The interrogation and complete examination is essential to determine the etiology. Particularly discriminating:
– The age and sex of the patient;
– Thermal curve;
– Schedule arthralgia: nocturnal onset or early morning, the notion of morning stiffness are very suggestive of inflammatory arthralgias;
– The seat of the joints affected predominantly (small joints of the extremities, large proximal joints, spine and / or sacroiliac joints, etc.);
– Arthritis signs in the review and in particular the existence of a punctured effusion (mostly knees); if there are more than 2 000 cells / mm3 for the aspirated fluid, there is an inflammatory joint disease or infection; synovial fluid may also contain crystals (mainly calcium pyrophosphate or uric acid).
The clinical examination is supplemented by biology looking for leukocytosis and / or inflammation [ESR, C-reactive protein (CRP), serum fibrin, haptoglobinémie, ferritin].
In case of inflammation, procalcitonin can help distinguish bacterial infections (procalcitonin> 0.5 ng / mL) of non-infectious inflammatory rheumatism.
The diagnostic approach for a patient polyarthralgique encompasses virtually all rheumatology. It is different depending on whether or not arthritis and / or an inflammatory syndrome.
DIAGNOSTIC APPROACH IN THE PRESENCE OF INFLAMMATORY ARTHRITIS:
It is important to distinguish infectious arthritis, particularly bacterial, which will require antibiotic treatment, and non-infectious inflammatory arthritis.
Remember that it must at all costs avoid prescribing antibiotics before bacteriological samples.
Inflammatory arthritis of infectious origin:
Bacterial septic arthritis:
These are essentially monoarthritis, but we observe multiple septic arthritis in the streptococcal septicemia, staphylococcal or gonorrhea.
This is usually of reactive arthritis: joint aspiration reveals no germ.
In mainland France, rheumatic fever has disappeared.
Brucellosis has become a rare, apart from occupational exposures.
In case of heart valve disease, known or detected on a routine ultrasound, endocarditis Osler must be carefully sought: there are arterial embolism or valvular vegetations ultrasound? Are positive blood cultures?
Lyme disease is evoked in case of tick bite (found in 50% of cases) or rash a member type of erythema chronicum migrans) or radicular pain.
Treatment: amoxicillin (2 to 3 g / day, 2 weeks) or rocéfine (1 g / day IV [intravenous] and IM [IM], 2 weeks).
Reactive arthritis to genital infection with Chlamydia are part of the table Fiessinger Reiter syndrome (search diarrhea, conjunctivitis and pain preferably sitting at the spine and the sacroiliac joints).
Reactive arthritis infection mycoplasma or Ureaplasma urealyticum are rare.
Reactive arthritis to digestive door entry (Shigella fl exneri, Salmonella enteritidis, Yersinia enterocolitica, Clostridium diffi cult, etc.) Are also rare.
Special case: Whipple’s disease. The germ (Tropheryma whippeli) is sometimes found in the joint aspiration. The diagnosis is suspected if there is diarrhea, uveitis or central neurological disorders.
Parasitic reactive arthritis:
They are exceptional, and can be observed in the filariasis (Loa).
Inflammatory arthritis of viral origin:
We must first think of the parvovirus B19. This is usually trace arthritis most commonly affects the knees, and this in the mother or in the entourage of a small child who has just made a rash illness.
The presence of IgM antibodies can retain the diagnosis.
The arthritis indicative of infection by the hepatitis B virus (HBV) are conventional; they are often accompanied by other elements of the triad Caroli (urticaria and headache).
Infection with EBV (Epstein Barr Virus) and CMV (Cytomegalovirus) may be associated with arthralgia. The existence of liver function changes is a major policy element.
Trace arthritis to HTLV-1 virus (Human T cell Leukemia / lymphoma virus) are much rarer, but must be discussed in patients (mainly women) from the Caribbean, Japan and even the Meeting or Black Africa.
Arthralgia noninfectious inflammatory:
They must place a “check list” of systemic diseases whose frequency varies with age of onset of arthralgia.
In young subjects:
Research is first 4 groups of systemic diseases: connective, ankylosing spondylitis (AS) and psoriatic arthritis, the vasculitis, sarcoidosis.
Still’s disease is a diagnosis of exclusion.
Connective:
By convention, the class within connective: systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Sjogren Sjogren’s syndrome, systemic sclerosis.
Research of specific antibodies will help considerably in diagnosis.
Systemic lupus erythematosus (SLE):
SLE is mentioned first in a young woman (sex ratio = 8/1) complaining of arthralgia inflammatory wrists and hands (metacarpophalangeal and proximal interphalangeal), especially if there are erythematous rash of the face or mucous membranes and photosensitivity. Arthritis of lupus are called non-erosive: normal radiographs of hands.
