Rheumatoid arthritis usually progresses slowly and intermittently and
can be difficult to diagnose. The joints involved are symmetric and in- volve the metacarpal-phalangeal joints, proximal interphalangeal joints, wrists, elbows, shoulders, knees, ankles, metatarsophalangeal joints, and the cervical spine (Klippel 1997). The distribution is different in osteoarthritis. In rheumatoid arthritis the joints are stiff after pro- longed immobility, for example, when the patient first wakes up in the morning. The stiffness or joint pain usually lasts longer than 1 hour. Af- ter some activity, the joints loosen up and mobility improves. Examina- tion of the affected joints may reveal limited range of motion and swelling of the joint space. An X ray may reveal joint space narrowing or erosion of the bone. Laboratory results may include chronic anemia or elevated values for rheumatoid factor or antinuclear antibodies. If rheumatoid arthritis is suspected, the patient should be evaluated by a rheumatologist.
Degenerative joint disease, or osteoarthritis, is more prominent in the
older population. It most commonly affects the hips, knees, cervical and lumbar spine, the distal and proximal interphalangeal joints, and the first metacarpal-phalangeal joint (Klippel 1997). The process includes degeneration of joint cartilage and bony changes at the joint. The joint pain in osteoarthritis progresses during the day and is worse at night or after extended activity. Patients usually present with slowly progressing joint pain with acute flare-ups, such as knee pain after increased activity. An X ray may show narrowing of joint spaces and osteophyte forma- tion. Treatment is rest of the joint and acetaminophen at larger doses, such as 1,000 mg three to four times a day. Treatment also includes weight loss, physical therapy, and, in some cases, surgery, such as knee or hip replacement.
Gout is a disease involving overproduction or underexcretion of uric
acid. The patient presents with a suddenly red-hot tender joint, most commonly the first metatarsophalangeal joint. If the patient has no pre- vious diagnosis of gout, arthrocentesis must be done to confirm the di- agnosis. Analysis of the fluid can reveal crystals. NSAIDs are used for
the treatment of an acute gout attack. Other treatment options include colchicine and corticosteroids. After the acute attack subsides, some pa- tients may receive long-term treatment. Patients with overproduction of uric acid are treated with allopurinol, and patients with underexcretion of uric acid are treated with probenecid.
The presentation of pseudogout is similar to that of gout, except that the knee is more commonly involved. Treatment of an acute attack of psuedogout is similar to the treatment of gout; NSAIDs such as ibupro- fen or indomethacin are used, as well as the alternatives colchicine or corticosteroids.
One should be suspicious of septic joint in any young, sexually active patient who presents with a fever and a red, warm, tender, or edema- tous joint. A rheumatologist or emergency medicine physician must perform arthrocentesis in such patients as soon as feasible. The aspi- rated joint fluid should be sent for laboratory studies, which include white blood cell count, Gram stain culture, and crystal studies. White blood cell counts in the joint fluid may range from 10,000 to 100,000 cells/µL but are typically closer to 100,000 cells/µL in septic joints (Burton 2000). Organisms responsible include Neisseria gonor-
rhoeae or Staphylococcus aureus (60%), gram-negative bacilli (20%), and
others (20%). If gonorrhea is suspected, throat, cervical, and urethral cultures must also be obtained, because the Gram stain plus culture. Treatment choices include ceftriaxone if gonorrhea is suspected or nafcillin plus a third-generation cephalosporin if +C is suspected not for a total of 14–28 days. NSAIDs such as ibuprofen may be used for pain control.
Polymyalgia rheumatica presents with pain and stiffness of the proxi-
mal joints such as the hips and shoulders (Klippel 1997). The pain and stiffness are usually worse after immobility or in the early morning. Laboratory abnormalities include an elevated erythrocyte sedimenta- tion rate (ESR). If polymyalgia rheumatica is suspected, the patient should be referred to a rheumatologist. Treatment includes a prolonged course of prednisone.
