Polyarthritis with joint swelling

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

Diseases  | Clinical manifestations | Para-clinical findings  | Gold standard | Additional findings

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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
Other seronegative spondyloarthritides | Ankylosing spondylitis[5] | \+  | \-  | +/-  | +/-  | \+  | \-  | 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[6] | \+  | \-  | \-  | \-  | \-  | \+  | 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[7] | \+  | \+  | \-  | \-  | \+  | +/-  | 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[8] | \+  | \-  | \+  | \+  | \+  | \-  | 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[9] | \+  | +/-  | \-  | \-  | \-  | \+  | 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[10] | \+  | \-  | +/-  | \-  | \-  | \+  | 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
Behçet's syndrome[11] | \+  | \-  | \-  | \-  | \-  | \-  | Erythema nodosum | Normocytic normochromic anemia | ↑  | Cell count < 25% PMNs (non-inflammatory)  | Serum complement levels, Human leukocyte antigen (HLA)-B51  | Soft tissue swelling  | Non-erosive synovitis | \-  | Dermal vessels infiltration with lymphocytes and plasma cells, Immune deposits of immunoglobulin M (IgM) and C3 | Clinical findings  | Oral ulcer, Mucosal erosion
Relapsing polychondritis[12] | \+  | \-  | \-  | \-  | \-  | \-  | \-  | Leukocytosis, Anemia | \-  | Cell count < 25% PMNs (non-inflammatory)  | Cryoglobulins, ANA, C-ANCA | Tracheal stenosis in CXR | Calcification of cartilaginous structures | Aortic root dilatation and degree of aortic regurgitation in echocardiography | Chondrolysis, Chondritis, Perichondritis  | Clinical findings coupled with imaging  | Ear pain and redness, Polyarthritis
Other systemic illnesses | Sarcoidosis[13] | \+  | \-  | \-  | \-  | \-  | \-  | 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
Palindromic rheumatism[14] | \+  | \-  | \-  | +/-  | \+  | \-  | Rheumatoid nodules | Anemia | ↑  | High WBC count (5000-15,000/µL) with >50% of PMN leukocytes | RF, Anti-CCP antibody, ↑Cr or BUN,

↑ALT or AST, ANA

| Effusions in joints | Microfractures | Basilar invagination with cranial migration of an eroded odontoid peg in MRI | Influx of inflammatory cells into the synovial membrane, withangiogenesis, proliferation of chronic inflammatory cells | Clinical findings coupled anti-CCP antibody | Rheumatoid nodules
Polyarticular pain  | Viral arthritis  | Parvovirus[15] | \+  | \+  | +/-  | \-  | \-  | \-  | Fifth disease/ Erythema infectiosum | Aplastic crisis | ↑  | Normal  | ANA, RF, CRP | Joint swelling  | \-  | \-  | Immune complex deposition | Parvovirus IgM antibody | Transient aplastic crisis, Fetal infection
Soft tissue abnormalities  | \+  | \-  | \-  | \-  | \-  | +/-  | Maculopapular rash | Normal  | \-  | Cell count < 25% PMNs (non-inflammatory)  | CRP, Ca | Joint swelling  | Synovial edema and thickness  | Mild joint effusion in ultrasonography | Mild inflammation | Clinical findings  | Mucositis, Enthesitis

## References

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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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
5. ↑ 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.
6. ↑ 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.CS1 maint: Multiple names: authors list (link)
7. ↑ Orchard TR (2012). "Management of arthritis in patients with inflammatory bowel disease". Gastroenterol Hepatol (N Y). 8 (5): 327–9. PMC 3424429. PMID 22933865.
8. ↑ Heidari B (2011). "Rheumatoid Arthritis: Early diagnosis and treatment outcomes". Caspian J Intern Med. 2 (1): 161–70. PMC 3766928. PMID 24024009.
9. ↑ Reginato A, Paul H, Schumacher HR (September 1982). "Crystal-induced arthritis". Arch Phys Med Rehabil. 63 (9): 401–8. PMID 6287963.
10. ↑ Manson JJ, Rahman A (2006). "Systemic lupus erythematosus". Orphanet J Rare Dis. 1: 6. doi:10.1186/1750-1172-1-6. PMC 1459118. PMID 16722594.
11. ↑ Sugawara S, Ehara S, Hitachi S, Sugimoto H (March 2010). "Hand and wrist arthritis of Behçet disease: imaging features". Acta Radiol. 51 (2): 183–6. doi:10.3109/02841850903401349. PMID 20121672.
12. ↑ Emmungil H, Aydın SZ (2015). "Relapsing polychondritis". Eur J Rheumatol. 2 (4): 155–159. doi:10.5152/eurjrheum.2015.0036. PMC 5047229. PMID 27708954.
13. ↑ Iannuzzi MC, Rybicki BA, Teirstein AS (November 2007). "Sarcoidosis". N. Engl. J. Med. 357 (21): 2153–65. doi:10.1056/NEJMra071714. PMID 18032765.
14. ↑ Iyer VR, Cohen GL (February 2011). "Palindromic rheumatism". South. Med. J. 104 (2): 147–9. doi:10.1097/SMJ.0b013e318200c4cc. PMID 21206416.
15. ↑ Moore TL (July 2000). "Parvovirus-associated arthritis". Curr Opin Rheumatol. 12 (4): 289–94. PMID 10910181.