Polyarthritis

Polyarthritis - inflammation of the four joints and more. It can be the main manifestation of diseases of the joints themselves, primarily RA and psoriatic arthritis, but it is also found as one of the symptoms of a wide variety of rheumatic and non-rheumatic diseases. In the first days and weeks of polyarthritis, first of all, it is required to exclude diseases in which urgent medical actions are necessary.

Urgent therapeutic actions, often intensive, are required in such systemic rheumatic diseases accompanied by polyarthritis, as systemic lupus erythematosus, mixed connective tissue disease, recurrent polychondritis, acute rheumatic fever. In addition to polyarthritis, for all these diseases, as a rule, there is an extra-verbal manifestation that allows to presume a diagnosis. However, they are not always obvious and can only be detected with a targeted search. To diagnose systemic rheumatic diseases, an additional examination is usually necessary, the nature and volume of which depends on the preliminary diagnosis.

[1], [2], [3]

What causes polyaritrate?

Systemic lupus erythematosus

It is characterized by:

• unstable, asymmetric, migrating polyarthritis or oligoarthritis of any location;
• severe pain syndrome with moderate exudative phenomena;
• often note the non-inflammatory nature of changes in the cerebrospinal fluid
• polyarthritis with persistent or often recurrent lesion of the joints of the hands ("rheumatoid-like" arthritis), a feature of which is the predominant defeat of the tendon apparatus with the gradual development of the deformities of the fingers (Jacques syndrome);
• ineffectiveness of NSAIDs and the absence of radiographic signs of joint destruction even in the long course of polyarthritis.

Mixed connective tissue disease

Characterized by polyarthritis with frequent involvement of the joints of the hands ("rheumatoid-like" arthritis), accompanied by diffuse edema of the wrists due to tenosynovitis. Perhaps the chronic course of polyarthritis with the development of destructive changes and deformities of the joints characteristic of RA. Almost all patients in the blood serum reveal a high titer of ANA (mottled luminescence), which can be used as a screening test.

Systemic vasculitis

Polyarthritis is possible with all systemic vasculitis, but most naturally develops with hemorrhagic vasculitis (Shenlaine-Henoch disease): the paroxysmal course is characteristic, the primary lesion of the knee and ankle joints, the presence of dermal purpura, which is often palpated ("palpable purpura").

 Recurrent polychondritis

It is possible mainly migratory, paroxysmal polyarthritis with lesion of knee, ankle and small joints of hands and feet. In some cases, persistent damage to large joints with a gradual loss of cartilage. Known defeat of rib-chest joints.

Acute rheumatic fever

It is typical oligo- and polyarthritis of large and medium joints, symmetry of the lesion, a significant intensity of pain ("immobilizing" pain), a migrating nature of arthritis, spontaneous reverse development of it.

If the above-mentioned urgent situations are absent or excluded, a systematic, systematic examination of the patient with a careful, focused study of complaints, anamnesis and the results of direct examination is necessary. The age of the onset of the disease and the sex of the patient are of some importance. Thus, for example, the predominant development of systemic lupus erythematosus and mixed connective tissue diseases in women of young age, RA in women in general, and Bekhterev's disease in young men is known. In some diseases (Behçet's disease), an ethnic predisposition is noted.

[4], [5], [6], [7], [8], [9]

How to recognize polyarthritis?

Anamnesis is especially important in the diagnosis of a number of acute infections that precede polyarthritis, for example infections with typical exanthems (rubella, parvovirus infection) or manifesting acute intestinal or urogenital disorders (salmonellosis, dysentery, chlamydia). An epidemiological anamnesis should be taken into account, especially in the case of the patient's recent stay in regions that are unsuccessful in arthritogenic infections. Sometimes, mainly in the case of spondyloarthritis, the family history is of diagnostic importance. Valuable information can be obtained by analyzing the concomitant diseases and how they are treated (allergic reactions to medications, vaccines and serums). Specific features of polyarthritis localization, peculiarities of pain sensations (night pains indicate significant arthritis and / or lesion of bone structures), other possible complaints, such as paresthesia (concomitant peripheral nervous system damage) or muscle weakness (and in this case tests should be performed, objectively assessing the strength of individual muscles).

