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Polyarthritis

Polyarthritides

Polyarthritis refers to the simultaneous inflammation of more than four joints and may complicate a wide variety of diseases of autoimmune, infectious, metabolic and neoplastic pathogenesis, e.g., rheumatoid arthritis, seronegative arthritis and systemic lupus erythematosus.

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Presentation

Symptoms of polyarthritis are those of arthritis affecting five or more joints. Frequent complaints are:

Affected joints may be in close proximity to each other or may be located in distant parts of the human body. In fact, many forms of polyarthritis compromise several joints of both hands or feet. The above listed symptoms and signs may not be noted at all times; they are likely to diminish or worsen with rest or exercise. Patients suffering from inflammatory polyarthritis may additionally report fatigue, fever, night sweats, weight loss and lymphadenopathy.

Every form of polyarthritis may severely affect the patient's ability to cope with everyday tasks.

Pain
  • Separate regression analyses were run for pain intensity, sensory pain, and affective pain.[ncbi.nlm.nih.gov]
  • Patients with polyarthritis can experience chronic pain from rheumatic or psoriatic arthritis and treatment is mainly focused on reducing the pain and controlling inflammation, and not necessarily trying to cure it.[jointhealthmagazine.com]
  • The dependent variables were self-efficacy over other symptoms and self-efficacy over for pain after one year.[ncbi.nlm.nih.gov]
  • Joint pains associated with this condition may recur for many months after initial illness for up to a year. See also [ edit ] Polyarteritis nodosa External links [ edit ][en.wikipedia.org]
  • Upon questioning, he reported pain in almost all joints. The patient reported no rash, twitching, or focal numbness.[ncbi.nlm.nih.gov]
Fever
  • A maculopapular rash may present 4–8 days post symptom onset and may be accompanied by an increase in fever. Joint pains associated with this condition may recur for many months after initial illness for up to a year.[en.wikipedia.org]
  • On admission, the patient developed cough, expectoration, and fever. According to the clinical manifestations and the findings in radiological examinations and sputum cultures, pneumonia was considered.[ncbi.nlm.nih.gov]
  • The patient usually has a moderate fever and 1 to 5 days of migratory polyarthralgia with variable signs of inflammation.[medical-dictionary.thefreedictionary.com]
  • Fever of Unknown Origin with Polyarthritis. J Pediatr Care. 2016, 2:3. doi:10.21767/2471-805X.100017 Abstract We describe a 14 years old male child presented with since 5 days of fever, polyarthritis and Salmon colored rash.[pediatrics.imedpub.com]
  • CASE PRESENTATION: A 19-year-old Caucasian woman presented to our hospital with fever, intense leg pain, and a transient rash. A physical examination showed asymmetric polyarthritis and no neurological abnormalities.[ncbi.nlm.nih.gov]
Weight Loss
  • We describe the case of a 73-year-old man who presented with progressive palmar swelling, erythema, pain, and contractures of both hands, This presentation and associated weight loss eventually led to the diagnosis of metastatic pancreatic adenocarcinoma[ncbi.nlm.nih.gov]
  • Dogs with IMPA may have nonspecific (eg, weight loss, inappetence, lethargy, reluctance to move) or more specific (eg, fever, stiff/stilted gait, swelling of multiple joints) clinical signs.[cliniciansbrief.com]
  • Apart from the pain associated with arthritis other symptoms frequently involve weight loss, lung damage, fatigue, vision issues, and coronary conditions. Are You In Pain? Take a look at Provailen![healthglimmer.com]
  • Symptoms include: Pain Stiffness Swelling or redness in the affected area Limited range of motion Rash Tiredness or a lack of energy The temperature of 100.4 degrees or above Swollen lymph nodes Sweating Lack of appetite Unexpected weight loss Causes[verywell.com]
Fatigue
  • Although bisphosphonates are safety drugs, they have numerous side-effects such as arthralgia, elevated erythrocyte sedimentation rate and C-reactive protein, gastrointestinal disturbances, and flu-like illness with symptoms of fatigue, fever, chills,[ncbi.nlm.nih.gov]
  • OBJECTIVES: Patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or unspecified polyarthritis (UA) deal with several symptoms such as joint stiffness, pain, physical limitations and fatigue.[ncbi.nlm.nih.gov]
  • Symptoms include chronic fatigue, weakness, abdominal pain, joint pain - all things which can can have any number of causes. A blood test for fasting transferrin saturation and ferritin is a worthwhile part of any checkup for such symptoms.[holistic-doc-pain-support.com]
  • Polyarthritis due to Lupus presents as joint pain and swelling accompanied by skin rashes, photosensitivity (Allergy to exposure to sunlight), fatigue etc.[avnarogya.in]
