spondylitis differ from the changes found in the spondylitis associated with inflammatory bowel disease, psoriasis, and reactive arthritis?" . Ann. Rheum. Dis . 57 (3): 135–40. PMC 1752543 . PMID 9640127 .
↑ Moll JM, Haslock I, Macrae IF, Wright V (September 1974). "Associations between ankylosing spondylitis, psoriatic arthritis, Reiter's disease, the intestinal arthropathies, and Behcet's syndrome". Medicine (Baltimore) . 53 (5): 343–64. PMID 4604133 .
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↑ Soor P, Sharma N, Rao C (2017). "Multifocal Septic Arthritis Secondary to Infective Endocarditis: A Rare Case Report" . J Orthop Case Rep . 7 (1): 65–68. doi :10.13107/jocr.2250-0685.692 . PMC 5458702 . PMID 28630844 .
↑ Kumar RK, Tandon R (2013). "Rheumatic fever & rheumatic heart disease: the last 50 years" . Indian J Med Res . 137 (4): 643–58. PMC 3724245 . PMID 23703332 .
↑ Colmegna I, Cuchacovich R, Espinoza LR (2004). "HLA-B27-associated reactive arthritis: pathogenetic and clinical considerations" . Clin Microbiol Rev . 17 (2): 348–69. PMC 387405 . PMID 15084505 .
↑ Hill Gaston, J (2003). "Arthritis associated with enteric infection". Best Practice & Research Clinical Rheumatology . 17 (2): 219–239. doi :10.1016/S1521-6942(02)00104-3 . ISSN 1521-6942 .
↑ McVeigh CM, Cairns AP (2006). "Diagnosis and management of ankylosing spondylitis" . BMJ . 333 (7568): 581–5. doi :10.1136/bmj.38954.689583.DE . PMC 1570004 . PMID 16974012 .
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↑ Avouac, J.; Clements, P. J.; Khanna, D.; Furst, D. E.; Allanore, Y. (2012). "Articular involvement in systemic sclerosis". Rheumatology . 51 (8): 1347–1356. doi :10.1093/rheumatology/kes041 . ISSN 1462-0324 .
↑ Briemberg HR, Amato AA (September 2003). "Dermatomyositis and Polymyositis". Curr Treat Options Neurol . 5 (5): 349–356. PMID 12895397 .
↑ Kadavath S, Efthimiou P (February 2015). "Adult-onset Still's disease-pathogenesis, clinical manifestations, and new treatment options". Ann. Med . 47 (1): 6–14. doi :10.3109/07853890.2014.971052 . PMID 25613167 .
↑ Sugawara S, Ehara S, Hitachi S, Sugimoto H (March 2010). "Hand and wrist arthritis of Behçet disease: imaging features". Acta Radiol . 51 (2): 183–6. doi :10.3109/02841850903401349 . PMID 20121672 .
↑ Emmungil H, Aydın SZ (2015). "Relapsing polychondritis" . Eur J Rheumatol . 2 (4): 155–159. doi :10.5152/eurjrheum.2015.0036 . PMC 5047229 . PMID 27708954 .
↑ Iannuzzi MC, Rybicki BA, Teirstein AS (November 2007). "Sarcoidosis". N. Engl. J. Med . 357 (21): 2153–65. doi :10.1056/NEJMra071714 . PMID 18032765 .
↑ Iyer VR, Cohen GL (February 2011). "Palindromic rheumatism". South. Med. J . 104 (2): 147–9. doi :10.1097/SMJ.0b013e318200c4cc . PMID 21206416 .
↑ Yildirim K, Uzkeser H, Uyanik A, Karatay S, Kiziltunc A (2011). "Trace element levels in patients with familial mediterranean Fever" . Eurasian J Med . 43 (2): 79–82. doi :10.5152/eajm.2011.18 . PMC 4261345 . PMID 25610168 .
↑ Soubrier, Martin; Dubost, Jean Jacques; Thiéblot, Philippe; Ristori, Jean Michel (2009). "Oligo-arthritis and type IV hyperlipoproteinemia". Joint Bone Spine . 76 (1): 95–97. doi :10.1016/j.jbspin.2008.03.009 . ISSN 1297-319X .
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↑ Moore TL (July 2000). "Parvovirus-associated arthritis". Curr Opin Rheumatol . 12 (4): 289–94. PMID 10910181 .
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