Page 244-250 diagnostic dialemma in diagnosing.pmd

September-December 2012; Vol 10 (No.3);244-250 Acute monoarthritis & mono articular rheumatoid arthritis ¡ Case Report
Diagnostic dialemma in diagnosing acute monoarthritis and mono articular
rheumatoid arthritis of right elbow in a 24 year old young lady
P Chaudhary1, B P Shrestha1, G P Khanal1, R Rijal1, N K Karn1, R Maharjan1, A K Sinha2 1Department of Orthopaedics, 2Department of Pathology B.P.Koirala Institute of Health Sciences, Dharan, Nepal Abstract
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 pseudo gout), trauma, and Here, we present a case of 24-year-old young lady who had presented to the Orthopaedic depatment of B.P.Koirala Institute of Health Sciences, Dharan, Nepal with pain,swelling and restriction of movement of right elbow for 3 days. With all these characteristics and literature reviewed, we thought that this case unique and rare and needs to be reported Keywords: acute monoarthritis, elbow joint, rheumatiod arthritis, incisional biopsy
Introduction
and restriction of movement of right elbow for 3 Joint pain is among the most common complaints days.On physical examination, elbow was swollen, encountered in family practice.2 Many joint disorders tender and lcoal temperature was increased, Skin initially can produce pain and swelling in a single looked shiny, sperficial veins were more promonent.
joint. Because patients with acute monoarthritis often Natural fossae around elbow were obliterated.
present to their family physician, a proper diagnostic approach is important. Acute monoarthritis in adults reduced both on active and passive movement.
can have many causes but crystals, trauma, and Radiological examination showed decreased joint infection are the most common. Prompt diagnosis of space of elbow with periarticular osteopenia. General and systemic examination was within normal limits.
hematogenously, is crucial because of its destructive Routine blood examination was done. All other course.3 True intraarticular problems cause
parameters were within normal limits except erythro restriction of active and passive range of motion, sedimentation rate which was increased. Based on whereas periarticular problems restrict active range clinicoradiological findings, Anti-tubercular drugs of motion more than passive range of motion.
were started. Patient improved symptomatically with ATT drugs in terms of pain, swelling and range of Case report
movement. She took ATT for 15 months. After 2-3 24-year-old young lady who had presented to the months of stoppage of ATT, she again had recurrence Orthopaedic depatment of B.P.Koirala Institute of of symptoms with pain, swelling, tenderness and Health Sciences, Dharan, Nepal with pain, swelling restricted movements of elbow. MRI scanning of __________________________________________________ elbow was done which came to be inconclusive. After routine investigation, PAC was done and Incisional Associate Professor, Department of Orthopaedics biopsy was done and material was sent for BP Koirala Institute of Health Sciences, Nepal histopathological examination. The HPE report suggestive of rheumatoid arthritis of elbow. Patient September-December 2012; Vol 10 (No.3);244-250 Acute monoarthritis & mono articular rheumatoid arthritis together along with steroid. she is taking DMRDSfor last 4 weeks with symptomatic improvement.
Fig:3 Post- operative photographs after incisional Etiology of acute monoarthritis
Acute monoarthritis in adults can have many causes Fig:1 Pre-operative photograph of right elbow joint but crystals, trauma, and infection are the most common. Prompt diagnosis of joint infection, which often is acquired hematogenously, is crucial because of its destructive course. A prospective, three-year study3 found that the most important risk factors for septic arthritis are a prosthetic hip or knee joint, skin infection, joint surgery, rheumatoid arthritis, age greater than 80 years, and diabetes mellitus.
