Arthritis in Its Many Forms

Arthritis is defined as the inflammation of a joint. There are various types of arthritis and despite their similarities, they can be differentiated from one another based on a number of factors. Early detection and treatment of each kind are important for conserving the functions of the joints involved. What to think when you have a swollen, red and painful joint? Here are some of the common conditions that cause a swollen painful joint.

1. Gout

Gout is a condition characterized by the deposition of monosodium urate crystals in the joint. Commonly affected joints are - the first metatarsophalangeal joint (75 % of the cases), ankle joint, knee joint and other joints, single or even multiple.

Symptoms:

1. Red shiny joint.
2. Swelling around the joint.
3. Pain and tenderness in the joint.
4. Raised temperature of the affected joint.
5. Asymmetrical involvement.

Risk Factors:

• Too much meat or seafood in the diet.
• Being overweight or obese.
• Genetic predisposition.
• Too much alcohol or fructose consumption.
• Diabetes mellitus.
• Hypothyroidism.
• Medications such as Aspirin in low doses, Thiazide diuretics, etc.
• Menopause.
• Chronic renal failure.

Diagnosis and Treatment:

Examination of aspirated joint fluid under a polarizing microscope reveals the urate crystals which are needle-shaped and yellow or blue in color. They are negatively birefringent. Blood uric acid levels are elevated but could be normal during an acute attack. Treatment of an acute attack is with oral NSAIDs (nonsteroidal anti-inflammatory drugs), Colchicine, steroids or injectable intraarticular steroids. Chronic cases are treated with Allopurinol or Febuxostat.

2. Pseudogout

Also called Calcium pyrophosphate deposition (CPPD), disorders are also characterized by painful swollen joint due to the deposition of calcium pyrophosphate dihydrate crystals in the joints. Joints commonly involved are the knees. Other joints can also be affected.

Symptoms:

1. Swelling around the affected joint.
2. Warmth and redness around the joint.
3. Pain and tenderness in the joint.
4. Symmetrical or asymmetrical.
5. One or more joints affected.
6. Restricted movement of the affected joint.

Risk Factors:

• Old age.
• Genetics and family history.
• Any injury to the joint.
• Osteoarthritis.
• Hypothyroidism.
• Hyperparathyroidism.

Diagnosis and Treatment:

Calcium-containing crystals can be isolated from the joint fluid of the affected joints by observing under a microscope. They are positively birefringent. X-ray of the joint will also be helpful in diagnosis.

3. Septic Arthritis

This is defined as infectious arthritis characterized by infection of the joint by microorganisms like bacteria, virus, fungi, etc. This requires immediate treatment as the infection might spread to surrounding tissues and even the bloodstream. That is why any acute case of swollen red and hot joint is evaluated by ruling out septic arthritis. Joint fluid microscopic examination and culture are done as first-line investigations.

Symptoms:

1. Red swollen joint.
2. Warmth around the joint.
3. Pain and tenderness in the affected joint.
4. Restricted movement of the joint due to pain.
5. Fever with or without chills.

Diagnosis and Treatment:

It usually affects any single joint of the body like the knee joint for instance. Oral or injectable antibiotics are needed to treat the infection if it is bacterial in nature. Paracetamol or NSAIDs are given for pain relief.

4. Reactive Arthritis

It is an inflammation of joints as a reaction to bacterial infection in the gastrointestinal tract, urinary tract or the genital tract. Joints commonly affected are the knees or ankles. Other joints may also be involved. This is also called reactive arthritis and is an autoimmune process. Bacteria commonly involved are - chlamydia trachomatis, salmonella, shigella, and E.coli.

Symptoms:

1. Swollen, painful joint or joints.
2. Asymmetrical involvement.
3. Restricted movement of the joint.
4. Iritis.
5. Conjunctivitis.
6. Urethritis.
7. Rash on the soles and palms (keratoderma blennorrhagicum).
8. Balanitis.

Risk Factors:

• Strong association with HLA B-27 gene.
• Exposure to sexually transmitted diseases like chlamydia.
• Recent gastrointestinal tract infections.

Diagnosis and Treatment:

Diagnosis is done by history and clinical examination. HLA B27 testing is also done. Treatment is with NSAIDs, steroids, and Sulfasalazine. Antibiotics are also given to treat the underlying infection.

5. Rheumatoid Arthritis

It is an autoimmune disease characterized by warm swollen painful joints. It commonly affects the wrists and the small joints of the hands.