If there are distortions of the fingers, they are reducible, the rheumatism Jaccoud.
The most visceral characteristics are:
– The leuropéricardites p;
– The rotéinurie p and hematuria;
– The convulsive c rises.
The blood count may show:
– Hemolytic anemia with positive Coombs; – A peripheral thrombocytopenia (associated with hemolytic anemia, it is the Evans syndrome);
– Leukopenia on neutrophils and / or lymphocytes.
Antiphospholipid antibodies are found in more than one third of lupus.
The diagnostic criteria of SLE were reviewed by the ACR(American College of Rheumatology) in 1997:
– Malar erythema (vespertilio);
– Discoid lupus;
– Photosensitivity;
– Oral or nasopharyngeal ulceration;
– Non-erosive arthritis;
– Pleurisy and / or pericarditis;
– Proteinuria> 0.5 g / 24 h;
– Seizures or psychosis;
– Autoimmune haemolysis and / or leukopenia and / or lymphopenia and / or thrombocytopenia (<100,000 / mm3);
– Antinuclear antibodies;
– Anti-DNA antibodies or anti-Sm antibodies or
antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant circulating, serology dissociated from Treponema).
Treatment: therapeutic climbing for SLE is quite well codified.
Rheumatoid arthritis:
This is the most common connective. It mainly affects women, but usually begins later in life than SLE. Initially, arthralgia inflammatory hands resemble those of SLE; Search autoantibodies is discriminating, knowing that the onset of rheumatoid factor is often delayed for a few months; cyclic citrullinated antipeptides antibody (anti-CCP, ex antikeratin antibodies) are very specific, but insensitive (found in less than half of the patients).
Treatment: biotherapy can prevent the onset of irreducible joint deformities and bone lesions characteristic (geodes, joint space narrowing, carpite amalgamating, etc.). Their disadvantages are the risk of opportunistic infections (especially tuberculosis) and high cost (about € 12,000 per year).
Sjögren’s syndrome (GS):
Almost as common as the PR (2% of the population), it is observed especially in women after 40 years. It can be associated with another connective tissue. Arthralgia are often in the background, patients are especially bothered by dry eye (printing grittiness) and / or oral (a sugar placed in the background language in addition to 3 min).
The diagnosis objective elements are:
– The presence of specific autoantibodies (anti SSA and anti SSB);
– Positivity lip biopsy (at least 50 infiltration by lymphocytes field in the salivary glands: Chisholm stage III or IV).
lymphocytic sialadenitis relatives of GS may be secondary to a viral infection: hepatitis C, HIV (HIV) and other retroviruses frequent the Caribbean and Asia, HTLV-I.
The severity of the GS is related to the occurrence (rare) visceral complications:
– Tubulopathy with hypokalemia, hypophosphatemia and osteomalacia;
– Sensory peripheral neuropathy;
– Psychiatric and central neurologic manifestations;
– ILD.
In addition, the occurrence of lymphoma (particularly saliva) is over 40 times more common than in the general population.
The mainstay of treatment includes:
– Eye drops to fight against dry eye;
– Pilocarpine potion or pills of Salagen (expensive and not reimbursed);
– Hydroxychloroquine (Plaquenil®), 200 to 400 mg / d, with eye monitoring and ECG (risk of conduction disorders).
Systemic sclerosis (SDS):
It begins, in 90% of cases, Raynaud’s phenomenon may precede more than 10 years (in megacapillaries capillaroscopy); polyarthralgia may accompany the onset of cutaneous sclerosis. In the affected areas, it is difficult to pinch the skin between two fingers.
According to the headquarters of this sclerosis, there are:
– Has croscléroses that affect only the ends (including the face);
– SDS and diffuse that reach the root of the limbs and / or trunk.
Among acroscléroses it individualizes the CREST syndrome: calcinosis subcutaneous (C), Raynaud’s phenomenon (R), esophageal disease (E), sclerodactyly (S), telangiectasia (T). CREST syndrome must fear pulmonary arterial hypertension (PAH), but the practice of systematic echocardiography showed that the prevalence of PAH is less than 10%.
CREST prognosis is much better than the SDS broadcasts exposing to 4 types of visceral:
– Digestive tract (esophagus, but also the small intestine);
– Pulmonary (alveolar-interstitial fibrosis that can progress to lung cancer);
– Heart (restrictive cardiomyopathy);
– And especially kidney (scleroderma renal crisis, oligoanuric with renal failure rapidly progessive requiring emergency treatment with angiotensin converting enzyme).
