Acute monoarthritis is a common medical emergency with wide differential diagnosis. Common underlying causes include trauma, septic arthritis, crystal induced arthritis (gout and pseudogout), and reactive arthritis. Of these, septic arthritis is the diagnosis not to miss because of its association with significant morbidity and mortality. Precise diagnosis of the underlying cause of monoarthritis relies on a good history, physical examination findings, and results of focussed investigations. In this article, a practical approach to diagnosis and initial management of patients presenting with acute monoarthritis is described with the aid of a case vignette.
1 Freed JF, Nies KM, Boyer RS, et al. Acute monoarticular arthritis. A diagnostic approach. JAMA 1980; 243(22): 2314-6.
2 Jeng GW, Wang CR, Liu ST, et al. Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis. Am J Emerg Med 1997; 15(7): 626-9.
3 Parker JD, Capell HA. An acute arthritis clinic- one year’s experience. Br J Rheumatol 1986; 25(3): 293-5.
4 Schmerling RH, Delbanco TL, Tosteson AN, et al. Synovial fluid tests. What should be ordered? JAMA 1990; 264(8): 1009-14.
5 Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001; 40(1): 24-30.
6 Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in a single UK health district 1982-91. Ann Rheum Dis 1999; 58: 214-19.
7 Kaandorp CJ, van Schaardenburg D, Krijnen P, et al. Risk factors for septic arthritis in patients with joint disease: a prospective study. Arthritis Rheum 1995; 38: 1819-25.
8 Cooper C, Cawley MI. Bacterial arthritis in an English health district: a 10 year review. Ann Rheum Dis 1986; 45(6): 458-63.
9 Morgan DS, Fisher D, Merianos A, et al. An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect 1996;117(3): 423-8.
10 Peters RH. Rasker JJ, Jacobs JW, et al. Bacterial arthritis in a district hospital. Clin Rheumatol 1992; 11(3): 351-5.
11 Kwiatkowska B, Filipowicz-Sosnowska A. Reactive arthritis. Pol Arch Med Wewn 2009; 119(1-2): 60-5.
12 Suresh E. Diagnosis and management of gout: a rational approach. Postgrad Med J 2005; 81(959): 572-9.
13 Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet 2010; 375: 846-55.
14 Till SH, Snaith ML. Assessment, investigation and management of acute monoarthritis. J Accid Emerg Med 1999; 16: 355-61.
15 Carpenter CR, Schuur JD, Everett WW, et al. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med 2011; 18(8): 781-96.
16 Swan A, Amer H, Dieppe P. The value of synovial fluid assays in the diagnosis of joint disease: a literature survey. Ann Rheum Dis 2002; 61: 493-98.
17 Abdullah S, Young-Min SA, Hudson SJ, et al. Gross synovial fluid analysis in the differential diagnosis of joint effusion. J Clin Pathol 2007; 60: 1144-47.
18 Soderquist B, Jones I, Fredlund H, et al. Bacterial or crystalassociated arthritis? Discriminating ability of serum inflammatory markers. Scand J Infect Dis 1998; 30: 591-6.
19 Wang CH, Yen ZS. Best Evidence Topic report. BET3. Is there a role for serum procalcitonin in the differentiation between septic and non-septic arthritis. Emerg Med J 2010; 27(2): 144-45.
20 Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology (Oxford) 2006; 45(8): 1039-41.
21 Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken) 2012; 64(10): 1447-61.
22 Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: a network meta-analysis. BMJ 2011; 342: c7086.
23 Zhang W, Doherty M, Bardin T, et al. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) Ann Rheum Dis 2006; 65: 1312-1324.
24 Colchicine full prescribing information, www.mims.com/USA/drug/info/colchicine.
25 Schlesinger N. Response to application of ice may help differentiate between gouty arthritis and other inflammatory arthritides. J Clin Rheumatol 2006; 12(6): 275-6.
26 Odio CM, Ramirez T, Arias G, et al. Double blind, randomised, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children. Pediatr Infect Dis J 2003; 22(10): 883-8.
27 Yu KH, Luo SF, Liou LB, et al. Concomitant septic and gouty arthritis- an analysis of 30 cases. Rheumatology (Oxford) 2003; 42(9): 1062-6.
28 McGillicuddy DC, Shah KH, Friedberg RP, et al. How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis? Am J Emerg Med 2007; 25: 749-52.
29 Jordan KM, Cameron JS, Snaith M, et al. British Society of Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxford) 2007; 46(8): 1372-4.
30 Choi HK, Atkinson K, Karlson EW, et al. Alcohol intake and risk of incident gout in men: a prospective study. Lancet 2004; 363(9417): 1277-81.
31 Dessein PH, Shipton EA, Stanwix AE, et al. Beneficial effects of weight loss associated with moderate calorie/carbohydrate restriction, and increased proportional intake of protein and unsaturated fat on serum urate and lipoprotein levels in gout: a pilot study. Ann Rheum Dis 2000; 59(7): 539-43.