  • Apart from the pain associated with arthritis other symptoms frequently involve weight loss, lung damage, fatigue, vision issues, and coronary conditions. Are You In Pain? Take a look at Provailen![healthglimmer.com]
Lymphadenopathy
  • Check major lymph nodes for evidence of lymphadenopathy. Check the skin for rashes (eg, psoriasis, SLE) and evidence of vasculitis. Feel extensor aspects of forearms for nodules. Check shins for evidence of erythema nodosum.[patient.info]
  • Only 39% had lymphadenopathy, 10% had pericarditis, and fewer had hepato-splenomegaly [ 15 ]. Patient in our case had the required criteria for the diagnosis of systemic arthritis by the ILAR criteria.[pediatrics.imedpub.com]
  • Patients suffering from inflammatory polyarthritis may additionally report fatigue, fever, night sweats, weight loss and lymphadenopathy. Every form of polyarthritis may severely affect the patient's ability to cope with everyday tasks.[symptoma.com]
  • ., PAN) Seizures SLE Lymphadenopathy Tumor-associated arthritis, SLE TABLE 4 Selected Extra-Articular Manifestations Associated with Conditions That Result in Polyarticular Joint Pain* Physical finding Diagnoses to consider Skin and mucous membranes Rash[aafp.org]
Night Sweats
  • Patients suffering from inflammatory polyarthritis may additionally report fatigue, fever, night sweats, weight loss and lymphadenopathy. Every form of polyarthritis may severely affect the patient's ability to cope with everyday tasks.[symptoma.com]
Arthritis
  • In patients with primary immunodeficiencies (PID), septic arthritis due to pyogenic bacteria or mycoplasmal arthritis are the most common osteoarticular manifestations.[ncbi.nlm.nih.gov]
  • For example, juvenile idiopathic arthritis is the most common arthritis in children. Family history may be present in cases of rheumatoid arthritis (RA), seronegative arthropathies and osteoarthritis (OA).[patient.info]
  • Abstract Several forms of arthritis and rheumatism can sometimes complicate leprosy. However, its presentation as an acute onset arthritis is unusual.[ncbi.nlm.nih.gov]
  • METHODS: Patients with rheumatoid arthritis, psoriatic arthritis and unspecified polyarthritis were randomised to the intervention group (n 71) or a waiting list (n 70).[ncbi.nlm.nih.gov]
  • To our knowledge, this is the first reported case of efalizumab-induced anti-CCP-positive rheumatoid arthritis (RA).[ncbi.nlm.nih.gov]
Joint Swelling
  • Associated conditions [ edit ] It may be associated with bilateral edema in lower limbs, pain and joint swelling. Sometimes there is previous history of inflammatory joint problems and bilateral edema of lower limbs.[en.wikipedia.org]
  • Associated Conditions of Polyarthritis The disease would spread to bilateral edema in lower limbs, joint swelling, and cause pain.[byjus.com]
  • In general, arthritis manifests in form of arthralgia, joint swelling, reduced motion ranges and possibly crepitation.[symptoma.com]
  • He added, "many a time, people experience morning stiffness and spontaneous joint swelling. Regular physical activity reduces stiffness in joints and helps in toning up the muscles and stance. Stretching exercises also help in gaining flexibility."[zeenews.india.com]
  • Dogs with IMPA commonly present with no obvious joint swelling or localizable pain. Underlying infection, inflammatory disease, or neoplasia should be thoroughly investigated.[cliniciansbrief.com]
Knee Pain
  • He also complained of shoulders, hips and knees pain with morning stiffness lasting 45 minutes. Diabetes mellitus and peripheral vascular disease were noted on past medical history, but no previous osteoarticular complaints.[ard.bmj.com]
  • Left knee painful at extension, not warmer than right knee, no swelling and painful wrists with limited movement [ 1 - 10 ]. Laboratory tests ( Table 2 ) showed striking elevation in indicators of inflammation.[pediatrics.imedpub.com]
  • The patient who presents with psoriasis and knee pain in the absence of inflammation may have the dual diagnosis of psoriasis and osteoarthritis.[aafp.org]
Joint Stiffness
  • OBJECTIVES: Patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or unspecified polyarthritis (UA) deal with several symptoms such as joint stiffness, pain, physical limitations and fatigue.[ncbi.nlm.nih.gov]
  • Find Rheumatologists near you Although I don't know all of the information about your case, I therefore gather that you have a fairly significant degree of joint stiffness and pain that affects multiple joints.[zocdoc.com]
Leg Pain
  • CASE PRESENTATION: A 19-year-old Caucasian woman presented to our hospital with fever, intense leg pain, and a transient rash. A physical examination showed asymmetric polyarthritis and no neurological abnormalities.[ncbi.nlm.nih.gov]
  • Approximately four days before this hospital admission, the patient reported acute onset of lateral left leg pain. The symptoms progressed in the following days, necessitating admission to the hospital.[ncbi.nlm.nih.gov]

