Rheumatoid arthritis differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]
Overview
Rheumatoid arthritis must be differentiated from [[Osteoarthritis], [differential dx2], and [differential dx3].
Differentiating Rheumatoid arthritis from other Diseases
- Osteoarthritis (OA):
- Signs and symptoms of osteoarthritis are usually minimal and spares the wrist joint and the metacarpophalangeal joint. It typically affects the distal inter-phalangeal joint and frequently associated with Heberden's nodes.
- Joint stiffness is usually minimal in OA and lasts less than one hour. In contrast, joint stiffness is a very prominent symptom of RA and should last more than an hour for atleast 6 weeks in order to fulfill the criteria for diagnosis defined by The American College of Rheumatology.[1]
- Systemic lupus erythematosus (SLE):
- Symptoms specific to SLE like butterfly malar rash, Discoid lupus erythromatosus, photosensitivity, myositis, nephritis are not seen in RA.
- The C reactive protein levels are often normal or mildly elevated in SLE, whereas it is always elevated in RA. However, the erythrocyte sedimentation rate is found to be elevated in both.
- Septic arthritis
- Bacterial cause: Characterized by fever, chills, joint swelling and tenderness, demonstration of causative organism in the aspirated joint fluid by gram staining or microbial culture.
- Viral cause: rubella, parvovirus B19, hepatitis B virus, hepatitis C virus are the most common responsible etiologic agents. The syndrome is often self limiting, lasting for a few weeks, and rarely beyond 6 weeks. Serology can help identifying HBV, HCV, parvovirus B19. Anti-CCP antibody is more specific than Rheumatoid factor for establishing a diagnosis of RA, as Rheumatoid factor levels may be raised in HCV infection.
- Lyme Arthritis: It is characterized by intermittent, persistent or migratory pattern of arthritis, often involving large joints like knee, shoulder, ankle, elbow, wrist and temporomandibular joint in the decreasing order of incidence. Involvement of small joints of the hand is not common with Lyme disease. Diagnosis is made by serology. Other clues include residing in an endemic area, antecedent history of erythema chronicum migrans.
- Gout:
- Polymyalgia rheumatica:
- It often asymmetric, seen in those above 50 years of age, involves proximal muscles of shoulder and hip, and tends to have a milder course.
- Stiffness involves the axial muscles more often than the small joints of hand that predominates RA.
- They are typically seronegative or have only a mild elevation of Rheumatoid factor and respond dramatically to glucocorticoids.
- Paraneoplastic syndromes:
- Hypertrophic pulmonary osteoarthropathy]]: Characterized by clubbing of digits, joint pain (deep and nagging type) and periosteal reaction.
- Myelodysplastic syndrome: Patients with myelodysplastic syndrome often present with various autoimmune diseases including polyarthritis which could be confused with RA.[2]
- Other differentials:
Abbreviations: ANA: Antinuclear antibody, RF: Rheumatoid factor, Anti-CCp: Anti-cyclic citrullinated protein antibody, Anti U1RNP: Anti-U1 ribonucleoprotein antibodies , Anti Sm : Anti-Sm antibodies, Anti Ro: Anti Ro antibody also called anti-Sjögren's-syndrome-related antigen A antibody, Anti-dsDNA: Anti-double stranded DNA.
