Fever with joint pain-differential diagnosis?

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Permalink Reply by Dindukurthi Sudhakar on July 15, 2009 at 3:51pm

This is an excerpt from emedicine....

Differential Diagnoses
Amyloidosis, Overview
Myelodysplastic Syndrome

Calcium Pyrophosphate Deposition Disease
Osteoarthritis

Cryoglobulinemia
Paraneoplastic Syndromes

Fibromyalgia
Polychondritis

Hepatitis B
Polymyalgia Rheumatica

Hypothyroidism
Psoriatic Arthritis

Inflammatory Bowel Disease
Sarcoidosis

Lyme Disease
Sjogren Syndrome

Mediterranean Fever, Familial
Systemic Lupus Erythematosus

Multicentric Reticulohistiocytosis
Whipple Disease


Other Problems to Be Considered
Infectious arthritis - Bacteria (eg, Lyme disease), fungi, mycobacteria, viruses (eg, hepatitis B, rubella, parvovirus, human T-cell leukemia virus 1)
Autoimmune connective tissue diseases (eg, systemic lupus erythematosus, progressive systemic sclerosis, mixed connective tissue disease, Sjögren syndrome, vasculitis, cryoglobulinemias)
Other rheumatic diseases (eg, polyarticular gout, seronegative spondyloarthropathy [eg, ankylosing spondylitis, reactive arthritis])
Subacute bacterial endocarditis
Hemoglobinopathies
Angioimmunoblastic lymphadenopathy
Workup
Laboratory Studies
No pathognomonic test is available to help confirm the diagnosis of rheumatoid arthritis (RA); instead, the diagnosis is made using clinical, laboratory, and imaging features.

Markers of inflammation, such as ESR and CRP, are associated with disease activity; additionally, the CRP value over time correlates with radiographic progression.
Hematologic parameters include a CBC count and synovial fluid analysis.
Complete blood cell count
Anemia of chronic disease is common and correlates with disease activity; it improves with successful therapy.
Hypochromic anemia suggests blood loss, commonly from the GI tract (associated with NSAIDs).
Anemia may also be related to disease-modifying antirheumatic drug (DMARD) therapy.
Thrombocytosis is common and is also associated with disease activity.
Thrombocytopenia may be a rare adverse event of therapy and may occur in patients with Felty syndrome.
Leukocytosis may occur but is usually mild.
Leukopenia may be a consequence of therapy or a component of Felty syndrome, which may then respond to DMARD therapy.
Synovial fluid analysis
Inflammatory synovial fluid (WBC count >2000/µL) is present with WBC counts generally from 5,000-50,000/µL.
Usually, neutrophil predominance (60-80%) is observed in the synovial fluid (in contrast with mononuclear cell predominance in the synovium).
Because of a transport defect, the glucose levels of pleural, pericardial, and synovial fluids in patients with RA are often low compared to serum glucose levels.
Immunologic parameters include autoantibodies (eg RF, anti-RA33, anti-CCP, antinuclear antibodies).
Rheumatoid factor
RF is present in approximately 60-80% of patients with RA over the course of their disease but is present in fewer than 40% of patients with early RA.
RF values fluctuate somewhat with disease activity, although high-titered RF generally remains present even in patients with drug-induced remissions.
Antinuclear antibodies: These are present in approximately 40% of patients with RA, but test results for antibodies to most nuclear antigen subsets are negative.
Newer antibodies (eg, anti-RA33, anti-CCP): Recent studies of anti-CCP antibodies suggest a sensitivity and specificity equal to or better than those of RF, with an increased frequency of positive results in early RA. The presence of both anti-CCP antibodies and RF is highly specific for RA. Additionally, anti-CCP antibodies, as do RF, indicate a worse prognosis.
Imaging Studies
Radiography: Note that erosions may be present in the feet, even in the absence of pain and in the absence of erosions in the hands.
Extremities - Hands, wrists, knees, feet, elbows, shoulders, hips, cervical spine
Others when indicated
MRI: This modality is used primarily in patients with abnormalities of the cervical spine; early recognition of erosions based on MRI images has been sufficiently validated.
Ultrasonography: This allows recognition of effusions in joints that are not easily accessible (eg, hip joints, shoulder joints in obese patients) and cysts (Baker cysts). High-resolution sonograms may allow visualization of tendon sheaths, changes and degree of vascularization of the synovial membrane, and even erosions; however, this needs further validation. Ultrasonography may be used as an office-based procedure.
Bone scanning: Findings may help to distinguish inflammatory from noninflammatory changes in patients with minimal swelling.
Densitometry: Findings are useful for helping diagnose changes in bone mineral density indicative of osteoporosis.
Other Tests
HLA-DR4 (shared epitope) may constitute a helpful marker in early undifferentiated arthritis.
Procedures
Joint aspiration, diagnostic arthroscopy (histology), and biopsies (eg, skin, nerve, fat, rectum, kidney) may be considered if vasculitis or amyloidosis is suggested.
Histologic Findings
The lymphoplasmacytic infiltration of the synovium with neovascularization seen in RA is similar to that seen in other conditions characterized by inflammatory synovitis. Early rheumatoid nodules are characterized by small-vessel vasculitis and later by granulomatous inflammation.

