With a good history and proper physical examination, clinicians can reach a diagnosis. The duration of symptoms, the extent of joint involvement, and the patient’s age narrow the differentials to reach a diagnosis. Systemic lupus erythematosus (SLE) and reactive arthritis occur more frequently in the young; whereas, RA is more frequent in middle age. Gout, spondyloarthritis, and ankylosing spondylitis are more common in men than in women; whereas, RA and lupus are more frequent in women than in men. Racial predilections may be evident as well. Polymyalgia rheumatica commonly affect whites; whereas, sarcoidosis and SLE more commonly affect African Americans. Familial aggregation is most common with ankylosing spondylitis and gout. The patients’ complaints may evolve differently and can be classified as chronic (RA), intermittent (crystal or Lyme arthritis), or migratory (rheumatic fever, gonococcal, or viral arthritis). The upper extremities are frequently involved in RA and OA; whereas, lower extremity arthritis is characteristic of reactive arthritis and gout at their onset. Involvement of the axial skeleton is common in ankylosing spondylitis but is infrequent in RA, with the notable exception of the cervical spine. Presence of precipitating factors also help to narrow down the diagnosis; antecedent infection is often seen in reactive arthritis, renal insufficiency and use of drugs (steroids and diuretics) are associated with gout.

Inflammatory arthritis is accompanied by elevated ESR and CRP, thrombocytosis, anemia of chronic disease. Duration of stiffness is prolonged in inflammatory arthritis, and the stiffness improves with activity. By contrast, in noninflammatory conditions (such as osteoarthritis [OA]), stiffness is shorter in duration (less than 60 minutes), and exacerbated by activity; furthermore, inflammatory markers are absent. When evaluating a patient with joint pain, clinicians should first find out whether the patient is having articular or nonarticular symptoms. If the complaints are articular, find out the duration. If it has been for less than 6 weeks, it is classified as acute and includes infectious, gout and pseudo-gout. If the symptoms have lasted for more than 6 weeks, they are classified as chronic. Clinicians classify it as oligo-arthritis if there are less than 3 joints involved and polyarthritis with more than 3 joints involved. Arthrocentesis should be performed in affected swollen joints to exclude diagnosis including infectious or crystal-induced arthritis. Testing includes complete blood cell (CBC) count, differential, Gram stain, culture, and crystal search. Imaging studies include plain radiograph. Erosions are typically seen in patients with rheumatoid arthritis.[1][12][13]

Septic arthritis usually presents as fever, single swollen painful joint. When there is suspected joint infection, synovial fluid aspiration should be done before antibiotics are administered. Fluids should be sent for Gram stain and culture, leucocytes with differential, and assessment of crystals. Septic arthritis is characterized by polymorphonuclear lymphocytes greater than 20000 mm3 and inflammatory arthritis due to autoimmune and crystal deposition is characterized by polymorphonuclear lymphocytes of 2000 to 20,000 mm3. Needle-shaped yellow crystals are seen in gouty arthritis, and rhomboid-shaped crystals are seen in pseudo-gout. If the cause mentioned above does not explain arthritis and the person meets the criteria for a typical autoimmune disease, then arthritis can be attributed to the autoimmune disease. Elevation of rheumatoid factor and anti-citrullinated protein antibody, elevated ESR and CRP are consistent with the diagnosis of rheumatoid arthritis. Patients with inflammatory back symptoms, a history of inflammatory bowel disease, or inflammatory eye disease may have spondyloarthropathy. Persons with less than 6 weeks of symptoms may have a viral process such as Parvovirus.

Inflammation is generally reversible, while joint destruction is not. Early and appropriate treatment before a definitive diagnosis may prevent disease persistence, joint damage, and disability. The goal of therapy is the suppression of inflammation and prevention of recurrent inflammation and joint damage. In patients with undifferentiated arthritis such as RA, clinicians use a multidisciplinary management approach that includes patient education, physical and occupational therapy, and pharmacological therapy. Surgical measures are rarely needed in the early stage of arthritis. Once the patient has evolved from UA to a specific diagnosis that usually occurs within a year or less of presentation, we recommend treatment for the patient’s specific disorder. Initial drug therapy of patients with UA should follow pretreatment screening which includes baseline routine laboratory testing (CBC, liver and renal chemistries, acute phase reactants), screening for hepatitis B and C and latent tuberculosis. A baseline chest x-ray should be obtained before starting methotrexate therapy. Combination therapy with 2 or more DMARDs is more effective than monotherapy, but the adverse effects may also be greater. If symptoms are not well controlled with a nonbiologic DMARD, a biologic DMARD should be added. Tumor necrosis factor (TNF) inhibitors are first-line biologic therapy. If TNF inhibitors are ineffective, additional biologic therapies can be considered, for example, adalimumab. Concurrent use of more than one biologic therapy is not recommended because of an unacceptable rate of adverse effects. The initial therapeutic goal is to achieve significant clinical improvement within 3 months which may be defined as at least a 50% reduction in disease activity. [7][14][15]

