Download Approach to Patient with Monoarthritis by Dr Maryam khalil

APPROACH TO PATIENT
WITH MONOARTHRITIS
Dr Maryum khalil
HO MU1 HFH
MONOARTHRITIS
“Inflammation of a single joint”
*Acute
*Chronic
CAUSES OF ACUTE
MONOARTHRITIS
IN A PREVIOUSLY NORMAL JOINT:
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Septic arthritis
Crystal synovitis
Trauma
Haemarthrosis
Foreign body
reaction

Monoarticular presentation
of oligo- / polyarthritis
R.A
Erythema nodosum
Juvenile Idiopathic
arthritis
Reactive, Psoriatic or
other Seronegative
spondarthritis
IN A PREVIOUSLY ABNORMAL JOINT
DAMAGED JOINT:
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EXISTING
INFLAMMATORY
DISEASE ( WITH OR
Pseudogout in assc WITHOUT DAMAGE):
with O.A
Bone disease

Septic arthritis
Cartilage disease

Exacerbation of underlying
Haemarthrosis
disease
Septic arthritis
CAUSES OF CHRONIC
MONOARTHRITIS
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Foreign body
Infection
Ch. Sarcoidosis
Enteropathic Arthritis (mainly Crohn’s)
Amyloidosis
Pigmented villonodular synovitis
Synovial pathology (sarcoma, chondromatosis)
Monoarticular presentation of oligo- / poly
articular disease
HISTORY & PHYSICAL
EXAMINATION

Acute monoarthritis can be the initial
manifestation of many joint disorders. The first
step in diagnosis is to verify that the source of
pain is the joint, not the surrounding soft tissues.
The most common causes of monoarthritis are
crystals (i.e., gout and pseudogout), trauma, and
infection. A careful history and physical
examination are important because diagnostic
studies frequently are only supportive.
DIAGNOSTIC CLUES
Clues from history and
physical examination
Diagnoses to consider

Sudden onset of pain in
seconds or minutes

Fracture, internal
derangement, trauma,
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Onset of pain over
several hours or one to
two days

Infection, crystal deposition
disease, other
inflammatory arthritic
condition

Insidious onset of pain
over days to weeks

Indolent infection,
osteoarthritis, infiltrative
disease, tumor
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Intravenous drug use,
immunosuppression
Previous acute attacks in
any joint, with
spontaneous resolution

Septic arthritis

Recent prolonged course
of corticosteroid therapy
Coagulopathy, use of
anticoagulants
Urethritis, conjunctivitis,
diarrhea, and rash
Psoriatic patches or nail
changes such as pitting


Crystal deposition
disease, other
inflammatory arthritic
condition
Infection, avascular
necrosis
Hemarthrosis

Reactive arthritis

Psoriatic arthritis

Use of diuretics,
presence of tophi, history
of renal stones
 Eye inflammation, low
back pain

Young adulthood,
migratory
polyarthralgias,
inflammation

Hilar adenopathy,
erythema nodosum

Gout

Ankylosing spondylitis

Gonococcal arthritis of
the tendon sheaths of
hands and feet,
dermatitis

Sarcoidosis
DIAGNOSTIC STUDIES
1-SYNOVIAL FLUID EXAM:
Arthrocentesis is required in most patients with
monoarthritis and is mandatory if infection is suspected.
In some instances, obtaining as little as one or two drops
of synovial fluid can be useful for culture and crystal
analysis.
Cell counts
B) Microscopy
C) C/S
A)
Categorization of Synovial Fluid
Noninflammatory: <2,000
WBC per mm3
Inflammatory: >2,000
WBC per mm3


Osteoarthritis
 Trauma
 Avascular necrosis
 Charcot's arthropathy
 Hemochromatosis
 Pigmented villonodular
synovitis
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Septic arthritis
Crystal-induced
monoarthritis (e.g., gout,
pseudogout)
Rheumatoid arthritis
Spondyloarthropathy
SLE
Juvenile R.A
Lyme disease
MICROSCOPY:
C/S:
Synovial fluid cultures are more likely to be
positive in patients with nongonococcal arthritis
(90 percent) than in those with gonococcal
arthritis (less than 50 percent).
2- CBC & ESR
4- BLOOD CULTURE
Blood cultures should be obtained in
patients with suspected septic arthritis.
Cultures are positive in about 50 percent of
nongonococcal infections but are rarely
positive (about 10 percent) in gonococcal
infection.
Pharyngeal, urethral, cervical, and rectal
swabs are necessary if gonococcal infection
is suspected
5-RADIOGRAPHY:
Although plain-film radiographs
often show only soft tissue
swelling, they are indicated in
patients with a history of trauma
or patients who have had
symptoms for several weeks.
Occasionally, unsuspected bony
lesions, such as osteomyelitis or
malignancy, may be detected.
5-MRI:
Magnetic resonance imaging is superior in detecting
ischemic necrosis, occult fractures, and meniscal and
ligamentous injuries.
6-RADIONUCLIDE SCANS:
Radionuclide scanning can detect infection in
deep-seated joints.
7- OTHERS:
Other diagnostic procedures, such as synovial
biopsy or arthroscopy, may be useful to rule out
deposition diseases (e.g., hemochromatosis,
atypical infections) and intra-articular tumors.
SEPTIC ARTHRITIS
 Bacterial
Gonococcal
Non-gonococcal(Staphylococcus aureus ,
nongroup-A beta-hemolytic streptococci, gramnegative bacteria, and Streptococcus pneumoniae)
– HBV, Rubella, Mumps, I.M, Parvovirus,
Enterovirus, Adenovirus
 Viral
 Fungal
MANAGEMENT
1- Hospitalization
2- Gen. Supportive care
3- I/V Antibiotics
4- Repeated Arthrocentesis
5- Surgical Drainage
CRYSTAL INDUCED
SYNOVITIS
A- GOUT:
ACUTE:
NSAIDs, Glucocorticoids,Colchicine
CHRONIC:
Allopurinol, Uricosuric Drugs
B- PSEUDOGOUT:
- May present as acute mono- or
oligoarthritis mimicking Gout, or as a
chronic polyarhthritis mimicking R.A &
O.A
- NSAIDs, Glucocorticoids, Colchicine
C- APATITE DISEASE:
- May present with periarthritis or
tendinitis
- Rx same as Pseudogout
QUESTIONS
A 67 year old male presents with his first
episode of knee pain and swelling
together with the following x-ray.
Which of the following
investigations is the next
investigation indicated
diagnostically?
(a) Thyroid function tests
(b) Serum urate
(c) Knee aspiration
(d) Serum iron
(e) Skeletal survey
The following pelvic x-ray displays
radiographic features of which of the
following rheumatic disorders?
(a)Rheumatoid arthritis
(b) Paget’s disease
(c) Osteonecrosis
(d) Osteoarthritis
(e) None of the above
Which of the following types of joint
involvement is not seen in psoriatic
arthritis?
(a) Symmetrical small joint arthropathy
(b) Jaccoud’s arthropathy
(c) Sacroiliitis
(d) Monoarthritis
(e) DIP joint arthropathy
In septic arthritis which one of the
following pairings is most commonly
found in hospital practice?
(a) Ankle joint and Staph Aureus
(b) Knee joint and MRSA
(c) Wrist joint and Beta haemolytic
streptococci
(d) Knee joint and Staph Aureus
(e) Hip joint and Staph Aureus
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