| Disease | Arthritis | Auto-antibodies | Raynaud phenomenon | Rash pattern | Distinguishing/specific features | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Polyarthritis | Tenderness | Edema | Deformity /Erosion | Pattern | ANA | RF | Anti-CCp | Anti U1RNP | Anti Sm | Anti Ro | Anti-dsDNA | |||||
| Behçet's disease | +/- | +/- | +/- | - | Medium and large joints | - | - | - | - | - | - | - | Recurrent and usually painful mucocutaneous ulcers, acneiform lesions, papulo-vesiculo-pustular eruptions, superficial thrombophlebitis | Male dominancy | ||
| Systemic lupus erythematosus[3] | + | + | + | - | Small joints | ↑ | - | - | - | ↑ | ↑ | - | + | Malar rash and photosensitivity | ||
| Rheumatoid arthritis (RA)[4] | + | + | + | + | Small and large joints | - | ↑↑ | ↑↑ | - | - | - | - | + | Subcutaneous nodules | Erosive arthropathy | |
| Rhupus[5] | + | + | + | + | Small and large joints | ↑ | ↑ | ↑ | ↑ | ↑ | - | ↑ | + | Malar rash and photosensitivity | Erosive arthropathy | |
| Mixed connective tissue disease (MCTD)[6] | - | - | - | + | Small and large joints | - | ↑↑ | ↑ | - | - | - | - | + | Cutaneous eruptions, gottron’s papules, photodistributed erythema, poikiloderma, and calcinosis cutis | Overlapping features of SLE, systemic sclerosis (SSc), and polymyositis (PM) that lead to more than one diagnosis | |
| Undifferentiated connective tissue disease (UCTD)[7] | + | - | - | - | Lower extremity | ↑ | ↑ | - | - | ↑ | - | - | + | Erythematous macules, patches, or papules with delicate scale | Multiple connective tissue diseases with no enough criteria for a single diagnosis | |
| Systemic sclerosis (SSc)[8] | +/- | + | + | +/- | Lower extremity | ↑↑ | - | - | - | ↑ | - | ↑ | + | Hyperkeratosis, edema, and erythema | Sclerodactyly, Telangiectasias, Calcinosis, Malignant hypertension, acute renal failure | |
| Sjögren’s syndrome[9] | +/- | +/- | - | - | Lower extremity, axiallary creases | ↑ | - | - | - | ↑ | ↑ | - | - | Xerosis, scaly skin, annular erythema | Keratoconjunctivitis sicca | |
| Vasculitis | Giant cell[10] | - | + | + | - | Distal extremity | - | - | - | - | - | - | - | - | Rare | Involvement of cranial branches of arteries, visual loss |
| Takayasu[11] | - | +/- | +/- | - | Transient extremity | - | - | - | - | - | - | - | Erythema nodosum, pyoderma gangrenosum | Absent or weak peripheral pulse | ||
| Poly-arteritis nodosa[12] | - | +/- | - | - | General and mild | - | - | - | - | - | - | - | Tender erythematous nodules, purpura, livedo reticularis, bullous or vesicular eruption | Testicular pain or tenderness and neuropathies | ||
| Kikuchi’s disease[13] | - | +/- | - | - | medium and large joints | ↑/↓ | - | - | - | - | - | - | - | Transient skin rashes, malar rash, erythematous macules, patches, papules, or plaques | May be associated with SLE | |
| Serum sickness[14] | + | + | +/- | - | General | - | - | - | - | - | - | - | - | Pruritic rash, urticaria and/or serpiginous macular rash | Self-limited | |
| Psoriatic arthritis[15] | - | - | - | - | Small and large joints | - | - | - | - | - | - | - | - | Psoriasis and onychodystrophy | Dactylitis (sausage digits) | |
| Human parvovirus B19 infection[16] | + | + | - | - | Small joints | - | - | - | - | - | - | - | - | Erythematous rashes | Rare in adults, fifth's disease in children | |
References
- ↑ Arnett FC, Edworthy SM, Bloch DA; et al. (1988). "The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis". Arthritis and Rheumatism. 31 (3): 315–24. PMID 3358796. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Farmakis D, Polymeropoulos E, Polonifi A; et al. (2005). "Myelodysplastic syndrome associated with multiple autoimmune disorders". Clinical Rheumatology. 24 (4): 428–30. doi:10.1007/s10067-004-1059-4. PMID 15827686. Retrieved 2012-04-27. Unknown parameter
|month=ignored (help) - ↑ Ehmke TA, Cherian JJ, Wu ES, Jauregui JJ, Banerjee S, Mont MA (2014). "Treatment of osteonecrosis in systemic lupus erythematosus: a review". Curr Rheumatol Rep. 16 (9): 441. doi:10.1007/s11926-014-0441-8. PMID 25074031.
- ↑ Lee DM, Weinblatt ME (2001). "Rheumatoid arthritis". Lancet. 358 (9285): 903–11. doi:10.1016/S0140-6736(01)06075-5. PMID 11567728.
