|1: Monoarthritis||2-3: Oligoarthritis||>3: Polyarthritis||Causes of migratory arthritis|
- Night pain, morning stiffness, systemic symptoms, recent non-articular infections
- Sexual history, previous episodes (back pain), rash
- Joint line tenderness, movements, erythema, local increases in temperature, swelling, loss of joint function, muscle wasting.
- General examination for peripheral stigmata ( eg occular inflammation, mouth ulcers, psoriasis, erythema nodosum, vasculitic lesions )
- ESR, urate
- Renal and liver function ± blood culture ± serum for strep titres
- Urine culture
- Cultures for STDs if indicated
- Arthrocentesis- sterile technique, samples:
- Direct microscopy
- C & S samples
- Samples into blood culture media
- Fluid in FBC bottle for WCC etc
- x-rays normal for >2 weeks even in septic
|Associated||OA, trauma, ARF||Gout, pseudogout, spondyloarthropathies, RA, Lyme disease||Gonococcal and non-gonococcal sepsis, SLE|
Gonococcal septic arthritis
- Young adults, F > M
- From disseminated gonococcal infection
- Complicates 1-3% of all cases of gonnorhoea.
- May haave preceding migratory tendonitis or arthritis.
- ± vesiculopustular lesions, (esp. hands)
- ± multiple painless macules on limbs and trunk
- Generally large joints.
- Synovial fluid cultures are often negative
- …. the gonococcus has to be grown from elsewhere
- Note that reactive arthritis secondary to gonococcal infection is a separate entity.
- Treatment: Ceftriaxone or cefotaxime
Non-gonococcal septic arthritis
- Extreme of age and immunocompromised.
- NB prosthetic joints and rheumatoid arthritis.
- Irreversible loss of joint function in 25%
- Fatality rate is 10% (higher in rheumatoid)
- Large joints (textbook is knee)
- 10% SIJ, 10% are polyarticular.
- Haematogenous or local spread
- May not be systemically unwell
- Staph > streptococcus
- G-ve and mycobacterium in immonocompromised
- Joint aspirate more sensitive than blood cultures
- Treatment: beta-lactam and an aminoglycoside / 2nd generation quinolone until sensitivities known
More on the Gout / Pseudogout page
- Delayed from the time of spirochete infection.
- A history of tick bite, followed the rash of erythema chronicum migrans, is diagnostic.
- Arthritis typically an asymmetric mono- or oligoarthritis, affecting large joints.
- May be migratory.
More on the Reiter's syndroms page
- Ankylosing spondylitis
- Tumours ( local, metastatic, haematological, or as part of a paraneoplastic syndrome)
- Rheumatoid arthritis
- A sterile joint inflammation that may be related to a distant infection.
Infectious agents include:
- Viruses such as
- rubella, Hep B, parvovirus,
- EBV, CMV, HIV, mumps
|Clear cut septic joint or Septic infected joint||Urgent orthopaedic referral|
|Skin rash Swollen joint Unwell||Sepsis Consider :psoriasis, viral, connective tissue disorders||Referral rheumatology SpR or on-take medical SpR|
|Very painful joint swelling
|Gout / Pseudgout||Uric acid level
Diagnostic joint aspirate
NSAIDs (See gout)
GP follow up in next week
Admit if intractable pain or Dx unclear
Diarrhoea & Joint pain
|Reactive arthritis||OPD follow up Local "Early arthritis" referral policy|
|Early morning stiffness, joint pains
Swelling of hand, wrist, MTP or MCPs
|? Early rheumatoid arthritis||OPD follow up Local "Early arthritis" referral policy|
|Patient well Background of OA Mild trauma Age > 50||Probable osteo-arthritis||NSAIDs GP follow up|