9 A 22-Year-Old Female With Joint Pain


Case 9

A 22-Year-Old Female With Joint Pain



Dawn Piarulli, R. Michelle Koolaee



A 22-year-old female with no significant past medical history presents to an urgent care center reporting 3.5 months of worsening joint pain and swelling. She states that both her hands, her right knee, and her left ankle have been bothering her and are swollen at times.



Why is the duration of this patient’s joint pain important?


Table 9.1 summarizes the etiologies of inflammatory arthritis based on symptom duration. The duration of joint symptoms can implicate certain diagnoses over others. When the arthritis is acute (lasting a few days or less), one must immediately consider septic arthritis or crystal-induced arthritis (i.e., gout, pseudogout). Septic arthritis can occur secondary to organisms of bacterial, viral, or fungal origin. An arthrocentesis should be immediately performed to rule out this possibility as well as to evaluate for crystal-induced arthritis. See Case 47 for more information about septic and crystal-induced arthritis.



When symptoms have been present for more than a few days but less than 6 to 8 weeks, one should consider subacute types of infectious or parainfectious arthritides such as poststreptococcal arthritis or viral arthritis such as parvovirus B19 arthritis. Another differential diagnosis to consider is reactive arthritis. Reactive arthritis (formally known as Reiter’s syndrome) is an acute inflammatory arthritis that can occur after genitourinary infections (i.e., Chlamydia) or after gastrointestinal infections like Yersinia, Salmonella, Shigella, Campylobacter, or Clostridium difficile.



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Clinical Pearl


One mnemonic for reactive arthritis is “Can’t see, can’t pee, can’t climb a tree” for conjunctivitis, urethritis, and arthritis of reactive arthritis. The entire triad does not need to be present in order to consider this diagnosis.


In a patient who presents with chronic arthritis (more than 6 to 8 weeks), it is reasonable to consider autoimmune illnesses, which include systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), or the seronegative spondyloarthropathies (SpAs), to name a few. Be mindful that arthritis due to tuberculous or fungal infections may fall into the chronic category if not detected early on.



What is meant by the term oligoarthritis, and why is the number of joints involved in arthritis important?


Arthritis is usually categorized into monoarthritis, oligoarthritis, or polyarthritis. These terms refer to the number of joints involved in arthritis. Oligoarthritis refers to ≤4 affected joints, whereas polyarthritis refers to five or more affected joints. The number of joints involved is important because the differential diagnosis for each class of arthritis is a bit different (although there can be overlap). Table 9.2 highlights the differential diagnosis according to the number of joints involved.



On further questioning, the patient reports a history of pain, stiffness, and swelling worst at her second through fourth metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints bilaterally. She reports 2 hours of morning stiffness and has been having trouble opening jars and closing buttons on her clothes. Exercising has been difficult because of her joint swelling. Her mother’s sister was diagnosed with arthritis in her 30s; she has not kept in close contact with her and is not sure what type of arthritis. She has not had any recent infections. She denies diarrhea, rashes, or back pain.




Why is it important to ask about the duration of morning stiffness?


When trying to determine what is causing chronic arthritis, it is important to determine whether a patient is suffering from an inflammatory arthritis or a noninflammatory arthritis. Inflammatory arthritis is associated with at least 30 minutes and often greater than 1 hour of morning stiffness. Patients with osteoarthritis can also have morning stiffness, but it usually lasts less than 20 minutes.



The patient’s exam reveals an afebrile, well-nourished, well-developed young female with normal heart, lung, and abdominal exam. She has no clubbing, cyanosis, or edema. However, on musculoskeletal exam, there is synovitis of both wrists, several MCPs, and several PIPs. The right knee has a moderate effusion, and there is synovitis at the left tibiotalar joint. At the affected joints, she has decreased range of motion secondary to pain. There are no contractures on exam. Her skin reveals no rashes.



What is the definition of synovitis and what does it indicate?


Synovitis is the physical exam term used to indicate the finding of active inflammatory arthritis. A joint with synovitis may have bogginess, swelling, tenderness, and may or may not have a palpable effusion. Synovitis is not specific to any particular type of inflammatory arthritis; any type may have this finding. When an effusion is present with synovitis and no diagnosis has been made, arthrocentesis is critical to perform to help establish a diagnosis. See Case 47 for discussion on synovial fluid analysis. Table 9.3 summarizes ways in which inflammatory and noninflammatory arthritis differ.



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Clinical Pearl


The presence of a joint effusion is not always a definitive sign of inflammatory arthritis (i.e., patients with knee osteoarthritis very commonly present with knee effusions). In this case, arthrocentesis may be necessary to differentiate inflammatory versus noninflammatory arthritis.



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Clinical Pearl


When evaluating for synovitis, check range of motion by having the patient make a fist. A patient with severe inflammatory arthritis will have difficulty making a complete fist (this is a particularly helpful finding in someone with an equivocal exam for synovitis [i.e., obese patients]).




How would you summarize the findings and the most likely differential diagnoses?


In summary, this is a young female who presents with a chronic, polyarticular, symmetric arthritis affecting both small and large joints.


RA is a likely diagnosis, given the involvement of bilateral small joints in conjunction with symptom duration of greater than 6 to 8 weeks. Other possibilities include SpA with peripheral joint involvement such as ankylosing spondylitis (AS), psoriatic arthritis (PsA), or reactive arthritis. Peripheral joint involvement refers to joints of the extremities (such as shoulders, elbows, wrists, MCPs, PIPs, distal interphalangeal joints [DIPs], knees, ankles, or metatarsal interphalangeal joints [MTPs]). Axial joint involvement refers to spinal or sacroiliac joint involvement, which the patient does not have. She has no rash, so PsA is less likely (although 10% of the time the arthritic symptoms may precede the rash). With no history of recent infections, reactive arthritis is less likely. Patients with Sjögren’s syndrome may also present with polyarticular inflammatory arthritis; however, she does not have any symptoms of keratoconjunctivitis sicca (dry eye) or xerostomia (dry mouth). Given the chronicity of her symptoms, an infectious cause of her arthritis would be very unlikely.


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Jun 15, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on 9 A 22-Year-Old Female With Joint Pain

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