Gout's first episode can often be confused with cellulitis. It presents with swelling and pain, usually of 1 joint, accompanied by erythema and warmth. Classically, a gout attack involves the metatarsophalangeal joint of the first toe, called podagra, but it may involve any joint in the body. Some cases left untreated resolve spontaneously within 3 to 10 days, with no vesiiluat signs or symptoms. During an acute attack, the serum uric acid level may be normal or even low, likely as a result of the existing deposition of the urate crystals. Uric acid levels are. however, useful in monitoring hypouricemic therapy between attacks. Radiographs may show cystic changes in the joint surface, with punched-out lesions and soft-tissue calcifications. These findings are nonspecific and are also seen in osteoarthritis and rheumatoid arthritis.
An infection usually involves only 1 joint if it is of bacterial origin (>90% of cases). The knee. hip. and shoulder are the 3 most commonly involved joints. A chronic monoarticular arthritis or involvement of 2-3 joints may be caused by fungi or mycobacteria. In the case of acute polyarticular (>3 joints) arthritis, the etiology may be from endocarditis or a disseminated gonococcal infection.
Bacterial infections of a joint occur most commonly in persons with rheumatoid arthritis. The chronic inflammation of joints coupled with the use of steroids predisposes this group to Staphylococcus aureus infections. HIV-positive patients may develop pneumococcal, salmonella, or even Haemophilus influenzae joint infections. Intravenous drug users are most likely to get a streptococcal. staphylococcal. Gram-negative, or Pseiulomonas infection.
Range of motion (ROM) of the joint is an important maneuver of the physical examination. A septic joint will have a very limited ROM, coupled with effusion and fever. However, a nearby cellulitis, bursitis, or osteomyelitis will usually maintain the ROM of a joint. The aspirate of a septic joint will have a positive culture in >90% of cases.
Osteoarthritis (OA) is most commonly found in people older than 65 years of age (68% of patients) and is associated with trauma, history of repetitive joint use. and obesity (specifically for knee OA). It primarily affects the cartilage, but ends up damaging the bone surface, synovium, meniscus, and ligaments. The clinical presentation is usually that of a dull, deep, ache-type pain. The onset is usually gradual, with activity exacerbating the pain, and rest decreasing it. In the latter stages, pain is usually constant. On physical examination, a bony crepitus may be felt on passive ROM. There may be a small joint effusion and periarticular muscle atrophy. In the advanced stage, joint deformity with decreased ROM will be seen. X-rays are usually normal at first, with the gradual development of bone sclerosis, subchondral cysts, and osteophytes.
Rheumatoid arthritis (RA) is another common disorder that may affect people from any age group, but will usually present initially in those 30-55 years old. The presentation of RA can be varied, ranging from a monoarticular arthritis that is intermittent, to a polyarthritis that progresses gradually in intensity, leading to disability. It affects more women than men (3:1), and the treatment will usually depend on the stage at which the disease is diagnosed. The American Rheumatism Association has delineated specific diagnostic criteria to aid in the diagnosis of RA, among which are these:
1. Morning stiffness
2. Involvement of 3 or more joints
3. Involvement of hand joints
4. Symmetric arthritis
5. Presence of rheumatoid nodules
6. Positive rheumatoid factor
7. Radiographic changes which include erosions or decalcifications
Of all these diagnostic criteria, the first 4 must be present for at least 6 weeks, and the fulfillment of any 4 of these criteria is sufficient to diagnose
RA. Among the laboratory tests that may be abnormal in patients with RA are an elevated erythrocyte sedimentation rate, an elevated C-reactive protein, anemia, thrombocytosis, and low albumin. The level of hypoalbuminemia usually correlates with the severity of the disease.
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