Workup

Anamnestic data and results of physical examination should allow for the treating physician to answer the following:

  • Affected joints: hands, feet, limbs, axial involvement
  • Symmetrical or asymmetrical polyarthritis
  • Acute or chronic disease
  • Intermittent or constant complaints
  • Progressive or non-progressive course of the disease
  • Extra-articular symptoms

Moreover, it is important to distinguish between inflammatory and non-inflammatory forms of polyarthritis. This may be achieved by assessing inflammatory markers like serum levels of C-reactive protein and the erythrocyte sedimentation rate. Both positively correlate with inflammation.

All these data should be considered when compiling a list of differential diagnoses and deciding on a target-oriented diagnostic approach [1]. They do not yet allow for a definitive diagnosis and additional measures are required to confirm a suspicion.

  • Since many forms of polyarthritis are autoimmune-mediated, the presence of autoantibodies should be evaluated. Traditionally, rheumatoid factor and anti-cyclic citrullinated peptide antibody concentrations are assessed, but recent publications encourage to measure anti-carbamylated protein antibody levels, too, if RA is suspected [10]. Ascertainment of antinuclear antibodies is a very sensitive but little specific approach to SLE diagnosis.
  • Hemogram and blood chemistry may provide important information with regards to hematological anomalies.
  • Blood cultures, detection of pathogenic nucleic acids in blood samples by means of molecular biological techniques and serological tests are indicated if an infectious polyarthritis is suspected.
  • Pathogens may also be isolated from synovial fluid specimens, and cytologic and biochemical analysis of such samples may reveal further clues as to the underlying pathology.
  • Diagnostic imaging is often performed to assess the condition of the affected and apparently unaffected joints as well as the skeleton in general. Magnetic resonance imaging allows for a more detailed evaluation of cartilage damage than plain radiography.