Intravenous drug use and large-vein catheterization are predisposing factors for sepsis in unusual joints (e.g., sternoclavicular joint).4
Causes of acute monoarthritis
Common causes
Less common causes
Bowel-disease–associated arthritis Behçet’s syndrome Calcium pyrophosphate dihydrate Juvenile rheumatoid arthritis September-December 2012; Vol 10 (No.3);244-250 Acute monoarthritis & mono articular rheumatoid arthritis Gonococcal arthritis is the most common type of non- monoarticular swelling.11 The pain characteristically traumatic acute mono-arthritis in young, sexually worsens with movement and improves with rest.
active persons in the United States. It is three to There may be no history of trauma in patients with four times more common in women than in men.5,6 fractures secondary to osteoporosis.12 Penetrating Non-gonococcal septic arthritis, the most destructive injuries, such as those from thorns, can cause acute type, generally is monoarticular (80 percent of cases) synovitis, with symptoms sometimes occurring and most often affects the knees (50 percent of cases).4,7 Staphylococcus aureus is the most Patients might note concurrent or preexistent common pathogen in non-gonococcal septic arthritis involvement of other joints. Sequential monoarthritis (60 percent in some series), but non–group-A beta- in several joints is characteristic of gonococcal hemolytic streptococci, gram-negative bacteria, and arthritis or rheumatic fever. Monoarthritis Streptococcus pneumoniae can be present.4 occasionally is the first presenting symptom of an Anaerobic and gram-negative infections are common inflammatory polyarthritis such as psoriatic arthritis in immunocompromised persons. Inflammation of a but is an unusual initial symptom of rheumatoid single large joint, especially the knee, may be present arthritis. When the history reveals longstanding in Lyme disease. Mycobacterial, fungal, and viral symptoms in a joint, exacerbations of pre-existing infections are rare. Monoarticular inflammation can disease (e.g., worsening of osteoarthritis with excessive use) should be differentiated from a superimposed infection. In patients with rheumatoid arthritis, pain in one joint out of proportion to pain in monoarthritis, but monosodium urate (which causes other joints always suggests infection.14 gout) and calcium pyrophosphate dihydrate (CPPD, Sexual history and history of illegal drug use, alcohol which causes pseudogout) are the most common.
use, travel, and tick bites should be ascertained.
Calcium oxalate (especially in patients who are Reactive arthritis sometimes can develop after a receiving renal dialysis), apatite, and lipid crystals gastrointestinal or sexually transmitted disease.
Certain occupations, such as farming and mining, Transient arthritis sometimes results from intra- frequently are associated with overuse injuries and articular injection of corticosteroids. Osteoarthritis may worsen suddenly and manifest as pain and Pseudo gout affecting the wrists and knees is most effusion. Spontaneous osteonecrosis may occur in common among elderly persons. Disseminated patients with risk factors such as alcoholism or chronic gonococcal infection, reactive arthritis, and corticosteroid use. Aseptic loosening is often the ankylosing spondylitis affect young adults. Gout, source of pain in a prosthetic joint. Infection, which occurs more often in men, affects the first commonly from a skin source, is also possible and metatarsophalangeal joint, ankle, mid-foot, or knee; accompanying fever, redness, and pain can mimic infection. Minor trauma can precipitate gout or introduce infection through a break in the skin.9 Any acute inflammatory process that develops in a single joint over the course of a few days is Physical examination
considered acute monoarthritis (also defined as When a patient complains of joint pain, the first step monoarthritis that has been present for less than two is to determine whether the source of the pain is the weeks).10 Establishing the chronology of symptoms joint or a periarticular soft tissue structure such as a is important. Rapid onset over hours to days usually bursa or tendon. It is not uncommon to find that "hip indicates an infection or a crystal-induced process.
pain" actually is the result of trochanteric bursitis.