In principle, anticentromere antibodies are specific CREST and anti-Scl 70 or topoisomerase are specific diffuse SDS these antibodies excluding each other.
The characteristics Shulman’s syndrome, or fasciitis with eosinophilia are:
– Subcutaneous diffuse fibrosis;
– Often occurring after an unusual effort;
– Absence of Raynaud’s phenomenon, capillaroscopy normal and virtually no organ involvement;
– Discomfort of the patient by the tendons (especially the finger flexors);
– Essential risk: a bone marrow dysplasia.
Sharp syndrome:
It is a connective which combines clinically Raynaud’s phenomenon, arthralgia hands and stubby fingers.Capillaroscopy shows megacapillaries and capillaries branching characteristics dystrophies. These patients have antibodies anti-ECT individuals antiribonucléoprotéine (RNP), which have much value if they are isolated.
* Ankylosing spondylitis (SPA):
The SPA is sought in a young patient complaining of back pain inflammatory schedule; pain in the middle of the buttocks in the middle or end of night and heel pain are highly suggestive. One can observe a fever and inflammatory syndrome.
The discovery of the leukocyte antigen HLA B27 and an irregularity sacroiliac condensations with the banks or microgéodique appearance allow to confirm the diagnosis. The existence of associated diarrhea must seek Fiessinger Reiter’s syndrome but also inflammatory bowel disease (Crohn’s disease or ulcerative colitis). When the diagnosis of PPS is established, the cardiac monitoring must be particularly careful: ECG at least once a year in search of a conduction disorder (6-10% of cases), auscultation and echocardiography in search of a aortic insufficiency (3% of cases).
First-line treatment: anti-inflammatory drugs (NSAIDs). SPA remains one of the last directions phenylbutazone, whose dramatic efficiency can be considered as a diagnostic test.
Second-line therapy: methotrexate (7.5 mg to 15 mg once a week, IM or orally) with the same prescription dose Spéciafoldine® 48 hours later.
Of anterior uveitis can also complicate the development and require local emergency treatment.
In case of diarrhea:
– First-line treatment: Salazopyrine® (3 g / d) (in our experience, efficiency DMARD more variable than methotrexate);
– Second-line treatment: anti-TNF; the dose of infliximab (Remicade®) is higher than in the PR: 5 mg / kg by infusion instead of 3 mg / kg.
SPA, we can bring the SAPHO syndrome (acne-pustulosis-hyperostosis-osteitis).
Acne is often severe type conglobata; pustulosis particularly affects the palms and soles (Andrews bactérides), achieving the sternoclavicular joint is very characteristic, and bone scintigraphy allows the highlight.
* Psoriatic arthritis:
It particularly affects the knees and feet (toe in sausage), it can also be axial.
Psoriasis is sometimes very discreet, you have to look for lesions in the scalp or nails. This psoriatic arthritis may be associated with anti-CCP antibodies, where possible diagnostic difficulties with RA.
Treatment is similar to that of the SPA; TNF antagonists can be used in severe cases.
* Vasculitis:
Inflammatory polyarthritis may be the mode of revelation of vasculitis.
We must distinguish arteritis inflammatory large artery and artériolites involving vessels of less than 1 mm indiameter.
Arteritis inflammatory large artery:
Vasculitis of large vessels in young patients are essentially Takayasu’s arteritis and Behcet’s disease.
In Takayasu’s arteritis, arthralgia occur primarily to the systemic phase of the disease, when there is no arterial occlusion. At this point, there may also be erythema nodosum or episcleritis.
At the vascular phase, delayed usually 4 to 5 years from the first symptoms, the diagnosis of Takayasu arteritis and is mentioned in the presence:
– Aortic disease (renovascular hypertension, aneurysm of the descending aorta, aortic insufficiency);
– Or a large branch of the aorta (claudication on exertion of an upper limb, abolition of a radial pulse, etc.).
In the presence of arterial disease, it takes 3 of the following criteria 6 to retain the diagnosis:
– Female;
– Age of onset before age 40;
– Absence of vascular risk factor;
– Inflammatory syndrome;
– Stenosis or aneurysm of the descending aorta;
– Stenosis or occlusion of the subclavian postvertébrale.
Behçet’s disease is a vasculitis that affects the veins in 1/3 of cases and arteries in less than 10% of cases. Arthralgia mainly interested knees. Oral aphtose is essential for diagnosis. Other diagnostic criteria are genital aphthous stomatitis, ocular disorders (uveitis, retinitis), skin lesions (Pseudofolliculitis, erythema nodosum, skin hyperergie).
