I Have Arthritis That Affects A Lot Of My Joints... Could It Be Rheumatoid Arthritis And How Will The Doctor Know?

There are more than 100 different kinds ofinflammation can develop and affect multiple
arthritis. Most of them involve inflammation. Whenjoints. And, in cases where tophi (deposits of uric
a patient goes to a rheumatologist to get aacid under the skin) are present, it can be difficult
diagnosis, there is a process of elimination in orderto distinguish from erosive RA. However, crystal
to arrive at the proper diagnosis. This process ofanalysis of joints or tophi and blood tests should
elimination is called "differential diagnosis."be helpful in distinguishing gout from RA.
Differential diagnosis can be a difficult undertakingCalcium Pyrophosphate Deposition Disease (CPPD;
because so many forms of arthritis, particularlyPseudogout)
inflammatory forms of arthritis look alike. TheCPPD disease is caused by deposits of calcium
following is a list of types of inflammatory arthritispyrophosphate dehydrate crystals in a joint. The
that can be seen and must be considered whenbody's reaction to these crystals, leads to
evaluating a patient with inflammatory symptomssignificant inflammation. Diagnosis includes:
of arthritis.Â- Detailed medical history and physical
Rheumatoid Arthritis (RA)exam;
RA is an chronic, autoimmune, inflammatoryÂ- Withdrawing fluid from a joint using a
disease, that may affect any joint in the body butneedle;
preferentially attacks the peripheral joints (fingers,Â- Joint x-rays to show crystals deposited
wrists, elbows, shoulders, hips, knees, ankles, andon the cartilage (chondrocalcinosis);
feet. It can also affect non-joint organ systemsÂ- Blood tests to rule out other diseases
such as the lung, eye, skin, and cardiovascular(e.g., RA or osteoarthritis).
system. The onset of RA may be insidious-slow-In most cases, CPPD arthritis presents with acute
with nonspecific symptoms, including fatigue,arthritis affecting one or more joints. However, in
malaise, loss of appetite, low-grade fever, weightsome cases, CPPD disease can present with
loss, and vague aches and pains, or it may havechronic symmetric multiple joint erosive arthritis
an abrupt onset with inflammation involvingsimilar to RA. RA and CPPD disease can usually be
multiple joints. The joint symptoms usually occurdistinguished by joint fluid examination
bilaterally and are symmetric. Damage to joints-demonstrating calcium pyrophosphate crystals,
called "erosions" can be seen with magneticand by blood tests, including RF and anti-CCP
resonance imaging early on or by x-ray later inantibodies, which should be negative in CCPD
the course of disease. Approximately 80% ofarthritis.
patients with RA will have elevated levels ofSarcoid Arthritis
rheumatoid factor (RF) or anti-CCP antibodies.Sarcoidosis is an inflammatory type of arthritis.
Juvenile Rheumatoid Arthritis (JRA)The majority of patients with this disease have
JRA describes a group of arthritic conditions thatlung disease, with eye and skin disease being the
occur in children under the age of 16. Threenext most frequent signs of disease. In most
forms of JRA exist, including oligoarticular (1-4cases, the diagnosis of sarcoidosis can be made
joints), polyarticular (> 4 joints), andon clinical and x-ray presentation alone. Patients will
systemic-onset or Still's disease. The latter ishave acute arthritis, painful nodules under the skin
associated with significant internal organon the shins (erythema nodosum), and a chest
involvement and may also present with fever andx-ray showing enlargement of lymph niodes. In
rash in addition to joint disease. Polyarticular JRA issome cases, the demonstration of a specific type
considered to be the type that is most similar toof inflammation change, called a noncaseating
adult RA, and is responsible for approximatelygranuloma on tissue biopsy, is necessary for
30% of cases of JRA. Most children withdefinitive diagnosis.
polyarticular JRA are negative for RF and theirArthritis can be present in approximately 15% of
prognosis is usually good. Roughly, 20% ofpatients with sarcoidosis, and in rare cases can be
polyarticular JRA patients will have elevated RF,the only sign of disease. In acute sarcoid arthritis,
and these patients appear to be at more risk forjoint disease is usually rapid in onset, symmetric,
chronic, progressive joint destruction and damage.involving the ankle joints. The knees, wrists, and
Uveitis- an inflammatory condition of the eye- is asmall joints of the hands can be involved. In most
common finding in oligoarticular JRA, especially incases of acute disease, lung and skin disease are
patients who are antinuclear antibody (ANA)also present. Chronic sarcoid arthritis typically
positive. The dangerous feature of uveitis is thatinvolves one or maybe a few joints and due to
it can cause relatively few symptoms so carefulits often erosive nature can be difficult to
screening is recommended in order to avoiddistinguish from RA.