Fungal or mycobacterial infections usually have an Asking the patient to point to the exact site may be indolent and protracted course but can mimic bacterial helpful.15 Unlike with true joint inflammation, redness or swelling generally is not present with periarticular Fractures and ligamentous or meniscal tears resulting pain. However, a patient with inflammation of certain from trauma can present as mild to moderate bursae (e.g., prepatellar bursitis, olecranon bursitis) September-December 2012; Vol 10 (No.3);244-250 Acute monoarthritis & mono articular rheumatoid arthritis may present with redness or swelling that mimics Diagnostic studies
Arthrocentesis is required in most patients with True intraarticular problems cause restriction of monoarthritis and is mandatory if infection is active and passive range of motion, whereas suspected. In some instances, obtaining as little as periarticular problems restrict active range of motion one or two drops of synovial fluid can be useful for more than passive range of motion. Maximum pain at the limit of joint motion (i.e., stress pain) is For arthrocentesis, the joint line is identified, and a characteristic of true arthritis. In tendonitis or bursitis, pressure mark is made on the overlying skin with joint movements against resistance elicit pain. For the closed end of a retractable pen. The skin is example, elbow pain resulting from septic arthritis cleansed, and a needle is inserted without the occurs with active and passive motion in any physician’s finger touching the marked site, unless a direction. In contrast, elbow pain resulting from lateral sterile glove is worn. If the fluid withdrawn is initially epicondylitis (i.e., "tennis elbow") worsens with bloody rather than becoming bloody during aspiration, resisted active extension or supination of the wrist.
previous hemarthrosis should be suspected. Additional Specific manoeuvres’ can be diagnostic for other details on performing arthrocentesis are available conditions, such as medial epicondylitis; bicipital and rotator cuff tendonitis; troch-anteric bursitis; and Superimposed cellulitis is a relative contraindication patellar, prepatellar, and anserine bursitis.16 to arthrocentesis. The procedure can be performed Joint effusion may not be readily visible. In the knee safely in patients who are taking warfarin joint, the "bulge sign" can signal a small effusion.
(Coumadin).20 An experienced physician should The medial or lateral compartment is stroked, and perform arthrocentesis in these patients and use the the fluid moves through the suprapatellar area into the opposite compartment, resulting in a visible bulge.
Removal of as much synovial fluid as possible offers To detect effusion in the elbow joint, the triangular symptomatic relief and helps to control infection. If recess (area between lateral epicondyle, olecranon the fluid is loculated, aspiration of large amounts of process, and radial head) in the lateral aspect should fluid will be difficult; massaging the joint may help be palpated. To detect effusion in the ankle, the joint increase the amount of fluid aspirated. If infection is should be palpated anteriorly. Manoeuvres’ for suspected, intravenous antibiotics should be examining other joints are reviewed elsewhere.17 administered before culture results become available.
Joint pain may be referred from internal organs (e.g., If needle drainage is ineffective, urgent arthroscopic shoulder pain in a patient with angina). Referred pain or surgical drainage is indicated. Until infection has should be suspected in patients with a normal joint been ruled out, corticosteroids should not be injected into a joint. If even the smallest suspicion of infection The general physical examination may provide other exists, synovial fluid should be sent for a white blood diagnostic clues or reveal involvement of other joints.
cell (WBC) count with differential (specifically, the Fever and tachycardia may signal infection, but they percentage of polymorphonuclear neutrophilic are not reliable indicators, especially in leukocytes), crystal analysis, Gram staining, and immunocompromised patients and patients who are culture. Lipid panels and synovial fluid tests for other taking corticosteroids or antibiotics. Patients with chemistries, proteins, rheumatoid factor, or uric acid gonococcal infection may have a rash, pustules, or are not useful because the results may be misleading21.
hemorrhagic bullae. Patients with longstanding gout Sterile tubes should be used for culture. If may have tophi (i.e., firm subcutaneous deposits of urate) over the olecranon prominence, first metatarsal ethylenediaminetettraacetic acid should be used for joints, or pinnae. Patients with reactive arthritis may anticoagulation, because anticoagulants (e.g., oxalate, have inflamed eyes. A new cardiac murmur and lithium heparin) used in other tubes can confound splinter hemorrhages in the nail folds suggest crystal analysis.19 Synovial fluid cultures are more likely to be positive in patients with nongonococcal arthritis (90 percent) than in those with gonococcal September-December 2012; Vol 10 (No.3);244-250 Acute monoarthritis & mono articular rheumatoid arthritis Synovial fluid may be categorized as noninflammatory, about 50 percent of non-gonococcal infections25 but inflammatory, or hemorrhagic, depending on the are rarely positive (about 10 percent) in gonococcal appearance and cell counts. Normal synovial fluid is infection.26 Pharyngeal, urethral, cervical, and rectal colorless and transparent. Noninflammatory synovial swabs are necessary if gonococcal infection is fluid may be colorless or yellow and transparent enough to read through, whereas inflammatory Although plain-film radiographs often show only soft tissue swelling, they are indicated in patients with a The complete blood cell count may show leukocytosis history of trauma or patients who have had symptoms in some patients with infection. An erythrocyte for several weeks. Occasionally, unsuspected bony sedimentation rate may distinguish inflammatory lesions, such as osteomyelitis or malignancy, may be arthritis from noninflammatory arthritis, but this test detected. The presence of chondrocalcinosis could is nonspecific and may be overused. Tests for HIV support but not confirm CPPD arthritis.
