OA, polyarthritis

Types of arthritis: SOLOMON SALLFORS

Neuropathic
Gout, first
Pseudogout/ CPPD,
arthropathy
monoarthritis, poly
monoarthritis
(charcots joint) in late disease
NonInflammatory, nonInflammatory, noninflammatory
infectious
infectious

Classification

Non-inflammatory,

Pathogenesis

Degeneration, trauma,
obesity, cytokines
activate
metalloproteases which
degrade collagen (type
2) and proteoglycans,
hemochromatosis

Presentation

Insidious, Joint
DM,
crepitus, onset typically syringomyela,
women >50yo, almost
tabes dorsalis
universal over 65yo,
joint stiffness after
resting (gelling),
chronic, over years;
worse with use;

2nd neurologic
disease, loss
propioception
and deep
sensation leads
to recurrent
truama

Primary: inborn
error of purine
metab., 2nd : underexcretion (80-90%;
lead poison,
alcoholism, diet high
in meat, seafood,
beer) or overproduction (10-20%;
cell lysis, leukemia
treatment) uric acid.
Crystals proinflammatory, complement
C5a activated,
Neutrophils
phagocytose
crystals,

Calcium deposition
in cartilage (less
common tendons,
ligament, bursa,
synovium),
chondrocalcinosis,
neutrophils
phagocytose
crystals,

Men >30 (95%),

attacks begin at
night and worse first
12 hrs, fever/chills,
women after
menopause, CAD,
HTN, kidney stones;
triggered by diet,
illness, stress,
exercise, HCTZ;

Most common in
elderly, 50% occur
in >85yo; 4 variants:
most common OA;
Increased in
hemochromatosis,
hemosiderosis,
primary hyperparathyroidism,

Septic, monoarthritis, pain on

passive ROM
Inflammatory,
infectious, separated
by infectious agent
below
Lyme, migratory
(adult doxycycline,
child amoxicillin),
erythmema
chronicus migrans,
bells palsy; ELISA
screen, Western blot
confirm, poss PCR;
co-infect with
babesiosis,
hemolytic anemia
(atorvaquone+
azithromycin),
wright/giemsa stain,
serologic;

RA, polyarthritis,
non-erythematous

Gonococcal
(ceftriaxone), urban
pop., disseminated
more common in
women, knee wrist
ankles,

Insidious, Women
30-50, Morning
stiffness,
improves with
use, Freq
misdiagnosed as
DVT, Rheumatoid
nodules (20%
pts),
lung/heart/cervical

Inflammatory,
hypersensitivity
type 3
RF (anti-Fc IgM)
complexes with
IgG, which
activates
complement C5a,
WBCs enter jt
space to form
granulation tissue
(pannus), which
leads to scar
tissue/ankylosis,
esp inflams
synovium

sudden onset; fever,

tachycardia;
Chronic tophi
PE/Most common
joints

hands/esp 1st carpalmetacarpal (Watsons

test), knee/femoral
head, cervical/lumbar
vertebrae, mild
effusion,

disease, Sjogren
syndrome

1st podagra on
Knee most common,
tragus, 50% of first
more symmetrical
attacks, then
than gout
extensor
tenosynovium on
midfoot dorsum; red,
hot swollen;

Non-gonococcal,
migratory (MC
S.aureus,
nafcillin+3rd gen
ceph),
immunosuppressed,
CKD, bacteremia,
prosthetic joint,
blood cultures, Most
common in all joints
and prosthetics,

Joint aspiration/
analysis; needle,
negative birefringent
(yellow); uric acid
level >7 men, >6
women; 24 hour
urine uric acid <700
(under-excreters),
>900 (overproducers)
Punched out
erosions with
overhanging rim of
cortical bone

Cat/dog bite:
P.multocida,
amoxicillin+
clavulanate

3 of following: >50age,
stiffness <30mins,
boney tenderness, no
warmth, boney
enlargement, crepitus

Labs

Plain films
BCP crystals in 50%

Imaging

Fluid analysis

Narrowed jt space,
osteophytes,
subchrondral cysts and
sclerosis, findings dont
correspond to
symptoms
<2000 WBC, <25%
PMN

>5000 WBC, 5070% PMN

Plain films (linear

deposits), joint
aspiration;
rhomboid, weakly
positive birefringent
(blue)

linear deposits

Highly
Symmetric, distal
joints, Swan-neck
deformity (PIP
extended, DIP
flexed),
Boutoniere
demormity (opp
Swan neck), ulnar
deviation of MCP,
questionable
sparing DIP,
limited ROM, no
erythema,
RA, ANA, C3,
anti-CCP,

Narrowed jt
space, boney
erosions

>50,000 WBC, 7090 PMN, blood and

fluid cultures 90%

positive; except
gonococcal 25%
positive
Tx

Wt loss, PT, Heat,

Tylenol (limited
NSAIDs for
breakthrough pain),
assist devices, joint
unloading, ROM
exercises,
viscosupplementation

Immobilization,
pneumatic
walking devices

Diet control
Acute: NSAIDs,
colchicine (no
aspirin or tylenol)
Prophylactic:
uricosuric/
probenecid for
underexcreters,
allopurinol for
overproducers;
TARGET URIC
ACID <5

NSAIDs,
colchicines,
arthroscopic surgery

PT, Swim therapy,

NSAIDs, steroids,
methotrexate,
cyclosporine, gold
compounds,
hydroxylchloroquine,