Review Article. Appraoch to Patients with Polyarticular Symptoms. Introduction. Raymond WS Wong

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1 Review Article Appraoch to Patients with Polyarticular Symptoms Raymond WS Wong Abstract: Keywords: Polyarticular symptoms represent the most common symptom complex resulting in referral to a rheumatologist for consultation. They are not caused only by lesions in the joints but also by a list of other possible pathologies. The approach to patients with polyarticular symptoms is not fundamentally different from the approach to patients with any other medical problem. With a careful history, a good physical examination and appropriate laboratory tests and radiographs, the rheumatologist is very often able to establish eventually the correct diagnosis and institute appropriate therapy. Acute polyarthritis, chronic polyarthritis, inflammatory, non-inflammatory Introduction Chronic pain in and around multiple joints is the most common symptom complex resulting in referral to a rheumatologist for consultation, amounting to 58% in a personal series. This is in accord with the experience of others. The evaluation of chronic polyarthritis is not only the most common intellectual exercise facing the rheumatologist but also one of the most rewarding. Polyarticular symptoms are not caused only by lesions in the joints but also by a list of other possible pathologies as listed in Table 1. Table 1. Differential diagnosis of polyarticular symptoms Polyarthralgia / Polyarthritis Tendonitis and related disorders Fibrositis Muscular disorders Neuropathies Primary bone disease Functional / Psychogenic Unknown origin These problems can be classified into one of the four broad categories: inflammatory, degenerative-metabolic, functional (including neurotic), or of unknown origin. This classification does not deny the existence of an inflammatory component in a degenerative disorder or a degenerative component of inflammatory arthritides. There may be an organic component even in those syndromes listed as 'psychogenic'. Conversely, there is often a functional component to most organic illnesses. The 'unknown' category is important because of the tendency by many clinicians to 'force' a given patient's musculoskeletal complaints into a diagnostic pigeonhole. New syndromes and subsets of old ones are constantly being recognized. Polyarthralgia is defined as pain in 5 or more joints without demonstrable inflammation by physical examination. Polyarthritis is definite inflammation of 5 or more joints demonstrated by physical examination. A patient with 2 to 4 involved joints is said to have pauci- or oligo- articular arthritis. Chronic polyarthritis can be arbitrarily defined as symptoms persisting in the joints for more than 6 weeks. Diseases commonly presenting with acute and chronic polyarthritis are listed in Table 2. DEPARTMENT OF MEDICINE, QUEEN MARY HOSPITAL, 102 POKFULAM ROAD, POKFULAM, HONG KONG SAR Raymond WS Wong FRCP, FHKAM(Medicine) Correspondence to: Raymond WS Wong The approach to patients with polyarticular symptoms is not fundamentally different from the approach to patients with any other medical problem. With a careful history, a good physical examination, and appropriate laboratory tests and radiographs, a physician can establish the diagnosis and begin appropriated therapy in almost all cases. 20 Hong Kong Bulletin on Rheumatic Diseases