blindness.Polymyalgia Rheumatica (PMR) / Temporal
Systemic Lupus Erythematosus (SLE)Arthritis
SLE is a chronic inflammatory autoimmunePMR is a form of arthritis that leads to
disorder that can involve the skin, joints, kidneys,inflammation of tendons, muscles, ligaments, and
brain, and blood vessel walls. At least 4 of thetissues around the joints. It is characterized by
following symptoms which have been formulatedlarge muscle (shoulders, hips, thighs, neck) pain,
by the American College of Rheumatology areaching, morning stiffness, fatigue, and in some
generally present for a diagnosis to be made:cases, fever. It can be associated with temporal
Â- Red, butterfly-shaped rash on the face,arthritis/giant-cell arthritis (TA/GCA) which is a
affecting the cheeks;related but more serious condition in which
Â- Typical skin rash on other parts of theinflammation of large blood vessels can lead to
body;complications such as blindness, aneurysms and
Â- Sensitivity to sunlight;cramping pain in the arms or legs (limb
Â- Mouth sores;claudication) due to inflammation and narrowing of
Â- Joint inflammation (arthritis);the large blood vessels in the chest and
Â- Fluid around the lungs, heart, or otherextremities. PMR is diagnosed when the clinical
organs;picture is accompanied by elevated markers of
Â- Kidney dysfunction;inflammation (ESR and/or CRP). If temporal
Â- Low white blood cell count, low redarthritis is suspected (headache, vision changes,
blood cell count due to hemolytic anemia, or lowlimb claudication), biopsy of a temporal artery
platelet count;may be necessary to make the diagnosis.
Â- Nerve or brain dysfunction;PMR and TA/GCA can present with symmetric
Â- Positive results of a blood test for ANA;inflammatory arthritis similar to RA. These
anddiseases can usually be distinguished by blood
Â- Positive results of a blood test fortests. In addition, headaches, acute vision changes,
antibodies to double-stranded DNA or otherand large muscle pain are uncommon in RA, and if
antibodies including anti-Smith antibodies orthese are present, PMR and/or TA/GCA should
antiphospholipid antibodies.be considered.
Patients with lupus can have significantInfectious Arthritis
inflammatory arthritis. That is why lupus can beMany infections can present with arthritis either
difficult to distinguish from RA, especially if otherdue to direct joint infection or due to autoimmune
signs and symptoms of lupus are minimal.joint inflammation. In most cases, infections lead
Inflammatory Muscle Diseaseto acute single joint arthritis; however, in some
Polymyositis (PM) and dermatomyositis (DM) arecases, chronic arthritis affecting a few or many
types of inflammatory muscle disease. Thesejoints can be present. Because missed infections
conditions typically present with bilateral (bothcan lead to significant complications, it is crucial to
sides) large muscle weakness. In the case of DM,have a high index of suspicion for infection in any
rash can be a presenting sign. Diagnosis consistspatient presenting with acute or chronic arthritis.
of four major features, including elevation ofLyme disease
creatine kinase (CPK), signs and symptoms suchLyme disease is an infection due to a type of
as muscle weakness, elevated muscle enzymesbacteria called a spirochete. The disease is
(creatine kinase, aldolase), electromyograph (EMG)manifested by a skin rash, swollen joints and
abnormalities, and a positive muscle biopsy. Often,flu-like symptoms, caused from the bite of an
laboratory test abnormalities can be seen includinginfected tick. Symptoms may include:
the presence of autoantibodies such antinuclearÂ- A skin rash, often resembling a bulls-eye
antibody (ANA), and the myositis-associated(target lesion);
antibodies.Â- Fever;
In both PM and DM, inflammatory arthritis can beÂ- Headache;
present and can look like RA -- including lungÂ- Muscle pain;
involvement. In RA, however, unless an overlapÂ- Stiff neck; and
syndrome - ie., a patient having both RA as wellÂ- Swelling of knees and other large joints.