Artériolites inflammatory:
We distinguish those who are associated with cytoplasmic antibodies (ANCA) and others.
Vasculitis which usually accompany ANCA are: Wegener’s granulomatosis, microscopic polyangiitis and less often allergic vasculitis and Churg Strauss.
Polyarthralgias are a way of frequent revelation of Wegener’s granulomatosis. The guidance are:
– Chronic sinusitis;
– Earache and purulent otitis;
– Episcleritis;
– The existence of pulmonary nodules on CT excavated;
– Gross hematuria and / or proteinuria;
– Rapidly progressive renal failure.
The treatment is urgent and is generally based on prednisone (Cortancyl®) and cyclophosphamide (Endoxan®) in monthly bolus 700 mg / m2 or fortnightly.
The classic polyarteritis nodosa is rarely accompanied ANCA and is rarely revealed by arthralgia; the best sign of the orientation is mononeuritis, present in two thirds of patients.
The HSP occurs mainly in children and young adults; it is revealed by arthralgia predominate in the lower extremities and vascular purpura told because infiltrated and prevalent in dependent areas. Abdominal pain (sometimes accompanied by rectal bleeding) and microscopic or gross hematuria complete the clinical picture.
Skin biopsy and, if necessary, biopsy, kidney (IgA nephropathy) used to confirm the diagnosis.
* Sarcoidosis:
It can be revealed by inflammatory arthralgia, mainly of the ankles.
When accompanied by erythema nodosum of the lower limbs and mediastinal lymphadenopathy, they are Löfgrensyndrome. Diagnosis relies on lip biopsy (looking for epithelioid granuloma) and bronchoscopy with bronchial biopsies and bronchoalveolar lavage (hyperlymphocytosis the washing is very evocative).
The measurement of angiotensin converting enzyme has little diagnostic value because its rate is very variable in normal subjects, but if it is high, it is a good marker scalability.
The treatment is based solely on NSAIDs in benign forms with normal pulmonary function.
If pulmonary parenchymal disease or severe visceral involvement (cardiomyopathy, meningitis or central nervous system impairment, hepatosplenomegaly), prednisone is indicated (1 mg / kg / day), and it often means using immunosuppressant (methotrexate mainly) .
* Disease Still:
When this checklist is negative, it must evoke in the presence of inflammatory polyarthritis in a subject young diagnosis of Still’s disease, which:
– Often begins with a sore throat;
– Then combines:
– High fever with thermal Vesper peaks at 39 ° C or more,
– Highly inflammatory arthralgia (especially hands and carp, knees, ankles)
– And less frequently of very fleeting rash, flu-hives.
Biology basically shows leukocytosis neutrophils and often considerable ferritin (> 1000 ng / mL) with decrease in the percentage of glycated ferritin. If ferritin is high, we must fear a macrophage activation syndrome (MAS), the other criteria are: cytopenia on at least two lines, elevated transaminases, LDH (lactate dehydrogenase), triglycerides.
The therapeutic climbing comprises: NSAIDs (indomethacin at a dose of 100 to 150 mg / d), prednisone (1 mg / kg / d), methotrexate (15-20 mg / week), intravenous immunoglobulin, anti -TNF (see RA treatment) or thalidomide (100 mg / d) which has an anti-TNF activity.
In the elderly:
All diagnoses mentioned in the young may also be discussed, in particular the GS and Wegener’s granulomatosis, but we must first discuss the microcrystalline 3 rheumatism and polymyalgia rheumatica, with or without arteritis Horton.
* Three rheumatism microcrystalline:
They are: gout, chondrocalcinosis and rheumatism to hydroxyapatite.
Drop:
The diagnosis of gout is easy for the patient who has a nocturnal attack of the big toe, which has already renal colic by stones uric. It can be much more difficult if pseudophlegmoneuse drop (especially the carp) or polyarthritis.
The essential diagnostic criteria are:
– The detection of tophi (on the cartilage of the ear or fingers mainly) containing uric acid crystals;
– And hyperuricemia.
In very severe gout with uric acid stones and major hyperuraturie in a man, we can search for genetic cit challenge hypoxanthine guanine phosphoribosyl transferase (HGPRT).
Treatment is based on colchicine (2-3 mg / day) at the time of access and the bottom of allopurinol treatment (keeping to the colchicine 1 mg / day dose during the first weeks of treatment).
Chondrocalcinosis:
The acute crisis chondrocalcinose key:
– Essentially the knee (joint aspiration will help highlight calcium pyrophosphate crystals);
– Carp or hips.
One form is very atypical tooth syndrome crowned by achieving the dens, which can be mistaken for meningitis or spondylitis. This is the CT of the cervical spine that makes the diagnosis.