Acute monoarthritis is a common medical emergency with wide differential diagnosis. Common underlying causes include trauma, septic arthritis, crystal induced arthritis (gout and pseudogout), and reactive arthritis. Of these, septic arthritis is the diagnosis not to miss because of its association with significant morbidity and mortality. Precise diagnosis of the underlying cause of monoarthritis relies on a good history, physical examination findings, and results of focussed investigations. In this article, a practical approach to diagnosis and initial management of patients presenting with acute monoarthritis is described with the aid of a case vignette.
1 Freed JF, Nies KM, Boyer RS, et al. Acute monoarticular arthritis. A diagnostic approach. JAMA 1980; 243(22): 2314-6.
2 Jeng GW, Wang CR, Liu ST, et al. Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis. Am J Emerg Med 1997; 15(7): 626-9.
3 Parker JD, Capell HA. An acute arthritis clinic- one year’s experience. Br J Rheumatol 1986; 25(3): 293-5.
4 Schmerling RH, Delbanco TL, Tosteson AN, et al. Synovial fluid tests. What should be ordered? JAMA 1990; 264(8): 1009-14.
5 Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001; 40(1): 24-30.
6 Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in a single UK health district 1982-91. Ann Rheum Dis 1999; 58: 214-19.
7 Kaandorp CJ, van Schaardenburg D, Krijnen P, et al. Risk factors for septic arthritis in patients with joint disease: a prospective study. Arthritis Rheum 1995; 38: 1819-25.
8 Cooper C, Cawley MI. Bacterial arthritis in an English health district: a 10 year review. Ann Rheum Dis 1986; 45(6): 458-63.
9 Morgan DS, Fisher D, Merianos A, et al. An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect 1996;117(3): 423-8.
10 Peters RH. Rasker JJ, Jacobs JW, et al. Bacterial arthritis in a district hospital. Clin Rheumatol 1992; 11(3): 351-5.
11 Kwiatkowska B, Filipowicz-Sosnowska A. Reactive arthritis. Pol Arch Med Wewn 2009; 119(1-2): 60-5.
12 Suresh E. Diagnosis and management of gout: a rational approach. Postgrad Med J 2005; 81(959): 572-9.
13 Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet 2010; 375: 846-55.
14 Till SH, Snaith ML. Assessment, investigation and management of acute monoarthritis. J Accid Emerg Med 1999; 16: 355-61.
15 Carpenter CR, Schuur JD, Everett WW, et al. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med 2011; 18(8): 781-96.
16 Swan A, Amer H, Dieppe P. The value of synovial fluid assays in the diagnosis of joint disease: a literature survey. Ann Rheum Dis 2002; 61: 493-98.
17 Abdullah S, Young-Min SA, Hudson SJ, et al. Gross synovial fluid analysis in the differential diagnosis of joint effusion. J Clin Pathol 2007; 60: 1144-47.
18 Soderquist B, Jones I, Fredlund H, et al. Bacterial or crystalassociated arthritis? Discriminating ability of serum inflammatory markers. Scand J Infect Dis 1998; 30: 591-6.
19 Wang CH, Yen ZS. Best Evidence Topic report. BET3. Is there a role for serum procalcitonin in the differentiation between septic and non-septic arthritis. Emerg Med J 2010; 27(2): 144-45.
20 Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology (Oxford) 2006; 45(8): 1039-41.
21 Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken) 2012; 64(10): 1447-61.
22 Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: a network meta-analysis. BMJ 2011; 342: c7086.
23 Zhang W, Doherty M, Bardin T, et al. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) Ann Rheum Dis 2006; 65: 1312-1324.
24 Colchicine full prescribing information, www.mims.com/USA/drug/info/colchicine.
25 Schlesinger N. Response to application of ice may help differentiate between gouty arthritis and other inflammatory arthritides. J Clin Rheumatol 2006; 12(6): 275-6.
26 Odio CM, Ramirez T, Arias G, et al. Double blind, randomised, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children. Pediatr Infect Dis J 2003; 22(10): 883-8.
27 Yu KH, Luo SF, Liou LB, et al. Concomitant septic and gouty arthritis- an analysis of 30 cases. Rheumatology (Oxford) 2003; 42(9): 1062-6.
28 McGillicuddy DC, Shah KH, Friedberg RP, et al. How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis? Am J Emerg Med 2007; 25: 749-52.
29 Jordan KM, Cameron JS, Snaith M, et al. British Society of Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxford) 2007; 46(8): 1372-4.
30 Choi HK, Atkinson K, Karlson EW, et al. Alcohol intake and risk of incident gout in men: a prospective study. Lancet 2004; 363(9417): 1277-81.
31 Dessein PH, Shipton EA, Stanwix AE, et al. Beneficial effects of weight loss associated with moderate calorie/carbohydrate restriction, and increased proportional intake of protein and unsaturated fat on serum urate and lipoprotein levels in gout: a pilot study. Ann Rheum Dis 2000; 59(7): 539-43.
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MD, FRCP, Senior Consultant Physician and Director of Acute Medicine. Department of Medicine, Ng Teng Fong General Hospital, Singapore.
Problem Based Review: The Patient with Acute Monoarthritis
Cite this article as:
Suresh E. Problem based review: The patient with acute monoarthritis. Acute Med. 2013;12(2):111-6. PMID: 23732137.
Problem Based Review: The Patient with Acute Monoarthritis
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