ARTHRITIS AND FEVERS
ACUTE RHEUMATIC FEVER
POST-STREPTOCOCCAL REACTIVE ARTHRITIS (PSRA)
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Clinical picture does NOT meet the modified Jones criteria
Longer duration of arthralgias, arthritis
No skin rashes
Carditis can be seen, but rare
Prophylaxis controversial ---Red Book waffles—We recommend 1 yr without carditis--or if carditis occurs, same as ARF.
GONOCOCCAL ARTHRITIS
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Migratory polyarthritis
Tenosynovitis
Dermatitis
Fever
Purulent arthritis
o Monoarthritis
o Polyarthritis
66-70%
67%
39-67%
51-63%
42-80%
27-32%
10-53%
• N. gonorrhoeae difficult to grow in culture
• PCR can pick up 1 organism in joint fluid
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However, some joints may be immune complex mediated, especially in migratory
phase
MENINGOCOCCAL ARTHRITIS
LYME ARTHRITIS
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Recognized in 1975 with an unusual epidemic of JRA in Lyme, Conn.
Now recognized in North America, Europe, Russia, China, Japan and ?Australia
3 endemic areas in US: Northeast, Great Lakes, Northern California, Oregon
STAGE 1
EARLY LOCALIZED
EARLY DISSEMINATED
STAGE 2
STAGE 3
CHRONIC ARTHRITIS
CHRONIC NERVOUS
SYSTEM DISEASE
-Erythema migrans
-Secondary skin lesions
-Headache
-Musculoskeletal pain
-Flu-like illness
-Onset weeks to months
-15% total cases
-Cardiac (5%): Fluctuating AV block, first degree,
Wenkebach, complete
-Sometime carditis
-Organisms can be found in tissue
-Acute neurologic : Meningitis +/- encephalitis (15%)
Cranial neuritis, radiculoneuritis, chorea, transverse
myelitis, focal demyelinating encephalitis, polyneuropathy
-Not clearly local infection
-Months after onset, 60% of pts
-1-2 large joints, esp. knees
-Popliteal cysts
-PCR often positive
-Usu resolves with treatment but 10% can become chronic
-Onset months to years, 5% of pts
-Cognitive dysfunction
-Parasthesias
-Changes in EMG, NCV
To diagnose it….
• Clinical syndrome and exposure
• Lyme ELISA--high false positive rate (very rare false-negatives with arthritis)
• Positive ELISA needs to be confirmed with Western Blot
• Serology may not be positive for a few weeks after infection
• PCR may be positive in joint fluid
VIRAL ARTHRITIS
Parvovirus B19
-Small single stranded DNA virus
-Erythema infectiosum (Fifth’s Disease)
-Rash fades in 10 d but may recur
-7% of children have arthralgias
-Arthritis occurs in up to 50% adults and 5% children
-Arthritis involves multiple joints, hands, fingers, feet
-No infectious virus detected but PCR +
-Can see chronic disease
Hepatitis B
-“Serum sickness” early
-Rash maculopapular or urticarial
-Nonmigratory polyarthritis
-Immune complex mediated
-Symptoms decrease as jaundice increases
-Can see arthritis following Hep B vaccination
Hepatitis C
-Multiple autoimmune syndromes including arthritis
Rubella
-33% of older patients (adolescents and older),
-Onset 2-3 days following rash
-Polyarthritis
-Duration usually 1 week
-? Chronic forms, ? Relation to JRA
-Virus present in blood and synovial fluid
Rubella vaccine
-Occurs 10-28 d after immunization
-5-11% of adult women, much lower in children
Less common viruses associated with arthritis:
Alpha viruses (Australia, S. Pacific, Africa, Asia)
Mumps
CMV
EBV
Varicella
Enteroviruses
HIV (Reiter’s Syndrome)
OTHER INFECTIONS WITH ARTHRITIS
Brucellosis
Cat scratch fever
Mycoplasma and
ureaplasma
-Joint involvement in 33%, sacroiliitis 47%, peripheral 38%
-Monoarthritis
-Associated with hypogammaglobulinemia
ARTHRITIS ASSOCIATED WITH MYCOBACTERIA AND MYCOSES
Coccidioidomycoses
-Polyarthritis with E. nodosum
-Monoarthritis of knee
Blastomycosis
Cryptococcosis
Histoplasmosis
Sporotrichosis
Tuberculosis
Atypical TB
Candidiasis
Actinomyces
Leprosy
-Monoarthritis of large lower extremity joints associated with skin
and joint involvement, spondylitis
-Monoarthritis secondary to osseous infection, spondylitis
-Polyarthritis with E. nodosum
-Monoarthritis of knee, wrist or hand;
-polyarthritis with disseminated skin lesions
-Spondylitis, monoarthritis of large weight bearing joints
-Arthritis/tendonitis in hand or wrist or bone/joint/tendon
involvement in AIDS
-Monoarthritis of knee with serious systemic illness
-Spondylitis
-Polyarthritis with E. nodosum;
-destruction of small bones of hands and feet; neuropathic joints
PRESUMED INFECTION-RELATED SYNDROMES
Toxic synovitis, Henoch-Schoenlein purpura, Kawasaki syndrome, Discitis
FEVER OF UNKNOWN ORIGIN (A RHEUM PERSPECTIVE)
Cryopyrinopathies
Hereditary Autoinflammatory Syndoromes
LessMore
Severity
One MUST exclude infectious/oncologic causes before considering the following:
Disease
Fever Characteristics
Other Characteristics
Systemic Lupus Erythematosus
Variable
See above
(SLE)
Systemic JIA
1-2x/d
Characteristic salmon-colored rash linked to fevers; associated
with Macrophage Activation Syndrome (MAS) /
Hemophagocytic Lymphohistiocytosis (HLH)
Behcets
Variable
Scarring oral/genital ulcers, arthritis; rarely colitis, aneurysms
Vasculitis
Variable
Must think of individual dz for w/u: ANCA, U/A, CXR
(Wegener’s), 4 limb BP’s (Takayasu’s), etc.
Familial Mediterranean Fever
12-72h Q 7-28d
Most common Mendelian autoinflammatory syndrome;
(FMF)
response to colchicine can help w/ dx; Mediterranean heritage
Familial Cold
12-24h
Cold triggering
Autoinflammatory
Syndrome (FCAS)
Muckle-Wells Syndrome 2-3d
Rare cold triggering
(MWS)
Neonatal Onset Multisys- Continuous
No cold triggering; developmental delay
temic Inflammatory
Disease (NOMID) /
Chronic Infantile
Neurologic Cutaneous
and Articular Syndrome
(CINCA)
Tumor Necrosis Factor
>1-4wks
AKA Familial Hibernian Fever; migratory rash w/ underlying
Receptor-Associated Periodic
myalgia; conjunctivitis, periorbital edema; frequently
Syndrome (TRAPS)
associated w/ pleuritis
Hyperimmunoglobuminemia D 3-7d Q 14-28d
High IgD levels; northern European heritage; severe abd pain,
with Periodic Fever Syndrome
vomiting, diarrhea > constipation, rarely peritonitis; symmetric
(HIDS)
poly-arthritis/arthralgias
Cyclic Hematopoiesis (CH) / Cyclic
3-5d Q 21-28d
ANC <200 during flare and low-normal to normal in between
Neutropenia
cycles
Periodic Fever with Aphthous
Q 21-28d
NSAIDs as tx; colchicine, cimetidine as prophylaxis;
Stomatitis, Pharyngitis, and (cervical)
glucocorticoids as abortive
Adenitis (PFAPA)