Measures described herein typically reveal the following in case of RA, SNA and SLE:

  • RA: symmetrical involvement of joints of hands and/or feet, chronic disease, constant complaints albeit with matutinal exacerbation, slowly progressive course, possibly inflammation of cutaneous, cardiac, pulmonary and ocular tissues, elevated concentrations of inflammatory markers, rheumatoid factor and/or anti-cyclic citrullinated peptide antibody positive [11]
  • SNA: rheumatoid factor negative, otherwise any combination of symptoms and signs, e.g., seronegative RA manifests as described previously except for the result of the measurement of rheumatoid factor
  • SLE: symmetrical polyarthritis preferentially affecting interphalangeal joints, chronic disease, disease course marked by remission and relapse, malar rash, inflammation of cardiac, pulmonary and renal tissues, elevated levels of inflammatory markers, antinuclear antibodies positive, possibly anemia, leukopenia and thrombocytopenia

Treatment

If at all possible, causative treatment should be applied to cure the underlying disease. Unfortunately, causative treatment is not available for many forms of polyarthritis and only supportive therapy can be provided. In any case, therapy should be adjusted to the individual case, to present complications and comorbidities, to the patient's response to therapy, possible side effects and adverse events. The following treatment options may be considered:

  • Rest
  • Cold and heat
  • Physical therapy in order to maintain or regain motion ranges
  • Dietary and lifestyle adjustments, e.g., weight loss, avoidance of triggers of recurrence
  • Analgesia, primarily achieved by application of paracetamol, metamizol or opioids and derivatives
  • Anti-inflammatory therapy to reduce arthritis and inflammatory pain, with non-steroidal anti-inflammatory drugs and corticosteroids being most frequently administered
  • Further immunosuppressive treatment and application of disease-modifying antirheumatic drugs, e.g., hydroxychloroquine, methotrexate, sulfasalzine, cytokine blockers like abatacept and rituximab
  • Intraarticular injection of hyaluronic acid [12]

This list is restricted to treatment options for articular manifestations of polyarthritis. Many diseases that cause polyarthritis are associated with extra-articular symptoms, e.g., myocarditis, pleuritis and nephritis, and these conditions require an appropriate management as well.

Prognosis

The patient's prognosis largely depends on the cause of polyarthritis.

  • Long-term immunosuppressive therapy is generally required to relieve symptoms associated with autoimmune-mediated polyarthritis, and such treatment may have side effects. With regards to RA, patients who test positive for rheumatoid factor are generally expected to develop more severe extra-articular complications than those who are diagnosed with seronegative RA or SNA [8]. SLE is a potentially life-threatening disease, but mortality has been diminished during the last decades. Nowadays, 5-, 10-, and 15-year survival rates are 96%, 93% and 76%, respectively [9].
  • Although many infectious diseases that may trigger polyarthritis are curable, patients developing such conditions are often immunocompromised and severe immunodeficiency may negatively affect the outcome.

Etiology

Polyarthritis results from pathophysiological events that simultaneously take place in several joints of the body. In general, joints are susceptible to virtually all kinds of disturbances, e.g., to malfunction of the immune system, infection with pathogens and release of toxins, interruption of blood supply, nutrient deficiency and metabolic perturbances, carcinogenic stimuli, and trauma. Only in case of generalized disease, polyarthritis may develop. In this context, generalized may refer to systemic diseases, hematogenous or lymphogenous spread of pathogens or tumor cells. With regards to the aforegiven list, compromise of five or more joints is more likely if a patient suffers from autoimmune diseases, nutrient deficiencies and metabolic disorders. In contrast, vascular events, neoplasms and traumas commonly affect one or few joints. This classification is not irrefutable though: RA may manifest in form of monarthritis and polyarthritis may be part of a paraneoplastic syndrome [3] [4].

In detail, the following diseases may be associated with polyarthritis [1]:

Epidemiology

Due to the large number of differential diagnoses, epidemiological data regarding the overall incidence and prevalence of polyarthritis cannot be provided. Similarly, underlying disorders vary largely with respect to racial and gender predilection and age distribution. In general, patients of all races, both genders and all age groups may develop polyarthritis.

  • RA is a common disease affecting up to 1% of the population, with women being significantly more susceptible than men. RA is typically diagnosed in the elderly. Juvenile rheumatoid arthritis, also referred to as juvenile idiopathic arthritis, constitutes a different entity. Here, symptom onset occurs during the first two decades of life.
  • SLE has recently been reported to affect about 0.1% of the US-American population [6]. Similarly to RA, women have been shown to be more prone to SLE than men. Symptom onset may occur at any age.

