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Polyarthritis with fever


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Joint Swelling Fever Weight loss Claudication Morning stiffness Local erythema Skin manifestation CBC ESR Synovial fluid Other X-ray CT scan Other
Polyarthritis Infectious arthritis Lyme disease[1] + + +/- +/- – – Erythema migrans Leukopenia, Thrombocytopenia – Cell counts 500-98,000/µL Microscopic hematuria, Proteinuria, ↑ALT or AST – – – Fibrosis of the deeper dermis and hyalinization of collagen bundles Serologic tests Erythema migrans
Bacterial endocarditis[2] + + + – – +/- Janeway lesions, Osler nodes, Roth spots Normochromic-normocytic anemia ↑ ↑WBC, S. aureus in culture Hyperglobulinemia, Cryoglobulinemia Joint erosion and effusion – – Vegetation or intracardiac abscess demonstrating active endocarditis Echocardiography (TTE) Vertebral osteomyelitis
Postinfectious (reactive) arthritis Rheumatic fever[3] + + – – – +/- Erythema marginatum rheumaticum Leukocytosis ↑ Sterile inflammatory reaction with cells<20,000/μL Streptococcal antibody titer Cardiomegaly Valvular or pericardial calcification Echocardiographic changes in heart valves Edema, Fibrinoid necrosis, Mononuclear cell infiltrate Echocardiography Chorea, Carditis 
Reactive arthritis[4] +/- +/- – – – – Genital ulceration Normocytic normochromic anemia ↑  High WBC count (10,000-40,000/µL)  HLA-B27 test  Periosteal reaction and proliferation of tendon insertion site Sacroiliitis Enthesitis in ultrasonography Keratoderma blennorrhagicum, Balanitis circinata   Spondyloarthritis and unequivocal demonstration of preceding infection Conjunctivitis, Uveitis
Enteric infection[5] – + – – – – Keratoderma and psoriaform lesions, Erythema nodosum Neutrophilia ↑ PCR of causative organism Stool exam and culture – – – Neutrophilic infiltration in synovial tissues PCR of causative organism in synovial fluid Diarrhea, Enthesopathy
Other seronegative spondyloarthritides Inflammatory bowel disease[6] + + – – + +/- Pyoderma gangrenosum (ulcerative colitis), Erythema nodosum (Crohn disease) Iron deficiency anemia, Leukocytosis, Thrombocytosis ↑ Mild to moderate inflammatory fluid, PMN predominance ↑RF, Antiendomysial Ab, Antitransglutaminase Ab Bilateral sacroiliitis, Syndesmophytes and apophyseal joint involvement in spine – Early detection of spinal and sacroiliac lesions in MRI – Clinical findings and history Acute anterior uveitis
Crystal-induced arthritis[7] + +/- – – – + Joint erythema Leukocytosis ↑ Needle shaped urate crystals, WBC count > 2000/µL Urinary uric acid (>1100 mg in 24h) Punched-out erosions or lytic areas with overhanging edges  Complementary for recognizing erosions Tophi or edema in MRI Large pale pink acellular areas (urate crystals), surrounded by histiocytes and multinucleated giant cells Synovial fluid assay Conjunctival nodules
Other systemic illnesses Familial Mediterranean fever[8] – + – – – – A well-demarcated, erythematous, warm rash, particularly below the knee Leukocytosis ↑ Cell counts as high as 100,000/µL CRP, Amyloid A protein, Fibrinogen Synovial effusions Pleural effusions Air-fluid levels in MRI Massive amyloid infiltration of the blood vessels and endothelial side of the glomerular basement membrane Clinical findings Abdominal pain, Severe myalgia, Scrotal attacks
Polyarticular pain Viral arthritis Hepatitis B and C[9] – + + – – – Urticarial and maculopapular eruptions  Leukocytosis ↑ Cell counts < 100,000/µL LFT, HBsAg Joint space narrowing – – Deposition of immune complexes, Cryoprecipitates containing HBsAg and complements HBsAg Liver failure, Icterus
Rubella[10] – + +/- – – – Acute maculopapular rash Leukocytosis ↑ Rubella virus antigen LFT, CRP Joint space narrowing – – proliferation of the synovial lining cells, without inflammatory

cells

Serological evidence Headache, Malaise
Parvovirus[11] + + +/- – – – Fifth disease/ Erythema infectiosum Aplastic crisis ↑ Normal ANA, RF, CRP Joint swelling – – Immune complex deposition Parvovirus IgM antibody Transient aplastic crisis, Fetal infection

References

  1. ↑ Lantos PM (2015). “Chronic Lyme disease”. Infect Dis Clin North Am. 29 (2): 325–40. doi:10.1016/j.idc.2015.02.006. PMC 4477530. PMID 25999227.
  2. ↑ Soor P, Sharma N, Rao C (2017). “Multifocal Septic Arthritis Secondary to Infective Endocarditis: A Rare Case Report”. J Orthop Case Rep. 7 (1): 65–68. doi:10.13107/jocr.2250-0685.692. PMC 5458702. PMID 28630844.
  3. ↑ Kumar RK, Tandon R (2013). “Rheumatic fever & rheumatic heart disease: the last 50 years”. Indian J Med Res. 137 (4): 643–58. PMC 3724245. PMID 23703332.
  4. ↑ Colmegna I, Cuchacovich R, Espinoza LR (2004). “HLA-B27-associated reactive arthritis: pathogenetic and clinical considerations”. Clin Microbiol Rev. 17 (2): 348–69. PMC 387405. PMID 15084505.
  5. ↑ Hill Gaston, J (2003). “Arthritis associated with enteric infection”. Best Practice & Research Clinical Rheumatology. 17 (2): 219–239. doi:10.1016/S1521-6942(02)00104-3. ISSN 1521-6942.
  6. ↑ Orchard TR (2012). “Management of arthritis in patients with inflammatory bowel disease”. Gastroenterol Hepatol (N Y). 8 (5): 327–9. PMC 3424429. PMID 22933865.
  7. ↑ Reginato A, Paul H, Schumacher HR (September 1982). “Crystal-induced arthritis”. Arch Phys Med Rehabil. 63 (9): 401–8. PMID 6287963.
  8. ↑ Yildirim K, Uzkeser H, Uyanik A, Karatay S, Kiziltunc A (2011). “Trace element levels in patients with familial mediterranean Fever”. Eurasian J Med. 43 (2): 79–82. doi:10.5152/eajm.2011.18. PMC 4261345. PMID 25610168.
  9. ↑ Ganem, Don; Prince, Alfred M. (2004). “Hepatitis B Virus Infection — Natural History and Clinical Consequences”. New England Journal of Medicine. 350 (11): 1118–1129. doi:10.1056/NEJMra031087. ISSN 0028-4793.
  10. ↑ Spruance SL, Metcalf R, Smith CB, Griffiths MM, Ward JR (March 1977). “Chronic arthropathy associated with rubella vaccination”. Arthritis Rheum. 20 (2): 741–7. PMID 849368.
  11. ↑ Moore TL (July 2000). “Parvovirus-associated arthritis”. Curr Opin Rheumatol. 12 (4): 289–94. PMID 10910181.

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