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Polyarticular arthritis

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Version Jan 2023

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Polyarticular arthritis > 5 joints affected
First determine if inflammatory or non-inflammatory
Inflammatory have more Pain, Stiffness Swelling, Nighttime pain and morning stiffness than non-inflammatory

Age and Gender related Differentials

Young
- Reactive arthritis (M>F)
- Systemic lupus erythematosus (F>M)
- Ankylosing spondylitis (M>F)
- Rheumatoid arthritis (F>M)
- Sjögren’s syndrome (F>M)
- Psoriatic arthropathy
- Enteropathic arthropathy
Middle age
- Gout (M>F)
- Osteoarthritis
- Rheumatoid arthritis (F>M)
Elderly
- Osteoarthritis
- Polymyalgia rheumatica
- Pseudogout

Joint sepsis is an emergency and needs urgent diagnosis with joint aspiration and treatment

Differentials: See individual topics for more

Causes	Comments
Rheumatoid arthritis	Symmetrical, any joint, legs and arm on over hours. Usually spares the hip and knees and elbows and DIP. Severe pain. Usually, 1st MTP. Red hot. Elevated CRP/ESR Anti-CCP. Positive RF Aspirate joint if diagnosis uncertain need to exclude sepsis. Examine for crystals. Recent dehydration, operation
Reactive Arthritis	Comes on over days. Symmetrical small joints, rash and prodromal symptoms. Viral, Lyme disease.
Osteoarthritis	Variable Symmetrical, DIP joints, knees, hips, back and neck, Heberden's, Bouchard's. Bloods normal
Psoriatic arthritis	Male, Asymmetrical PIP and DIP joints, nail changes. Pitting, onycholysis, Skin rash.
Ankylosing spondylitis	Large joints, Lower > upper. Back pain. Younger age.
Systemic lupus erythematosus	Females, Butterfly rash, Symmetrical, small join, synovitis

Clinical

The presence of the cardinal signs of inflammation on physical examination
Erythema, warmth, swelling, and tenderness, confirms inflammatory arthritis.
Noninflammatory arthritis may have swelling and tenderness, but does not cause erythema or warmth
Crepitation without warmth or erythema suggests a degenerative process, such as osteoarthritis.

General Guidance

Joint swelling, erythema, prolonged morning stiffness (more than one hour), and symmetric pain even at rest are suggestive of inflammatory conditions.
Weight bearing and movement worsen the pain of noninflammatory arthritis conditions, such as osteoarthritis.
Noninflammatory and inflammatory conditions can be differentiated with C-reactive protein and erythrocyte sedimentation rate tests; however, in the acute phase, erythrocyte sedimentation rate is less reliable than C-reactive protein.
In the diagnosis of gout, a high serum uric acid level has little diagnostic value. The standard of diagnosis is the presence of intracellular monosodium urate crystals on polarized microscopy.
Osteoarthritis is noninflammatory; is typically pauciarticular; and often involves the spine and weight-bearing joints, such as the hips and knees.
Do not test antinuclear antibody sub serologies without a positive antinuclear antibody test result and clinical suspicion of immune-mediated disease.
Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings.

References

Differential Diagnosis of Polyarticular Arthritis

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