2 WONG Table 2. Diseases commonly presenting with acute and chronic polyarticular Diseases commonly presenting with acute polyarticular symptoms Inflammatory conditions Infection Rheumatoid arthritis Gonococcal Systemic lupus erythematosus Meningococcal Reiter's syndrome Lyme's disease Psoriatic arthritis Acute rheumatic fever Polyarticular gout Bacterial endocarditis Viral (esp. rubella, hepatitis B, parvovirus, Epstein-Barr, HIV) Diseases commonly presenting with chronic (persisting >6 weeks) polyarticular symptoms Inflammatory Non-inflammatory Rheumatoid arthritis Osteoarthritis Systemic lupus erythematosus Fibromyalgia Progressive systemic sclerosis Benign hypermobility syndrome Polymyositis Reiter's syndrome Psoriatic arthritis Enteropathic arthritis Polyarticular gout Calcium pyrophosphate deposition (CPPD) disease Vasculitis Polymyalgia rheumatica History Taking The clinical history is by far the most important diagnostic tool in the evaluation of polyarticular disorders. A number of items deserve special attention. One should direct attention to the temporal pattern of the joint involvement. Three distinct patterns are recognized. The additive pattern is used to describe a clinical syndrome which tends to add on features as it flares and to substract these features in a similar manner as it becomes quiescent. This type of pattern is nonspecific and is characteristically seen in rheumatoid arthritis, lupus erythematosus, post-rubella arthritis, and spondylitis. The term migratory polyarthritis should be restricted to describe those situations in which initially inflammed joints totally remit while, simultaneously, other joints become actively inflammed. This pattern is quite unique and strongly suggestive of either acute rheumatic fever or gonococcal arthritis. The palindromic or intermittent pattern describes those conditions associated with repetitive attacks of polyarticular synovitis which completely remit without sequelae or spread to other joints. Typical examples would be gout and rheumatoid arthritis with palindromic onset. Distribution of joint involvement is also helpful in the differential diagnosis of polyarthritis. Different diseases characteristically affect different joints. Knowledge of the typical joints involved in each disease is a cornerstone of diagnosis in polyarthritis. In practice, knowledge of which joints are spared in each form of arthritis is also quite useful. Tables 3 & 4 list out some of the common examples. Accordingly, deformities of elbows, wrists or MCPs are not just due to 'wear and tear' but to a synovitic process. Similarly, low back pain in a patient with RA is usually caused by another cause and a patient with polyarticular pain involving the jaws and the hips is not suffering from gout. Specific joint symptoms should also be asked for and would prove fruitful. These include early morning stiffness, locking, giving way and the pattern of therapeutic response. Early morning stiffness refers to the amount of time it takes for Volume 2, No. 1, July

3 APPROACH TO POLYARTICULAR SYMPTOMS Table 3. Specific joint involvement in polyarthritis Joints involved Common with Not seen in Temporomandibular Rheumatoid arthritis, juvenile rheumatoid arthritis, psoriasis Gout, myalgias Elbows, wrists, Any synovitis Osteoarthritis metacarpophalangeals Hips Nonspecific Gout Ankles (only) Erythema nodosum Cricoarytenoid Rheumatoid arthritis All other Talonavicular Rheumatoid arthritis Cervical spine Rheumatoid arthritis, juvenile rheumatoid arthritis, psoriasis, Gout, gonococcal osteoarthritis, spondylitis, myalgias Thoracolumbar spine Spondylitis : Gout Ankylosing spondylitis Rheumatoid arthritis Psoriasis Reiter's syndrome Inflammatory bowel disease Table 4. Distribution of joint involvement in polyarthritis Disease Joints commonly involved Joints commonly spared Osteoarthritis First CMC, DIP, PIP, cervical spine, MCP, wrist, elbow, glenohumeral, ankle, thoracolumbar spine, hip, knee, first MTP, toe IP tarsal Rheumatoid arthritis Wrist, MCP, PIP, elbow, glenohumeral, cervical DIP, thoracolumbar spine spine, hip, knee, ankle, tarsal, MTP Polyarticular gout First MTP, instep, heel, ankle, knee Axial Gonococcal arthritis Knee, wrist, ankle, hand IP Axial Lyme arthritis Knee, shoulder, wrist, elbow Axial patients to 'limber up' after arising in the morning. Significant morning stiffness lasting for more than one hour tends to differentiate the chronic inflammatory process from other disorders. Its duration tends to parallel the severity of the synovitis. Its duration serves as a useful parameter in evaluating the effectiveness of anti-inflammatory therapy. Symptom of 'giving way' without warning usually suggests an unstable joint with muscle weakness whereas 'giving way' as a result of pain would mean meniscus tear or presence of loose bodies. Symptom of locking is said to be present when the patient is unable to take a joint smoothly through its complete range of motion. It may be due to internal derangement such as cartilage tear or extraarticular soft tissue blockage such as trigger finger. Pattern of therapeutic response is also frequently useful in the differential diagnosis. The typical example would be seen in the highly specific dramatic response of acute rheumatic fever to aspirin. Another situation is the rapid and dramatic response of polymyalgia rheumatica to prednisolone at a dose of 10 to 20 mg per day. Although colchicine is meant to be specific to treat gouty symptoms, it is also worth remembering that a sizable proportion of gouty attacks do not respond. Conversely, a patient with pseudogout may respond to colchicine. Again, although steroid is not recommended as the first line treatment, prednisone dose of about 20 mg per day will usually and invariably abort the synovitic features of SLE and RA completely but often will have little effect on the synovitis of the spondyloarthropathies. Another useful practical point to remember is that indocid is usually 22 Hong Kong Bulletin on Rheumatic Diseases