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Permalink Reply by Dev Senapati on July 15, 2009 at 4:27pm

sir, how do you explain the fever in the osteoarthritis??
take it this way, what are the common causes of joint pain with low grade fever for 2 months in a 37 years female??
please explain, i'm just a final year student...

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Permalink Reply by Dev Senapati on July 15, 2009 at 5:07pm

thanks for such a nice description...

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Permalink Reply by dr.v.k.agarwal on July 15, 2009 at 7:16pm

1st and formost,consider tuberculosis
and exclude or conclude

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Permalink Reply by Dindukurthi Sudhakar on July 16, 2009 at 3:32pm

I agree with 'sudheer ambekar' entirely.

I posted this by just copying and pasting from the source.

The student should classify and enumerate the most common ones first and the rarer ones later. His discussion should be to first how to confirm the common ones and differentiate the rarer ones.

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Permalink Reply by Marília Gusmão on July 20, 2009 at 7:06pm

Chronic polyarthritis

* Inflammatory
o Rheumatoid Arthritis
o Systemic Lupus Erythematosus
o Viral arthritis
o Psoriatic Arthritis
o Reactive Arthritis
o Enteropathic Arthropathies
o Behçet Disease
o Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy

http://emedicine.medscape.com/article/336054-diagnosis

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Permalink Reply by sudheer ambekar on July 15, 2009 at 10:45pm

I suppose that an undergraduate should emphasize more (or probably only) on common diseases such as rheumatic fever and connective tissue diseases (in this case) and not on obscure and rare diseases. after all, common diseases are commoner than the rare ones !! moreover you will have a number of questions to answer in an exam and not just ONE. having said that, having a comprehensive and sound knowledge of the possible differential diagnoses is always an added advantage. one is rarely right if one makes a rare diagnosis, but one is often right if one thinks of the common disease first.

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Permalink Reply by hiren dodia on July 16, 2009 at 12:39pm

chikungunya

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Permalink Reply by Linda on July 20, 2009 at 4:35pm

pp

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Permalink Reply by Marília Gusmão on July 20, 2009 at 7:00pm

Because the patient is an adult and a female I would think first of Rheumatoid Arthristis or Lupus.

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Permalink Reply by Dr. xee on July 20, 2009 at 7:37pm

37 years female
low grade fever-- 2 months
joint pain.

All of the first in a diagnosis to be made we have to consider the probability diagnosis which is region dependant..
like
Tuberculosis in this case if from india is very common and should be at the top of list
so exclude tuberculosis first and then others like

Rhumatoid arthritis
Reactive arthritis
Reiters syndrome (reactive)
rheumatic is uncommon in this age
systemic lupus erythematosus
Enteropathic like in Ulcerative colitis etc

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Permalink Reply by Dr. xee on July 20, 2009 at 7:41pm

ya got to comment upon the major differences in the history and physicals of each differential...

then ya got to do the basic investigations
and then the specific one for each to exclude all the differentials

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