Monoarthritis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Differential Diagnosis of Monoarthritis

Differentiating the diseases that can cause monoathritis:

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
Monoarthritis Osteoarthritis[1] + - - - - - Heberden nodes Anemia - Noninflammatory joint fluid Urinary pyridinium cross-links Joint-space loss, Subchondral bony sclerosis, Cyst formation Malalignment of the patellofemoral joint Early diagnosis of osteoarthritis of the hand with bone scan - Clinical findings Microfracture, Bone pain
Trauma[2] + - - - - + Wound or laceration - - Hemarthrosis - Severe joint effusion, Fracture Fracture, Synovial tear - - X-ray Deformity, Severe pain
Neoplasms[3] + - + +/- - - Rash Normocytic normochromic anemia ↑  High WBC count (10,000-40,000/µL) Hypercalcemia, Hyperphosphatemia Peri-articular osteoblastic or osteoclastic lesion Elevation of the periosteum Intense radionuclide uptake in bone scan Spindle-shaped and atypical stromal cells, with irregular nuclei Clinical findings and imaging Nocturnal pain, Pathologic fractures
Infection Gonococcal infection[4] + + - - - + Maculopapular, Pustular, Vesicular lesions on an erythematous base Leukocytosis ↑ Purulent with cell count > 50,000 WBC/µL (with PMNs > 90%) Blood and synovial fluid culture Minor articular damage - - Dermal vasculitis with perivascular neutrophils Nucleic acid amplification tests (NAATs) Dermatitis, Tenosynovitis
Nongonococcal bacterial infections[5] + + - - - + Local erythema Leukocytosis ↑ Purulent with cell count > 50,000 WBC/µL (with PMNs > 90%) Blood and synovial fluid culture Joint effusion, Cartilage destruction, Joint space narrowing Sternoclavicular or sacroiliac joint infections Periarticular osteomyelitis in MRI - Synovial fluid culture Limping, Malaise
Mycobacterial infection - + + + +/- - - - - -
Fungal infection - +/- - - - +/- - - - -
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
Crystal-induced arthritis Gout + + - +/- - + - - - -
Pseudo-gout + - - - - +/- - - - -
Systemic disorders Reactive arthritis[6] +/- +/- - - - - 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
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 Igand RF, Greater propensity for fibrous ankylosis, osseous resorption, and heterotopic bone formation Clinical findings Onycholysis, Splinter hemorrhages
Inflammatory bowel disease-associated arthritis[8] + + - - + +/- Pyoderma gangrenosum(ulcerative colitis),Erythema nodosum(Crohn disease) Iron deficiency anemia, Leukocytosis, Thrombocytosis ↑ Mild to moderate inflammatory fluid, PMNpredominance ↑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
Sarcoid periarthritis[9] + - - - - - 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
Rheumatoid arthritis[10] + - + + + - Rheumatoid nodules Anemia, Thrombocytosis ↑ WBC count >2000/µL (generally 5000-50,000/µL), with neutrophilpredominance (60-80%) Anti-CCP Ab, Hyperuricemia Joint-space narrowing Microfractures Synovitis in MRI Influx of inflammatory cells into the synovial membrane, withangiogenesis Clinical findings coupled anti-CCP antibody Rheumatoid nodules
Myelodysplastic and leukemic disorders[11] + + + +/- - - Petechia and purpura Anemia,

Leukocytosis,

Thrombocytopenia

↑ WBC count >2000/µL (inflammatory), with neutrophilpredominance LDH, Uric acid Articular surface erosion, Synovial effusion Thickened synovium Synovitis in MRI Inflammatory cells infiltration in synovial tissue Bone marrow biopsy Fatigue, Nausea, Recurrent infections

References

  1. ↑ Chen D, Shen J, Zhao W, Wang T, Han L, Hamilton JL; et al. (2017). "Osteoarthritis: toward a comprehensive understanding of pathological mechanism". Bone Res. 5: 16044. doi:10.1038/boneres.2016.44. PMC 5240031. PMID 28149655.
  2. ↑ Punzi L, Galozzi P, Luisetto R, Favero M, Ramonda R, Oliviero F; et al. (2016). "Post-traumatic arthritis: overview on pathogenic mechanisms and role of inflammation". RMD Open. 2 (2): e000279. doi:10.1136/rmdopen-2016-000279. PMC 5013366. PMID 27651925.
  3. ↑ Askling J (October 2007). "Malignancy and rheumatoid arthritis". Curr Rheumatol Rep. 9 (5): 421–6. PMID 17915099.
  4. ↑ Bardin T (April 2003). "Gonococcal arthritis". Best Pract Res Clin Rheumatol. 17 (2): 201–8. PMID 12787521.
  5. ↑ García-De La Torre I, Nava-Zavala A (February 2009). "Gonococcal and nongonococcal arthritis". Rheum. Dis. Clin. North Am. 35 (1): 63–73. doi:10.1016/j.rdc.2009.03.001. PMID 19480997.
  6. ↑ 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.
  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. ↑ Iannuzzi MC, Rybicki BA, Teirstein AS (November 2007). "Sarcoidosis". N. Engl. J. Med. 357 (21): 2153–65. doi:10.1056/NEJMra071714. PMID 18032765.
  10. ↑ Heidari B (2011). "Rheumatoid Arthritis: Early diagnosis and treatment outcomes". Caspian J Intern Med. 2 (1): 161–70. PMC 3766928. PMID 24024009.
  11. ↑ Mekinian A, Braun T, Decaux O, Falgarone G, Toussirot E, Raffray L; et al. (2014). "Inflammatory arthritis in patients with myelodysplastic syndromes: a multicenter retrospective study and literature review of 68 cases". Medicine (Baltimore). 93 (1): 1–10. doi:10.1097/MD.0000000000000011. PMC 4616329. PMID 24378738.


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