4 WONG dramatically more effective than other NSAIDs in gout and spondyloarthropathies. Systemic symptoms such as fever, night sweats and weight loss should be sought specifically and, when possible, quantified. Patients, unless asked, somehow often do not perceive relationships between joint pain and these symptoms. Presence of such features should prompt a thorough search for more sinister pathologies including infections, systemic rheumatic diseases or even malignancies. Rheumatic disease systems review is equally important. Thus, in addition to systemic symptoms, patients must be asked specifically about conditions associated with various forms of arthritis, including rash (photosensitive, psoriatic, purpuric, or petechial), areas of alopecia, Raynaud's phenomenon, sicca syndrome, uveitis, scleritis, oral and genital ulcers, urethritis or cervicitis, symptoms of inflammatory bowel disease, and pleuropericardial symptoms. In addition to asking about any type of arthritis in the family, one should inquire about a family history of any associated condition, such as psoriasis, uveitis, or inflammatory bowel disease. In patients suspected of having ankylosing spondylitis, it is important to obtain the history of any family members with chronic back pain and then to attempt to determine the nature of that condition. Differentiating features in the symptomatology among the different categories of polyarticular symptoms are summarized in Table 5. Physical Examination Both comprehensive musculoskeletal examination and complete systemic examination are essential. Each joint should be examined for warmth, synovial thickening, effusions, crepitation, deformity, and tenderness. Both active and passive range of motion should be tested. The spinal examination should include the range of motion of the cervical and lumbar regions, chest expansion, tenderness of the spinous processes and sacroiliac joints, abnormal curves and muscle spasms. Particular attention is given to sites about which the patient specifically complains or those having abnormalities of which the patient is often unaware. Each clinician should develop a standard, disciplined routine examination of the musculoskeletal system as for the abdominal and chest examination. The approach may differ among individual physicians, but it should be the same for a given clinician each time they lay hands on a patient. Typical joint deformities would alert one to the diagnosis of a specific collagen vascular problem, the classical example Table 5. Symptoms useful in differential diagnosis of polyarthritis Symptoms Degenerative Inflammatory Psychogenic Stiffness (duration) Few minutes; "gelling" after Hours (often); most pronounced Little or no variation in intensity prolonged rest after rest with rest or activity Pain Follows activity; relieved by rest Even at rest; nocturnal pain Little or no variation in intensity Flares not seen May interfere with sleep with rest or activity Variable course Flares common Progressively worsening course Often favorable response to medical therapy Weakness Present, usually localized and not Often pronounced Often a complaint; severe "neurasthenia" Fatigue Not usual Often severe with onset in early Often in mornings on arising afternoon Emotional depression Not usual Common; coincides with fatigue; often Often present and lability disappears if disease remits Volume 2, No. 1, July