and Lyme disease antibodies may be obtained if Radionuclide scanning can detect infection in deep- appropriate, but serologies usually are not helpful in seated joints. Magnetic resonance imaging is superior identifying the cause of acute monoarthritis.19,23 in detecting ischemic necrosis, occult fractures, and Indiscriminately ordering tests such as rheumatoid meniscal and ligamentous injuries. Other diagnostic factor and antinuclear antibodies can result in procedures, such as synovial biopsy or arthroscopy, confusion, because false-positive results are common.
may be useful to rule out deposition diseases (e.g., Blood cultures should be obtained in patients with hemochromatosis, atypical infections) and suspected septic arthritis. Cultures are positive in Common errors in diagnosing acute monoarthritis 1
Error
Reality
The problem is in the joint, because the The soft tissues around the joint can be the source of the pain (e.g., olecranon bursitis of the elbow, prepatellar bursitis of the knee). Crystal-proven diagnosis of gout or Crystals can be present in a septic joint. The presence of fever is useful in Fever may be absent in patients with infectious monoarthritis but distinguishing infectious causes from can be a presenting feature in acute attacks of gout or pseudogout. Fever may occur for other reasons in certain patients (e.g., the A normal serum uric acid level makes Serum uric acid levels often are lowered in patients with acute gout. Conversely, there may be unrelated hyperuricemia in patients with Gram staining and culture of synovial Cultures of blood, urine, or another primary site of infection (e.g., fluid are sufficient to exclude infection. abscess) must be obtained and repeated as necessary if infection is strongly suspected clinically. Culture results may be negative in Discussion
arthritis. Acute monoarthritis can be the initial Any acute inflammatory process that develops in a manifestation of many joint disorders. The first step single joint over the course of a few days is in diagnosis is to verify that the source of pain is the considered acute monoarthritis (also defined as joint, not the surrounding soft tissues5. The most monoarthritis that has been present for less than two common causes of monoarthritis are crystals (i.e., weeks).10 Establishing the chronology of symptoms gout and pseudo gout), trauma, and infection. A is important. Rapid onset over hours to days usually careful history and physical examination are indicates an infection or a crystal-induced process.
important because diagnostic studies frequently are Fungal or mycobacterium infections usually have an only supportive. Examination of joint fluid often is indolent and protracted course but can mimic bacterial essential in making a definitive diagnosis. Leukocyte September-December 2012; Vol 10 (No.3);244-250 Acute monoarthritis & mono articular rheumatoid arthritis counts vary widely in septic and sterile synovial fluids and should be interpreted cautiously. If the history bacterial arthritis. Rheum Dis Clin North Am.
and diagnostic studies suggest an infection, aggressive treatment can prevent rapid joint destruction. When 8. Berman A, Cahn P, Perez H, Spindler A, an infection is suspected, culture and Gram staining should be performed and antibiotics should be started.
immunodeficiency virus infection associated The general physical examination may provide other arthritis: clinical characteristics. J Rheumatol.
diagnostic clues or reveal involvement of other joints.
Fever and tachycardia may signal infection, but they are not reliable indicators, especially in Rabinowitz JL. Acute monoarthritis associated immunocompromised patients and patients who are with lipid liquid crystals. Ann Rheum Dis. 1985; 10. Freed JF, Nies KM, Boyer RS, Louie JS. Acute Conclusion
monoarticular arthritis. A diagnostic approach.
