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, |
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 joint 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 | + | + | - | - | +/- | +/- | |||||||||||||
| Rheumatoid arthritis | + | - | + | + | + | - | Rheumatoid nodules | Anemia, Thrombocytosis | ↑ | Hyperuricemia, Arthrocentesis and synovial fluid analysis to exclude gout, Serologic studies | CT scan: Microfractures | MRI and ultrasound: Synovitis | Influx of inflammatory cells into the synovial membrane, with angiogenesis, proliferation of chronic inflammatory cells | 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
- ↑ 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.
- ↑ 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.
- ↑ 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.