Polyarthritis

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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	+	+	+/-	+/-	-	-	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	+	+	+	-	-	+/-	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	+	+	-	-	-	+/-	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	+/-	+/-	-	-	-	-	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	-	+	-	-	-	-	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	+	-	+/-	+/-	+	-	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	+	-	-	-	-	+	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	+	+	-	-	+	+/-	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		+	-	+	+	+	-	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		+	+/-	-	-	-	+	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	+	-	+/-	-	-	+	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	-	-	+/-	+	-	-	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	-	-	+/-	-	-	-	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	-	-	+/-	-	-	+	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	-	-	+/-	-	+/-	+	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	+	-	-	-	-	-
		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		-	-	+	-	-	-