Evaluation of inflamed joint

Diseases

Summary

Inflammatory arthritis is a common term for several conditions that manifest as joint pain, swelling, and stiffness with varying degrees of functional impairment. These diseases can be broadly categorized as:

Infectious arthritis
Immune-mediated arthritis
Noninfectious and nonimmune-mediated inflammatory arthritis
Paraneoplastic arthritis
Neoplastic arthritis.

In patients with pain and swelling in a single joint, acute infection is a relatively common cause - one that can result in rapid and irreversible damage. In contrast, the majority of patients with involvement of multiple joints tend to have disorders of chronic duration. The prognosis is good for those who remain unclassifiable, with nearly 50% of such patients undergoing remission requiring no pharmacologic therapy at follow-up at 1 year.

Image

Differentiation of joint pain

In addition to inflammatory joint diseases, joint pain can also be due to:

Joint damage (e.g., osteoarthritis, or trauma leading to a fracture or internal derangement)
Referred pain
Altered pain threshold (as is seen in central sensitization syndromes such as fibromyalgia).

Pain due to an intra-articular pathology needs to be differentiated from referred pain arising from adjacent soft tissues or juxta-articular bone. In the context of referred pain, the range of motion of the joint is usually unaffected, and joint motion does not aggravate pain, whereas palpation over a regional bursa, tendon, or ligament can elicit pain.

Characteristics of inflammation

The classic signs of inflammation generally also apply to inflammatory joint disease:

Pain (aggravated by movement)
Erythema
Warmth
Swelling
Stiffness
Limitation of range of motion.

It is usually not possible to detect all of the above features (especially swelling and erythema) in deep-seated joints such as the shoulders, hips, intervertebral joints, and sacroiliac joints.

Mono- versus poly- site arthritis

Most causes of oligoarthritis (involving 2-4 joints) or polyarthritis (involving ≥5 joints) can also be causes of monoarthritis, because almost any arthritic condition can initially affect a single joint. The most important and serious condition that needs to be considered in the workup of an acute monoarthritis is septic (pyogenic) nongonococcal arthritis. If the diagnosis is missed and appropriate antimicrobial therapy is not instituted early, rapid destruction of articular cartilage can lead to irreversible joint damage.

Library

Acute monoarthritis of the right knee
Calcium pyrophosphate dihydrate (CPPD) crystals in synovial fluid under compensated polarized light microscopy
Tophaceous gout
Monosodium urate crystals from a tophus (polarized light microscopy)
Chondrocalcinosis (lateral meniscus of left knee)
Dactylitis of right third toe (reactive arthritis)
Rheumatoid nodules
Rheumatoid hand x-ray
Rheumatoid arthritis (chronic hand deformities)
Psoriatic arthritis with dactylitis (left middle and right index finger); skin and nail changes (left ring finger)
Erythema nodosum
Pulmonary sarcoidosis: right paratracheal, bilateral perihilar, and subcarinal adenopathy

Citations

Key Articles

Hazlewood GA, Aletaha D, Carmona L, et al. Algorithm for identification of undifferentiated peripheral inflammatory arthritis: a multinational collaboration through the 3e initiative. J Rheumatol Suppl. 2011 Mar;87:54-8.[Abstract]
Qaseem A, McLean RM, Starkey M, et al. Diagnosis of acute gout: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017 Jan 3;166(1):52-7.[Abstract][Full Text]
Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sep;62(9):2569-81.[Abstract][Full Text]
Plagou A, Teh J, Grainger AJ, et al. Recommendations of the ESSR Arthritis Subcommittee on Ultrasonography in Inflammatory Joint Disease. Semin Musculoskelet Radiol. 2016 Nov;20(5):496-506.[Abstract]

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