A direct examination of a patient with polyarthritis

A certain diagnostic and differential diagnostic value is the localization of polyarthritis, its combination with the damage of other anatomical structures of the musculoskeletal system, as well as with extraarticular changes.

• Polyarthritis with symmetrical (or close to symmetric) lesion of wrist joints and finger joints (metacarpophalangeal and proximal interphalangeal). The most common causes are RA, psoriasis, acute viral infections (parvovirus B19, rubella, hepatitis B), allergic and anaphylactic reactions. It can also occur in SLE, SZST, systemic vasculitis, hyperparathyroidism.
• Polyarthritis with lesion of distal interphalangeal joints of brushes. The most common cause is psoriatic, in some cases - ReA. Similar changes can be noted with multicentric reticulogistiocytosis and erosive osteoarthritis.
• Polyarthritis with "axial" lesion of the joints of the finger (simultaneous defeat of all three joints of one finger). The most common causes are seronegative spondylitis, sarcoidosis.
• Polyarthritis with involvement of the joints of the hands and expressed diffuse soft edema (tenosynovitis). The most common causes are remitting seronegative symmetric synovitis, accompanied by mild edema: RA (in elderly patients), rheumatic polymyalgia, polyartritis palmar aponeurosis syndrome, SZST.
• Polyarthritis with lesions of the joints of the bones of the axial skeleton (sternoclavicular joints, sternum joints, sternocostal joints, lone articulation, sacroiliac joints). The most common causes are seronegative spondyloarthritis, SAPHO syndrome, brucellosis.
• Polyarthritis of large and medium joints predominantly of the lower extremities in combination with enthesites (especially the calcaneal areas) and / or with tenosynovitis of the tendons of the fingers (dactylitis). The most common causes are seronegative spondyloarthritis; sarcoidosis.
• Polyarthritis in combination with lesion of the lumbar spine and / or sacroiliac joints. The most common cause of seronegative spondylitis.

Valuable significance for establishing the nosological affiliation of polyarthritis is the detection of certain "extra-articular" manifestations in the objective study of patients.

[10], [11], [12], [13], [14], [15], [16], [17]

Changes from the skin, mucous membranes, nails and periarticular soft tissues

Psoriasis of skin and nails. It is necessary to examine the "hidden" localizations (the scalp, armpits, perineum, gluteal folds, navel). The most characteristic types of psoriatic nail lesions are multiple point defects (nail in the form of a thimble) and subungual hyperkeratosis.

Keratodermia of the soles, palms are characteristic for ReA, SAPHO syndrome (erythematous spots, transforming into pustules, and then into cone-shaped horny papules or thick, covered with cortical plaques).

Corespid spotted erythematous rash on chest, abdomen and proximal limbs in patients with fever and polyarthritis. Typical for the syndrome of Still. The rash "blooms" during peak fever. Characterized by the phenomenon of Kebner: rubbing the skin in a "suspicious" place leads to the formation of a persistent area of redness, erythematous rashes on the cheeks and nose ("butterfly") are characteristic of SLE, and also typical of acute parvovirus infection.

Persistent erythematous spotted rash or erythematous papules with scales located above the joints. It is characteristic for dermatomyositis (it is often combined with periorbital edema and erythematous changes of eyelids), it can also be observed with SLE, SSTT. Violet-red bulbous foci on the face ("reflex lupus"): nodules brownish-cyanotic, small or larger. Characteristic for sarcoidosis. Sarcoid nodules are characterized by the presence of "dust particles" with diascopy.

The mesh (tree-like) livedo is a typical manifestation of APS, SLE, some types of systemic vasculitis (nodular polyarteritis).

Palpable purpura (a hemorrhagic rash that slightly rises above the skin and is not associated with thrombocytopenia) is characteristic primarily of hemorrhagic vasculitis, but may occur in other vasculitis involving small-caliber vessels: cryoglobulinemic vasculitis, Wegener's granulomatosis, the Chardz-Strauss syndrome, and microscopic polyangiitis.