The polyarticular forms may be accompanied by a temperature shift and an inflammatory syndrome.
The test treatment is colchicine, with or without NSAIDs.
* Rheumatism hydroxyapatite:
The hydroxyapatite rheumatism pains are periarticular qu’articulaires. Diagnosis can be retained only if there is multiple tendon calcifications on the clichés of the soft parts.
Polymyalgia rheumatica (PMR):
PPR is not observed until after 55 years. The schedule inflammatory pain affects the shoulders and hips, but also the arms and thighs. There is a significant morning stiffness.
Inflammatory biological syndrome is almost constant. Joint radiographs are normal, as well as the muscle biopsy is it simply the usual colorings.
PPR may be associated with temporal arteritis Horton; at the slightest headache or any visual disturbance, a temporal artery biopsy is indicated (at least 3 cm, starting with the painful side).
The treatment is based on corticosteroids at variable dosage:
– 20 to 30 mg / d of prednisone in case of single PPR;
– 0.7 mg / kg / day in case of Horton associated;
– 1 mg / kg / day if Horton is accompanied by visual disturbances.
In elderly patients, we must systematically involve calcium and vitamin D prednisone or seek treatment by bisphosphonates like Fosamax 70 or 35 Actonel once a week. It is unnecessary to give a gastric protector or potassium.
If Horton, it is prudent to prescribe aspirin (75-150 mg / day) or even a K antivitamine in early treatment to prevent coronary heart complications and stroke.
The existence of arthralgia ends associated with edema and an inflammatory syndrome in a patient aged defi nes the EP RS3 (seronegative symmetrical synovitis for remitting pitting edema with). For some teams, inflammatory arthritis, steroid-very, is only a peripheral shape of the PPR.
DIAGNOSTIC APPROACH IN THE ABSENCE OF INFLAMMATORY SIGNS:
The occurrence of diffuse arthralgias must discuss in this order: drugs, metabolic arthropathy, endocrine problems, osteoarthritis and fibromyalgia.
Arthralgia iatrogenic:
Many drugs have been accused of cause arthralgia, and the main ones are:
– Antibiotics (quinolones, tetracyclines, Rimifon);
– Statins (frequently associated myalgia);
– Bisphosphonates;
– Corticosteroids (search aseptic osteonecrosis);
– Anticancer (aromatase inhibitor);
– Antivirals (protease inhibitors: Crixivan);
– Ntithyroïdiens has the synthesis;
– Has ntivitamine K;
– Allopurinol;
– Sulfasalazine;
– Vaccines (rubella, BCG intravesical);
– Biotherapy (interferon α and β, interleukin-2, etc.)
The clinical picture may be even more misleading that some of these drugs are used to treat joint pain (corticosteroids, sulfasalazine, allopurinol, etc.).
If in doubt, it is better to stop, at least temporarily, the suspect medication before embarking on long and demanding explorations.
Metabolic arthropathy:
The main ones are those of the hemochromatosis gene mutation C 282 Y homozygous HFE gene (on chromosome 6).The most commonly affected joints are the metacarpophalangeal (2nd and 3rd fingers). The handshake is painful (it is the “iron hand”, common in Britain). Radiographs of hands are characteristic. The diagnosis is made by measuring the coefficient of saturation of transferrin (> 45%) and ferritin (> 500 ng / mL).
The closely spaced grooves (a week early) can eliminate iron, but rarely improve arthralgia hemochromatosis.
Endocrine:
May be associated with diffuse arthralgias:
– Acromegaly: frequent arthralgias, especially of the hands; hyperphosphataemia can be a meaningful biological sign, but it is necessary to dose growth hormone (GH) and somatomedin (or IGF-1);
– Menopause but also stopping hormone replacement therapy (HRT) or the prescription of anti-aromatase in breast cancer: arthralgia especially hands. The regression of pain HRT (if possible) to confirm the diagnosis.
Osteoarthritis:
Outbreaks of osteoarthritis may be of interest at the same time more joints (fingers, knees, hips), and accompanied by inflammatory signs objectives. The personal and family history of the patient and especially plain radiographs allow diagnosis.
Fibromyalgia:
If multiple unexplained joint pain and sometimes very disabling, after many consultations (usually a woman), it should evoke fibromyalgia (or diffuse idiopathic polyalgic syndrome). Diagnosis is based on:
– Pain rather periarticular qu’articulaires (enthesitis);
– The absence of signs of inflammation;
– Sometimes very severe pain to pressure from the tendon insertions;
– Constipation or irritable bowel syndrome and chronic fatigue (Chapter diffuse Algies).