In the patients with upper extremity involvement, or in those who have a positive test for RF, treatment with methotrexate rather than DMARDs is recommended. While in the patients with UA who lack RA and have involvement primarily in lower extremities, treatment with DMARDs is suggested. Treatment of patients who are resistant to initial therapy at 3 months or do not achieve remission or low disease activity after 6 months, combination therapy is preferred. Anti-inflammatory therapies including systemic and intraarticular steroids are used for temporary control of disease in patients who start treatment with DMARDs

• Psoriatic arthritis
• Ankylosing spondylitis
• Osteoarthritis
• Juvenile idiopathic arthritis
• Lyme arthritis

Prognosis depends on the cause of arthritis. Several studies have shown that 17% to 32% of the patients progress to rheumatoid arthritis, while 40% to 55% achieve spontaneous remission. In a study with a 2-year follow up of undifferentiated arthritis, a diagnosis of RA was made in 30% during the follow-up period, arthritis resolved in 41%, and 10% were lost to follow up. In another study, spontaneous remission of arthritis was rare once symptoms exceeded 8 weeks in duration. The so-called "window of opportunity theory" hypothesis that in an early stage of UA, a period may exist in which the disease course can be altered by the appropriate treatment, preventing it from being a chronic and disabling disease.

The course of reactive arthritis depends on the triggering pathogen and the genetic background of the host. The typical disease duration is 3 to 5 months. Most of the patients have complete remission or have little active disease within 6 to 12 months after presentation, but 15% to 20% may experience chronic persistent arthritis. Human leukocyte antigen B27 (HLA-B27) testing has been associated with a worse prognosis in some, but not all. An HLA-B27-positive patient is more likely to develop a chronic spondyloarthropathy with radiographic changes. Patients with a triad of post-infectious arthritis, urethritis, and conjunctivitis may also have a poorer prognosis.

• Persistent joint pain
• Disability
• Infections
• Anemia
• Osteoporosis
• Sicca syndrome
• Lung, GI and heart disease
• Lymphomas

Orthopedic surgeon

Rheumatologist

Inflammatory arthritis (IA) is the manifestation of a number of autoimmune and infectious diseases. It is different from noninflammatory arthritis( degenerative), in which there is no inflammation, but there is wear-and-tear of joint surfaces due to excessive weight and stress of joint. It is characterized by joint hypertrophy, unlike inflammatory arthritis which is characterized by joint erosion. Clinicians must differentiate between these 2 as the treatment may differ. Early rheumatology referral and treatment is important for patients with inflammatory arthritis. This will require measures for addressing delays at all levels, from patients with symptom onset to primary care assessment and referral to rheumatology assessment and initiation of therapy. It requires a combination of education of all involved and an adequate facility to ensure rapid access for patients with IA.

There is no cure for inflammatory arthritis and the key it to improve the quality of life. while the physicians manage the acute disease, the nurse, pharmacist, physical therapist, and dietitian have a vital role in the care of these patients. The patients should be encouraged to lose weight as this will relieve the burden on the joints. Further, patients should join an exercise program so that they regain muscle function and retain joint flexibility. Water exercises can help relieve pain and improve joint mobility. The pharmacists should educate the patient on the importance of medication compliance and be aware of the side effects. Nursing should monitor the patient at each visit, checking on patient compliance, noting any improvement or degradation of condition, answering patient questions, and reporting all findings to the clinician staff. Finally, a mental health counselor should see the patient as many patients develop fear, depression, and anxiety as a result of the progressive disability.[16][17] (Level V) 

Outcomes

The prognosis for most patients with rheumatoid arthritis is guarded. The disorder has no cure and is progressive. Most patients continue to have relapses and remissions and the overall quality of life is poor. Disability is common and many have severe joint disfigurement. Patients most likely to have a poor outcome include those with extra-articular manifestations, HLA-DRB1 genotype, younger age at diagnosis, female gender, large number of involved joints and presence of systemic symptoms. The presence of RF is usually associated with a poor prognosis. In addition, the medications used to treat inflammatory arthritis also have potent adverse effects, which are not always well tolerated. When the disease remains active for a year, it can rapidly lead to joint deformity and disability. As the disease progresses, many patients will develop damage to the lungs, heart and also develop malignancies. [18][19](Level V)