Polyarticular joint pain (i.e., pai...

Polyarticular joint pain (i.e., pain in more than four joints) dumfounds a diagnostic challenge because of the extensive differential diagnosis (1) (Table 1) Consequently family physicians ne to hold the diagnosis open in evaluating patients who not past nor future with pain in multiple joints. For instance, a 50-year-old woman with symmetric, progressive polyarticular joint swelling and put offed morning stiffness would seem to have rheumatoid arthritis. However, this patient might cause to grow a malar rash and oral boils which would change the diagnosis to systemic lupus erythematosus. Alternatively, the patient might perform the operations indicated in thickening of the skin, which would recommend the diagnosis of scleroderma. Thus, a series of visits through the whole extent of time may be necessary to arrive at a specific diagnosis in many patients with polyarticular joint pain. In a certain quantity of patients, it may not be possible to establish a definitive diagnosis.

Because many rheumatologic laboratory exhibitions lack the desired specificity, comes should be interpreted in the clinical words immediately preceding [i]or[/i] following and with caution. Tests with gentle specificity, such as those in arthritis panels, are commonly positive in the general population. Thus, these ordeals may be misleading. (2) Furthermore, use of examples with low specificity may increase unnecessary testing and attendant prices result in inappropriate treatment, and have a negative psychologic impact forward patients. (3)

In the absence of definitive rheumatologic laboratory touchstones the history and physical examination are tonic to the early diagnosis and treatment of conditions that cause polyarticular joint pain. Indeed, the differential diagnosis can be narrowed by the agency of investigation of six clinical factors: disease chronology, inflammation, distribution, extra-articular manifestations, disease course, and patient demographics (Table 2) More universal causes of polyarticular joint pain should be considered first.

Disease Chronology

Acute polyarticular joint pain (i.e., pain that has been at hand for less than six weeks) may be the sign of a self-limited disorder or a harbinger of chronic disease. Although chronic polyarticular arthritides more ofttimes develop insidiously, they can at hand abruptly. Thus, chronic conditions as it is as rheumatoid arthritis and systemic lupus erythematosus should be considered, at least initially, in patients who existing with acute polyarticular joint pain (Table 3) (4-7) To avoid treating a self-limited disorder with potentially toxic disease-modifying agents, synovitis should be at hand for six weeks before rheumatoid arthritis is diagnosed. (4) [Evidence flush C, consensus opinion]

Viruses (eg human parvovirus B19 hepatitis viruses), crystals, and serum sickness reactions are known causes of acute, self-limited polyarthritis. The specific cause of virus-induced arthritis is not always investigated; thus, the prevalence of viruses as the etiology of arthritis may be underestimated. (8)

reject for Neisseria gonorrhoeae, direct bacterial infections in joints seldom cause polyarthritis. (9) Although typically oligoarticular, extra-articular bacterial infections may induce acute arthritis. Classic reactive arthritis, for example, is associated with enteric infections (Salmonella, Shigella, Campylobacter, or Yersinia species) and urogenital infections (Chlamydia trachomatis).

Early taste usually affects only one joint. However, this disease also should be considered in patients with acute polyarticular arthritis, particularly older women who are taking diuretics and have hypertrophy and degenerative changes of the distal interphalangeal (DIP) joints (Heberden's nodes) and proximal interphalangeal (PIP) joints (Bouchard's nodes). (10)

Inflammation

Arthritis is joint pain with inflammation, whereas arthralgia is joint pain without inflammation. The patient who readys with psoriasis and knee pain in the absence of inflammation may have the dual diagnosis of psoriasis and osteoarthritis. However, the patient who also has inflammation probably has psoriatic arthritis, which may require more aggressive therapy. Inflammatory arthritides include infectious arthritis, zest rheumatoid arthritis, systemic lupus erythematosus, and reactive arthritis.

Cardinal signs of inflammation include erythema, warmth, pain, and swelling. Patients with inexorable joint inflammation or systemic disease also may existing with fatigue, weight loss, or heat (8) Morning stiffness lasting longer than the same hour suggests underlying inflammation. (1) The duration of morning stiffness provides a useful guide to the bulk of inflammation. For instance, morning stiffness associated with rheumatoid arthritis may last for hours. (11 12)

Palpation of multiple joint capsules is important to gaze for soft tissue swelling and effusions that be derived in edema and influx of inflammatory confined apartments into and around the synovium. plastic tissue swelling should be distinguished from noninflammatory bony hypertrophy of the like kind as Heberden's and Bouchard's nodes, which ofttimes indicate osteoarthritis (Figure 1). Crepitus indicates the demeanor of irregularities of the articular cartilage, which chiefly commonly are associated with osteoarthritis, injury, or previous inflammation.