Pointless, painless necrosis of the skin in the area of the flesh of fingers and around the nail bed (digital arteritis) is typical for RA. They can be noted in systemic vasculitis.

Ring-shaped erythema is observed with SLE, Lyme disease. In acute rheumatic fever, annular erythema (usually in the form of multiple elements) occurs on the skin of the trunk and proximal parts of the extremities, on the face. It may disappear within a few hours, but recur or "be protected steadfastly after the subsidence of the remaining manifestations of the disease. Ring-shaped erythema can be one of the types of skin manifestations in the so-called subacute lupus erythematosus. When Lyme disease ring-shaped erythema (a single element) is the stage of development of the diffuse erythematous spot appearing at the site of the tick bite.

Xanthelasms, xanthomas over the joints and tendons are observed during hypercholesterolemia.

Ulcers, skin necrosis in the region of the shins are characteristic for RA, Crohn's disease, systemic vasculitis, especially cryoglobulinemic vasculitis.

Painful recurrent, self-healing ulcers in the area of the external genitalia, scrotums are typical for Behcet's disease.

Diffuse hyperpigmentation of the skin with a bronze hue is a sign of hemichromatosis.

Slate-violet. Grief-gray coloration of the auricles, cartilage of the nose pathognomonic for ochronosis (dark staining of urine, sweat and tear fluid are also characteristic).

Local thickening of the skin and soft tissues in the proximal interphalangeal joints of the hands. There are two options:

• "Fibrous pads of fingers" (a thickening is noted only over the back of the joint);
• pachidactyly (thickening marked around the perimeter of the joint).

Nodular erythema is seen in many diseases, but in combination with polyarthritis it is characteristic primarily of sarcoidosis. In rheumatic diseases it is rarely noted.

Gouty subcutaneous tofusi, usually located in the area of the elbow joints, on the auricles, on the fingers of the hands, are painless. You can mark translucent through the skin whitish crumbly contents. The most convenient object for confirming the diagnosis of gout (examination of the contents in a polarization microscope for the detection of urate crystals).

Rheumatoid nodules are usually located in the area of the elbow joints, on the extensor surface of the forearms, on the fingers of the hands. Painless, they are detected in patients with seropositive variant of RA. They can be located subperiostally, in this case they are immovable. Externally, similar nodules can be found in amyloidosis, gout, hypercholesterolemia, SLE, calcification of soft tissues, anular granuloma (skin disease), and multicentric reticulogistiocytosis.

Recurrent aphthous stomatitis is typical of Behcet's disease. It can be diagnosed with SLE, Crohn's disease.

Painless painless erosions of the oral mucosa are characteristic of ReA. Focal changes in the oral mucosa are possible with psoriasis.

Circinar (annular) balanitis (vesicles with subsequent formation of painless erosion) is characteristic for ReA.

Single or multiple painless hemorrhagic maculae or papules are characteristic of gonorrhea. A similar rash can also be observed with meningococcal sepsis.

[18], [19], [20]

Eye Changes

• Iridocyclitis (anterior uveitis) is characteristic for seronegative spondyloarthritis, juvenile arthritis, Behcet's disease.
• Dry keratoconjunctivitis is typical for Sjogren's syndrome and disease.
• Acute conjunctivitis is inherent in ReA.
• Epicleritis, scleritis can be noted in RA, systemic vasculitis.

[21], [22], [23]

Laboratory research

Among the minimally necessary laboratory tests used for the diagnosis and differential diagnosis of inflammatory joint diseases, the main feature of which is polyarthritis, include a general blood test, a cytological analysis of cerebrospinal fluid, a biochemical blood test (concentration of uric acid, cholesterol, creatinine, calcium, phosphorus, iron, activity transaminases, alkaline phosphatase, KK, etc.), determination of CRP, rheumatoid and ANF in serum. Other studies (microbiological, immunological, study of liquor on crystals, etc.) are carried out according to indications.