Furthermore, risk groups may be defined for determined forms of polyarthritis. In this context, any condition associated with immunosuppression, e.g., diabetes mellitus, infection with human immunodeficiency virus and immunosuppressive treatment, may predispose for infectious polyarthritis. This also applies to behavior favoring infection with causative pathogens, e.g., men having sex with men and intravenous drug abuse.

Differences regarding the geographic distribution of polyarthritis is also best illustrated by those pathogens causing infectious polyarthritis: Hepatitis B is a major health concern worldwide, while the above described alphaviruses are prevalent only in determined countries [5].

Sex distribution
Age distribution

Pathophysiology

A healthy joint is formed by at least two bones whose articulating surfaces are able to move virtually frictionless against each other, whereby the joints' motion ranges differ largely. Most joints of the human body are synovial joints, i.e., the respective articulating surfaces are covered by smooth hyaline cartilage and synovial tissue that is further lubricated by synovial fluid contained in the synovial cavity, and the whole joint is surrounded by a fibrous joint capsule. Every process altering the properties of those joint-composing structures may provoke arthritis, and such processes may originate from articular or extra-articular events:

  • Immune reaction against joint tissues
  • Articular deposition of immune complexes
  • Pathogen-mediated cell lysis
  • Release of toxins
  • Release of pro-inflammatory mediators
  • Infiltrating inflammatory cells
  • Cellular hyperplasia
  • Tumor growth
  • Degenerative changes
  • Traumatic destruction of cartilage or underlying bone

In most cases, these pathophysiological events are mutually dependent. For instance, chronic, inflammatory polyarthritis is generally associated with excess release of pro-inflammatory cytokines interleukin-1β, tumor necrosis factor-α and transforming growth factor-β by synovial cells, infiltration of inflammatory cells that further stimulate inflammation, and proliferation of synovial tissue [7].

Prevention

In general, lifestyle decisions consistent with an overall good health, i.e., regular, moderate exercise, appropriate nutrition and maintenance of a healthy body weight contribute to joint health. Measures to prevent infectious diseases possibly associated with polyarthritis are also recommended and may comprise use of repellents, acaricides and insecticides, as well as safer sex.

Summary

As per definition, polyarthritis may be diagnosed if a patient presents with five or more inflamed joints [1]. In contrast, patients showing an inflammation of two to four joints suffer from oligoarthritis, whereas other diseases only affect one single joint and cause monarthritis [2].

In general, arthritis manifests in form of arthralgia, joint swelling, reduced motion ranges and possibly crepitation. This also applies to polyarthritis, a condition that is easily diagnosed based on anamnestic data and results of physical examination. However, there is an extensive list of differential diagnoses underlying polyarthritis and often, considerable efforts are required to identify the primary disorder and to choose an appropriate treatment. Polyarthritis may be the result of a myriad of generalized disorders, e.g., of autoimmune diseases, infection, endocrinologic imbalances, and, less frequently, metastatic neoplasms. As opposed to monarthritis, traumatic lesions of five or more joints are rare.

This article aims at providing information about a general approach to polyarthritis, since it is beyond its scope to discuss clinical presentation, diagnostic workup and treatment of any one differential diagnosis. The interested reader is thus referred to the respective articles. In order to illustrate the broad spectrum of diseases possibly associated with polyarthritis, rheumatoid arthritis (RA), seronegative arthritis (SNA) and systemic lupus erythematosus (SLE) shall serve as examples in determined sections of this review.

  • RA is one of the most common joint diseases. Affected individuals suffer from chronic, symmetrical polyarthritis. Extra-articular symptoms are less frequently observed than in patients diagnosed with SLE, but may affect skin, cardiovascular system, lungs and eyes.
  • SNE comprises seronegative RA, seronegative spondyloarthropathies and, in the broader sense of the word, all forms of autoimmune-mediated polyarthritis if the affected individual tests negative for the autoantibody rheumatoid factor.
  • SLE is an autoimmune disorder mainly characterized by cutaneous lesions. These are provoked by deposition of immune complexes in small vessels. SLE may be associated with polyarthritis, and patients may also suffer from central nervous system, cardiac, pulmonary and renal compromise.