- ↑ Panush RS, Edwards NL, Longley S, Webster E (1988). "'Rhupus' syndrome". Arch. Intern. Med. 148 (7): 1633–6. PMID 3382309.
- ↑ Cappelli S, Bellando Randone S, Martinović D, Tamas MM, Pasalić K, Allanore Y, Mosca M, Talarico R, Opris D, Kiss CG, Tausche AK, Cardarelli S, Riccieri V, Koneva O, Cuomo G, Becker MO, Sulli A, Guiducci S, Radić M, Bombardieri S, Aringer M, Cozzi F, Valesini G, Ananyeva L, Valentini G, Riemekasten G, Cutolo M, Ionescu R, Czirják L, Damjanov N, Rednic S, Matucci Cerinic M (2012). ""To be or not to be," ten years after: evidence for mixed connective tissue disease as a distinct entity". Semin. Arthritis Rheum. 41 (4): 589–98. doi:10.1016/j.semarthrit.2011.07.010. PMID 21959290.
- ↑ Alarcón GS, Williams GV, Singer JZ, Steen VD, Clegg DO, Paulus HE, Billingsley LM, Luggen ME, Polisson RP, Willkens RF (1991). "Early undifferentiated connective tissue disease. I. Early clinical manifestation in a large cohort of patients with undifferentiated connective tissue diseases compared with cohorts of well established connective tissue disease". J. Rheumatol. 18 (9): 1332–9. PMID 1757934.
- ↑ LeRoy EC, Black C, Fleischmajer R, Jablonska S, Krieg T, Medsger TA, Rowell N, Wollheim F (1988). "Scleroderma (systemic sclerosis): classification, subsets and pathogenesis". J. Rheumatol. 15 (2): 202–5. PMID 3361530.
- ↑ Roguedas AM, Misery L, Sassolas B, Le Masson G, Pennec YL, Youinou P (2004). "Cutaneous manifestations of primary Sjögren's syndrome are underestimated". Clin. Exp. Rheumatol. 22 (5): 632–6. PMID 15485020.
- ↑ Bablekos GD, Michaelides SA, Karachalios GN, Nicolaou IN, Batistatou AK, Charalabopoulos KA (2006). "Pericardial involvement as an atypical manifestation of giant cell arteritis: report of a clinical case and literature review". Am. J. Med. Sci. 332 (4): 198–204. PMID 17031245.
- ↑ Lupi-Herrera E, Sánchez-Torres G, Marcushamer J, Mispireta J, Horwitz S, Vela JE (1977). "Takayasu's arteritis. Clinical study of 107 cases". Am. Heart J. 93 (1): 94–103. PMID 12655.
- ↑ Pagnoux C, Seror R, Henegar C, Mahr A, Cohen P, Le Guern V, Bienvenu B, Mouthon L, Guillevin L (2010). "Clinical features and outcomes in 348 patients with polyarteritis nodosa: a systematic retrospective study of patients diagnosed between 1963 and 2005 and entered into the French Vasculitis Study Group Database". Arthritis Rheum. 62 (2): 616–26. doi:10.1002/art.27240. PMID 20112401.
- ↑ Kucukardali Y, Solmazgul E, Kunter E, Oncul O, Yildirim S, Kaplan M (2007). "Kikuchi-Fujimoto Disease: analysis of 244 cases". Clin. Rheumatol. 26 (1): 50–4. doi:10.1007/s10067-006-0230-5. PMID 16538388.
- ↑ Kunnamo I, Kallio P, Pelkonen P, Viander M (1986). "Serum-sickness-like disease is a common cause of acute arthritis in children". Acta Paediatr Scand. 75 (6): 964–9. PMID 3564980.
- ↑ Oriente P, Biondi-Oriente C, Scarpa R (1994). "Psoriatic arthritis. Clinical manifestations". Baillieres Clin Rheumatol. 8 (2): 277–94. PMID 8076388.
- ↑ Kaufmann J, Buccola JM, Stead W, Rowley C, Wong M, Bates CK (2007). "Secondary symptomatic parvovirus B19 infection in a healthy adult". J Gen Intern Med. 22 (6): 877–8. doi:10.1007/s11606-007-0173-9. PMC 2219874. PMID 17384979.