5 APPROACH TO POLYARTICULAR SYMPTOMS being rheumatoid arthritis. However, one should also be careful of not jumping to conclusion on spotting a specific physical sign. For instance, swan neck deformity does not equate the diagnosis of rheumatoid arthritis. As listed in Table 6, there are many other conditions which can be associated with swan neck deformity. A good physical examination would enable one to differentiate among various kinds of polyarthritis. Relevant useful signs are summarized in Table 7. Lesions of other organ systems should be carefully sought for. Dermatological manifestations often give tell tale clues to the underlying causes of polyarthritis. Notable examples are butterfly rash in SLE, tightness of skin in scleroderma, and heliotropic rash on eyelids in dermatomyositis. It is easy to miss small patches of psoriasis especially if they are located in the more occult areas such as the perianal and inframammary regions. Subtle nail changes should also be watched out for. The genital area is often omitted during routine examination to avoid causing embarrassment to the patient. However, in selected patients, this may reveal the genital ulcers of Behcet's disease or circinate balanitis in patients with Reiter's syndrome. The physician should provide adequate explanation and obtain consent from the patient before proceeding with the examination in an appropriate clinical environment. Investigations Non specific tests of inflammation may help to differentiate between inflammatory and non-inflammatory causes for the polyarticular symptoms. These tests include complete blood counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum albumin/globulin (A/G) ratio. Anemia, leucocytosis, thrombocytosis, raised ESR and CRP, reversed A/G ratio are all indicative of the presence of an underlying active inflammation. Checking for autoantibody profile may be helpful in specific diseases. Autoantibodies may have a role in diagnosis, in predicting patterns of disease expression and prognosis and in assessing disease activity. These tests must be ordered wisely because the background false positive rate can be quite high. For example, a positive rheumatoid factor may be more helpful in young persons, in whom background positivity is low whereas a negative result is not helpful in individual cases. On the other hand, a high titre of antinuclear antibody is suggestive of a rheumatic disease and a negative test virtually rules out active systemic lupus. If obtainable and when indicated, synovial fluid should be examined. The primary benefit of synovial fluid examination is to differentiate among non inflammatory, inflammatory and infective arthritis. Table 6. Disorders associated with swan neck deformity Rheumatologic diseases Rheumatoid arthritis Systemic lupus erythematosus Postrheumatic fever (Jaccoud arthropathy) Psoriatic arthritis Gout Polymyositis Table 7. Signs useful in differential diagnosis of polyarthritis Signs Degenerative Inflammatory Psychogenic Tenderness localized Usually present Almost always; the most sensitive Tender "all over', "touch-me-not over afflicted joint indication of inflammation attitude"; tendency to push away or to grasp the examining hand Swelling Effusion common; little synovial Effusion common; often synovial None reaction proliferation and thickening Heat and erythema (skin) Unusual but may occur More common None Crepitus Coarse to medium Medium to fine None, except with coexistent arthritis Bony spurs Common Sometimes found, usually with None, except with coexistent antecedent osteoarthritis osteoarthritis 24 Hong Kong Bulletin on Rheumatic Diseases

6 WONG In many cases, properly chosen radiological investigations are virtually diagnostic or eliminate certain diseases from further consideration. Imaging techniques for evaluation of polyarticular symptoms include conventional radiography, radionuclide joint imaging, arthrography, quantitative bone mineral analysis, computed tomography (CT) and magnetic resonance imaging (MRI). In addition to being diagnostically helpful, radiological assessment may also help to monitor disease progress and treatment response as well as to delineate systemic complications of the underlying rheumatic disease. Conclusion Polyarticular symptom is the most common indication for rheumatologic consultation. It represents a challenge to the skills and experience of the rheumatologist. It is soothing to note that by careful history taking and physical examination along with relevant investigations, the rheumatologist is very often able to establish eventually the correct diagnosis and institute appropriate therapy. Further Readings 1. Maddison PJ, Isenberg DA, Woo P, Glass DN (eds). Oxford Textbook of Rheumatology. Oxford University Press 1998, pp & Ruddy S, Harris ED Jr, Sledge CB (eds). Textbook of Rheumatology. W. B. Saunders Company 2001, pp Koopman WJ (ed). Arthritis and allied conditions. Williams & Wilkins 2001, pp West SG. Rheumatology secrets. Hanley & Belfus, inc. 1997, pp Volume 2, No. 1, July

How do polyarthritis, polyarthralgias, and diffuse aches and pains differ?

Approach to the patient with polyarthritis How do polyarthritis, polyarthralgias, and diffuse aches and pains differ? Polyarthritis is definite inflammation (swelling, tenderness, warmth) of more than