Joint pain is among the most common complaints encountered in Orthopaedic practice. Acute 11. Till SH, Snaith ML. Assessment, investigation, monoarthritis in adults can have many causes but and management of acute monoarthritis. J Accid crystals, trauma, and infection, are the most common.
Mono articular rheumatoid arthritis of elbow joint
12. Cibere J. Rheumatology: 4. Acute monoarthritis.
is extremely rare and most of time confused with infection. A careful history, physical, radiological and histopathological examination is important monoarthritis. N Engl J Med. 1993; 329:1013– References
14. Goldenberg DL. Infectious arthritis complicating 1. Siva C, Velazquez C, Mody A, Brasington R, rheumatoid arthritis and other chronic rheumatic Diagnosing acute monoarthritis in adults: A disorders. Arthritis Rheum. 1989; 32:496–502.
practical approach for family physician, Am Fam 15. Ensworth S. Rheumatology: 1. is it arthritis? 2. Stange KC, Zyzanski SJ, Jaen CR, Callahan EJ, 16. Sheon RP, Moskowitz RW, Goldberg VM. Soft Kelly RB, Gillanders WR, et al. Illuminating the tissue rheumatic pain: recognition, management ‘black box’. A description of 4454 patient visits and prevention. 3d ed. Baltimore: Williams & to 138 family physicians. J Fam Pract. 1998; 17. El-Gabalawy H. Evaluation of the patient: history 3. Kaandorp CJ, Van Schaardenburg D, Krijnen and physical examination. In: Klippel JH, P, Habbema JD, van de Laar MA. Risk factors Weyand CM, Crofford LJ, Stone JH. Primer on for septic arthritis in patients with joint disease.
the rheumatic diseases. 12th ed. Atlanta: Arthritis A prospective study. Arthritis Rheum. 1995; 4. Goldenberg DL. Septic arthritis. Lancet. 1998; arthrocentesis. Prim Care. 1993; 20:757–70.
19. Fye KH. Arthrocentesis, synovial fluid analysis, 5. O’Brien JP, Goldenberg DL, Rice PA.
and synovial biopsy. In: Klippel JH, Weyand CM, Crofford LJ, Stone JH. Primer on the rheumatic prospective analysis of 49 patients and a review diseases. 12th ed. Atlanta: Arthritis Foundation, of path physiology and immune mechanisms.
Medicine [Baltimore]. 1983; 62:395–406.
20. Thumboo J, O’Duffy JD. A prospective study 6. Cucurull E, Espinoza LR. Gonococcal arthritis.
of the safety of joint and soft tissue aspirations Rheum Dis Clin North Am. 1998; 24:305–22.
and injections in patients taking warfarin sodium.
September-December 2012; Vol 10 (No.3);244-250 Acute monoarthritis & mono articular rheumatoid arthritis 21. Shmerling RH, Delbanco TL, Tosteson AN, detection and identification of crystals in synovial Trentham DE. Synovial fluid tests. What should fluid. Ann Rheum Dis. 1989; 48:983–5.
be ordered? JAMA. 1990; 264:1009–14.
24. McCune WJ, Golbus J. Monoarticular arthritis.
22. Wise CM, Morris CR, Wasilauskas BL, Salzer In: Ruddy S, Harris ED, Sledge CB, Kelley WN.
WL. Gonococcal arthritis in an era of increasing Kelley’s Textbook of rheumatology. 6th ed.
penicillin resistance. Presentations and outcomes Philadelphia: Saunders, 2001:367–77.
in 41 recent cases (1985–1991). Arch Intern 25. Esterhai JL Jr, Gelb I. Adult septic arthritis.
Orthop Clin North Am. 1991; 22:503–14.
23. Pascual E, Tovar J, Ruiz MT. The ordinary light 26. Cucurull E, Espinoza LR. Gonococcal arthritis.
microscope: an appropriate tool for provisional Rheum Dis Clin North Am. 1998; 24:305–22.

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