Polymyositis presents as weakness that is more proximal than distal. Dermatomyositis is polymyositis with skin changes, such as heliotrope
rash of the eyelids or Gottron’s papules over the metacarpal-phalangeal joints of the hands. Laboratory abnormalities include an elevated crea- tine phosphokinase level. Additional tests include muscle biopsy and electromyography. If polymyositis is suspected, the patient should be evaluated by a rheumatologist. The treatment includes prednisone at high doses over a long period of time.
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Patients with fibromyalgia present with vague complaints of weak- ness and of being easily fatigued, general muscle aches, and difficulty with sleep. Aches and pains are located medially and not in the joints. Other conditions must be ruled out. Although no specific tests for fibro- myalgia exist, 18 symmetric points on the body are frequently tender in patients with fibromyalgia. These symmetric points of tenderness are located over muscle or tendons rather than at the joints. If fibromyalgia is suspected, the patient should be evaluated by a rheumatologist. The treatment includes tricyclic drugs (amitriptilyne or cyclobenzaprine), cognitive-behavioral therapy, and graded exercise.
Aging, decreased estrogen levels in women, decreased activity, and decreased calcium intake may lead to osteoporosis and increased risk for fracture, especially of the vertebrae and hips. Smoking, steroid use, and Asian ancestry are also risk factors for osteoporosis. Bone density mea- surements can be done to evaluate for osteopenia and risk of fracture. Preventive measures include exercise and administration of estrogen or raloxifene and calcium with vitamin D. Treatment options include alen- dronate, which is a bisphosphonate. Any back or hip pain in a patient with the risk factors for osteoporosis or with a diagnosis of osteoporosis should be evaluated with an X ray for possible fracture.
Ankylosing spondylitis most commonly presents with inflammation
of the sacroiliac joints. The pain and stiffness are usually located in the sacroiliac joints, lumbar area, or buttocks. Symptoms are worse in the morning or after immobility. The symptoms may initially be limited to one side of the body but may progress to become bilateral. Laboratory abnormalities may include an elevated ESR, elevated C-reactive protein and alkaline phosphatase levels, and mild anemia. An X ray may reveal sacroiliitis or fusion of the vertebrae. Treatment begins with NSAIDs.
Reiter’s syndrome is the triad of urethritis, conjunctivitis, and arthritis,
usually presenting in that order. Reiter’s syndrome is a reactive arthritis and typically follows a gastrointestinal or genitourinary infection. The ar- thritis typically involves lower extremity joints. The illness is self-limited, and NSAIDs may be used for the arthritis. The primary infection (often gonorrhea) must be identified and treated as soon as possible.
References
Abeles M: Fibromyalgia syndrome, in Functional Somatic Syndromes. Edited by Manu P. New York, Cambridge University Press, 1998, pp 32–37 Burton J: Acute disorders of the joints and bursae, in Emergency Medicine: A
Comprehensive Study Guide, 5th Edition. Edited by Tintinalli JE, Kelen GD, Stapczynski JS. New York, McGraw-Hill, 2000, pp 1895–1898
Dieppe PA, Lohmander LS: Pathogenesis and management of pain in osteoar- thritis. Lancet 365:965–973, 2005
Elliott AM, Smith BH, Penny KI, et al: The epidemiology of chronic pain in the community. Lancet 354:1248–1252, 1999
Hellman DB: Nonarticular rheumatic disorders, in Principles of Ambulatory Medicine, 6th Edition. Edited by Barker LR, Burton JR, Zieve PD, et al. Phil- adelphia, PA, Lippincott Williams & Wilkins, 2003, pp 1105–1114
Klippel JH: Primer on the Rheumatic Diseases, 11th Edition. Atlanta, GA, Ar- thritis Foundation, 1997, pp 89–154
Linaker CH, Walker-Bone K, Palmer K, et al: Frequency and impact of re- gional musculoskeletal disorders. Baillieres Best Pract Res Clin Rheumatol 13:197–215, 1999
Valeriano-Marcet J, Carter JD, Vasey FB: Soft tissue disease. Rheum Dis Clin North Am 29:77–88, 2003