Polyarthritis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Polyarthritis is any type of arthritis which involves five or more joints - an inflammation of two, three or four joints is an oligoarthritis.

Causes

Polyarthritis is most often caused by an auto-immune disorder such as Rheumatoid arthritis, Psoriatic arthritis, and Lupus erythematosus but can also be caused by infections such as Ross River Virus.

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[1] + + +/- +/- - - 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[2] + + + - - +/- 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[3] + + - - - +/- 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[4] +/- +/- - - - - 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[5] - + - - - - 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[6] + - +/- +/- + - 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[7] + - - - - + 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[8] + + - - + +/- 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[9] + - + + + - 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
Inflammatory osteoarthritis + +/- - - + +/-
Crystal-induced arthritis + +/- - - - +
Systemic rheumatic illnesses Systemic lupus erythematosus + - +/- - - +
Systemic vasculitis - - +/- + - -
Systemic sclerosis - - +/- - - -
Polymyositis/dermatomyositis - - +/- - - +
Still's disease - - +/- - +/- +
Behçet's syndrome + - - - - -
Relapsing polychondritis + - - - - -
Other systemic illnesses Sarcoidosis + - - - - -
Palindromic rheumatism + - - +/- + -
Familial Mediterranean fever - + - - - -
Malignancy +/- - + - - -
Hyperlipoproteinemias - - - - - -
Polyarticular pain Viral arthritis Hepatitis B and C - + + - - -
Rubella - + +/- - - -
Parvovirus + + +/- - - -
Fibromyalgia - - - +/- +/- -
Soft tissue abnormalities + - - - - +/-
Hypothyroidism - - - - - -
Neuropathic pain - - - - - -
Metabolic bone disease - - - - - -
Depression - - + - - -

References

  1. Lantos PM (2015). "Chronic Lyme disease". Infect Dis Clin North Am. 29 (2): 325–40. doi:10.1016/j.idc.2015.02.006. PMC 4477530. PMID 25999227.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. Sankowski AJ, Lebkowska UM, Cwikła J, Walecka I, Walecki J (2013). "Psoriatic arthritis". Pol J Radiol. 78 (1): 7–17. doi:10.12659/PJR.883763. PMC 3596149. PMID 23493653.
  8. Orchard TR (2012). "Management of arthritis in patients with inflammatory bowel disease". Gastroenterol Hepatol (N Y). 8 (5): 327–9. PMC 3424429. PMID 22933865.
  9. Heidari B (2011). "Rheumatoid Arthritis: Early diagnosis and treatment outcomes". Caspian J Intern Med. 2 (1): 161–70. PMC 3766928. PMID 24024009.

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