Patient Information

Polyarthritis is diagnosed if a patient presents with five or more inflamed joints. This condition is typically associated with joint pain, joint swelling, joint deformity, stiffness and reduced motion ranges. The skin surrounding the affected joints may be tender and reddened.

Polyarthritis may develop within the scope of a wide variety of disorders, and the aforementioned symptoms are very unspecific. Primary diseases that may be associated with polyarthritis are rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease and psoriasis - all of which are provoked by an immune reaction against the body's own tissues -, infectious diseases like Lyme disease, hepatitis B, hepatitis C and tuberculosis, as well as thyroid disorders and cancer.

Distinct parameters will be evaluated in order to identify the underlying disorder and to choose an adequate therapeutic approach. Important clinical data are relate to the course of the disease, to affected joints, the presence of inflammation and extra-articular manifestations. Treatment may comprise dietary and lifestyle adjustments, physical therapy and medication.

References

Article

  1. Mies Richie A, Francis ML. Diagnostic approach to polyarticular joint pain. Am Fam Physician. 2003; 68(6):1151-1160.
  2. Smith JW, Chalupa P, Shabaz Hasan M. Infectious arthritis: clinical features, laboratory findings and treatment. Clin Microbiol Infect. 2006; 12(4):309-314.
  3. de Hair MJ, Lehmann KA, van de Sande MG, Maijer KI, Gerlag DM, Tak PP. The clinical picture of rheumatoid arthritis according to the 2010 American College of Rheumatology/European League Against Rheumatism criteria: is this still the same disease? Arthritis Rheum. 2012; 64(2):389-393.
  4. Nadal R, McMahan ZH, Antonarakis ES. Paraneoplastic palmar fasciitis and polyarthritis syndrome in a patient with advanced prostate cancer. Clin Genitourin Cancer. 2013; 11(4):e15-23.
  5. Toivanen A, Toivanen P. Which viruses should we look for in a recent onset polyarthritis. Acta Reumatol Port. 2006; 31(1):39-47.
  6. Sacks JJ, Luo YH, Helmick CG. Prevalence of specific types of arthritis and other rheumatic conditions in the ambulatory health care system in the United States, 2001-2005. Arthritis Care Res (Hoboken). 2010; 62(4):460-464.
  7. Cheon H, Yu SJ, Yoo DH, Chae IJ, Song GG, Sohn J. Increased expression of pro-inflammatory cytokines and metalloproteinase-1 by TGF-beta1 in synovial fibroblasts from rheumatoid arthritis and normal individuals. Clin Exp Immunol. 2002; 127(3):547-552.
  8. Rozin AP, Hasin T, Toledano K, Guralnik L, Balbir-Gurman A. Seronegative polyarthritis as severe systemic disease. Neth J Med. 2010; 68(6):236-241.
  9. Doria A, Iaccarino L, Ghirardello A, et al. Long-term prognosis and causes of death in systemic lupus erythematosus. Am J Med. 2006; 119(8):700-706.
  10. Montes A, Regueiro C, Perez-Pampin E, Boveda MD, Gomez-Reino JJ, Gonzalez A. Anti-Carbamylated Protein Antibodies as a Reproducible Independent Type of Rheumatoid Arthritis Autoantibodies. PLoS One. 2016; 11(8):e0161141.
  11. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010; 62(9):2569-2581.
  12. Pohlig F, Guell F, Lenze U, et al. Hyaluronic Acid Suppresses the Expression of Metalloproteinases in Osteoarthritic Cartilage Stimulated Simultaneously by Interleukin 1beta and Mechanical Load. PLoS One. 2016; 11(3):e0150020.

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Last updated: 2018-06-22 12:11