as muscle disease) is present, muscle functionThe diagnosis of Lyme disease is typically made
should be normal. Also, in PM and DM, erosive jointby blood testing. If, however, chronic single joint
disease is unlikely. RF and anti-CCP antibodies arearthritis develops, joint fluid analysis or joint tissue
typically elevated in RA and not PM or DM.biopsy may be necessary for diagnosis. Lyme
Spondyloarthropathies (SA)arthritis can usually be distinguished from RA by
A group of arthritic conditions called theclinical presentation and blood tests.
spondyloarthropathies which include psoriaticAcute rheumatic fever (ARF)
arthritis, reactive arthritis, ankylosing spondylitis,Acute rheumatic fever is an inflammatory disease
and enteropathic arthritis are a category ofthat may develop after an infection with the
disease that cause inflammation throughout theStreptococcus bacteria (strep throat or scarlet
entire body, particularly in parts of the spine andfever). The disease can affect the heart, joints,
at other joints where tendons attach to bones.skin, and brain. Symptoms include:
They also can cause pain and stiffness in theÂ- Fever;
neck, upper and lower back, tendonitis, bursitis,Â- Joint pain;
heel pain, and fatigue. They are often calledÂ- Arthritis (mainly in the knees, elbows,
seronegative arthritis. The term 'seronegative'ankles, and wrists);
means that tests for lab markers such asÂ- Joint swelling; redness or warmth;
rheumatoid factor are negative. Symptoms ofÂ- Abdominal pain;
adult SA include:Â- Skin rash
Â- Back and/or joint pain;Â- Skin nodules;
Â- Morning stiffness;Â- A peculiar movement disorder
Â- Tenderness near bones;(Sydenham's chorea)
Â- Sores on the skin;Â- Nosebleeds;
Â- Inflammation of the joints on both sidesÂ- Heart problems, which can be
of the body;asymptomatic.
Â- Skin or mouth ulcers;The diagnosis of ARF is made by clinical
Â- Rash on the bottom of the feet; andassessment and blood testing for antibodies
Â- Eye inflammation.against streptococcal proteins. ARF and RA can
In some cases of SA, peripheral arthritishave similar clinical features including arthritis and
resembling RA can be present. Careful history andnodules. However, ARF can usually be distinguished
physical examination can usually distinguishfrom RA by clinical presentation. Rash and
between these syndromes, especially if anmigratory arthritis are unusual in RA. The use of
obvious disease that is aggravating inflammation isblood tests is also helpful.
present (psoriasis, inflammatory bowel disease). InViral arthritis (hepatitis B and C, parvovirus, EBV,
addition, since RA rarely affects the end joints ofHIV)
the fingers (DIP joints), if these joints are involvedArthritis may be a symptom of many viral
from inflammatory arthritis, the diagnosis of anillnesses. This makes viral infections a great
SA is favored. Usually, RF and anti-CCP antibodiesmasquerader. The duration is usually short, and it
are negative in SA, although in some cases ofusually disappears on its own without any lasting
psoriatic arthritis there may be elevations of RFeffects. Clinical features in adults:
and anti-CCP antibodies.Â- Joint symptoms occur in up to 60%.
Crystal Associated ArthritisThese can be symmetric and affect the small
Monosodium Urate Disease (Gout)joints of the hands, wrists, and ankles as well as
Gout is due to deposition of monosodium uratethe knees. Morning stiffness is also present.
crystals in a joint. Gouty arthritis is typicallyÂ- Parvovirus B19 is a very common viral
sudden in onset, very painful, with signs ofinfection that looks like RA.
significant inflammation on exam (red, warm,Â- Diagnosis of viral arthritis is made by
swollen joints). Gout can affect almost any joint inserologic testing. A high percentage of patients
the body, but typically affects "cooler" regionswith hepatitis C may have elevated titers of RF.
including the toes, feet, ankles, knees, and hands.Therefore, RF testing is not helpful in distinguishing
Diagnosis is made by withdrawing fluid from abetween hepatitis C infection and RA. However, in
joint and examining the fluid under a polarizingthese situations, testing for anti-CCP can be
microscope. Patients may also have elevatedhelpful as anti-CCP antibodies have not been
serum levels of uric acid.shown to be significantly elevated in isolated
In most cases, gout is an acute disease thathepatitis C infections.
affects one joint and is easily distinguished fromSo as you can see... "it ain't easy...
RA. However, in rare cases, chronic erosive