Symptoms:

1. Morning stiffness in the affected joints lasting more than 45 minutes.
2. Pain and swelling.
3. Warmth around the affected joints.
4. Symmetrical involvement.
5. Multiple joint involvement.
6. Swan neck deformity or Boutonniere deformity of the hand.

Risk Factors:

• Genetic predisposition - HLA-D4 carriers.
• A family history of rheumatoid arthritis.
• Smoking.
• Presence of other autoimmune diseases.

Diagnosis and Treatment:

Detection of the anti-cyclic citrullinated peptide in blood is highly specific for rheumatoid arthritis. Presence of rheumatoid factor is highly indicative of rheumatoid arthritis. However, it is not specific to it. X-ray of the affected joint also reveals findings characteristic of rheumatoid arthritis. Treatment is with oral NSAIDs, oral or injectable steroids, and oral DMARDs (disease-modifying antirheumatic drugs). Other medications and treatment are required to treat various other symptoms of this disease.

6. Psoriatic Arthritis

Characterized by inflammation of one or more joints in people who either have psoriasis or have a tendency to develop psoriasis. It is seronegative arthritis and occurs in more than 30 to 40 % of people with psoriasis.

Symptoms:

1. Pain and stiffness in affected joints.
2. Swelling around the affected joint.
3. Restricted movement of the joint.
4. If it is not treated soon enough, it has the ability to destroy a joint completely.
5. It commonly affects the distal joints of fingers and toes. It can be confused with osteoarthritis and gout.

Risk Factors:

• Existing psoriasis.
• A family history of psoriasis.
• HLA B27.

Diagnosis and Treatment:

Diagnosis is usually by the exclusion of other types of arthritis. Detection of psoriatic lesions and presence of HLA B27 in blood is highly suggestive of psoriatic arthropathy. Treatment is with DMARDs and NSAIDs for pain relief. TNF (tumor necrosis factor) inhibitors may be needed if the disease does not respond to DMARDs. Early detection and treatment are vital for joint conservation.

7. Lupus Arthritis

Arthritis associated with systemic lupus erythematosus affects more than 90 % of people with this chronic autoimmune disease which affects various parts of the body.

Symptoms:

1. Pain and stiffness in joints which is migratory or fleeting.
2. Redness and swelling around joints.
3. Restricted movement in affected joints.
4. Symmetrical involvement of joints.
5. It can affect any joint but the joints of the hands and wrists are most commonly affected.

Risk Factors:

• Female gender.
• Family history.
• Environmental triggers like sun exposure, infections.
• Certain medications.
• Reproductive age and periods.
• Hormonal fluctuations like pregnancy.

Diagnosis and Treatment:

Diagnosis of SLE is made on clinical grounds and by detection of antibodies to dsDNA, antinuclear antibodies, anti-ribonucleoprotein antibodies, etc. Treatment of joint inflammation is with NSAIDs as first-line followed by corticosteroids. DMARDs may also be used in severe cases.

8. Post-Traumatic Arthritis

This is a common type of osteoarthritis which occurs as a result of direct physical injury to the joint from trauma or overuse.

Symptoms:

1. Pain, swelling and restricted movement of the joint.
2. Redness and tenderness around the affected joint.

Risk Factors:

• Obesity/ overweight.
• Road traffic accident.
• Contact sports.

Diagnosis and Treatment:

X-ray of the affected joint shows damage to the articular cartilage and other osteoarthritic findings. This along with a history of direct physical trauma to the joint will give a diagnosis of post-traumatic arthritis. Treatment is with Paracetamol or oral NSAIDs. Injectible corticosteroids may also be used.

9. Juvenile Idiopathic Arthritis

This form of arthritis affects children. It is also an autoimmune disease which mimics adult rheumatoid arthritis.

Symptoms:

1. Pain and stiffness in joints.
2. Swelling around the joint.
3. Usually symmetrical involvement of joints.

Diagnosis and Treatment:

It is diagnosed through history, physical examination, and detection of rheumatoid factor and anti-cyclic citrullinated peptide. A marked rise in inflammatory markers such as ESR and C-reactive protein is seen. Mild cases are treated with oral NSAIDs. Moderate to severe cases are treated primarily with intraarticular steroids and then with DMARDs if the disease progresses. It is not curable. However, disease progression can be slowed and halted with early and effective treatment.

Conclusion:

The above-mentioned are the various types of arthritis. One should consult a doctor if any of the other symptoms may be felt. Earlier the diagnosis, better is the prognosis.

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