Gastrointestinal and liver disease
This is associated with HLA B27 and IS described. Autoimmune chronic active hepatitis This may be accompanied by an arthralgia that is like that seen in SLE. Joint pain occurs in a bilateral, symmetrical distribution, with the small joints of the hands being prominently affected. Joints usually look normal but sometimes there is a slight soft-tissue swelling. These patients often have positive tests for antinuclear antibodies.
Primary biliary cirrhosis
Patients occasionally have a similar symmetrical arthropathy to the above.
This is associated with osteoarthritis in 50% of cases; it is often the first sign of the disease and chondrocalcinosis is common. The metacarpophalangeal joints of the hands are particularly affected and the disease tends to be polyarticular, severe and progressive. Iron depletion does not solve the problem of the arthritis.
This is accompanied by fever and arthralgia.
Hypertrophic pulmonary osteoarthropathy Hypertrophic osteoarthropathy is most often associated with carcinoma of the bronchus. It is a non-metastatic complication and may be the presenting feature of the disease. It occurs only rarely with other conditions that cause clubbing. It is seen most often in middle-aged men, who present with pain and swelling of the wrists and ankles. Other joints are occasionally involved. The diagnosis is made on the presence of clubbing of the fingers, which is usually gross, and periosteal new bone formation along the shafts of the distal ends of the radius, ulna, tibia and fibula seen on X-ray. A chest Xray usually shows the malignancy. Treatment should be directed at the underlying carcinoma; if this can be removed, the arthropathy disappears. NSAIDs may help to relieve the symptoms.
Secondary gout occurs in conditions such as chronic myeloid leukaemia. Pain in the shoulder or back may be referred from malignant disease of the chest or abdomen. Secondaries around the joints may present with pain, but primary joint turn ours are very rare. A synovioma presents as a painless soft-tissue swelling adjacent to joints. It is highly malignant but extremely rare.
This is a seronegative arthritis occurring in patients with psoriasis.
Erythema nodosum can be due to several conditions, e.g. sarcoidosis, and is accompanied by arthritis in over 50% of cases. The knees and ankles are particularly affected and are swollen, red and tender. The arthritis subsides, along with the skin lesions, within a few months. Treatment is with NSAIDs or occasionally steroids.
Neuropathic joints (Charcot’s joints) are joints damaged by trauma as a result of the loss of the protective pain sensation. They were first described by Charcot in relation to tabes dorsalis. They are also seen in syringomyelia, diabetes mellitus and leprosy. The site of the neuropathic joint depends upon the localization of the pain loss:
• In tabes dorsalis, the knees and ankles are most often affected.
• In diabetes mellitus, the joints of the tarsus are involved.
• In syringomyelia, the shoulder is involved.
Neuropathic joints are not painful, although there may be painful episodes associated with crystal deposition. Presentation is usually with swelling and instability and eventually grotesque deformities appear. The characteristic finding is a swollen joint with abnormal but painless movement. This is associated with neurological findings that depend upon the underlyingdisease, e.g. dissociated sensory loss in syringomyelia or peripheral neuropathy in diabetes. X-ray changes are characteristic, with gross joint disorganization and bony distortion.
Treatment is symptomatic; surgery may be required in advanced cases.
Arthritis due to haem arthrosis is a common presenting feature of haemophilia. Attacks begin in early childhood in most cases and are recurrent. The knee is the commonest affected joint but the elbows and ankles are sometimes involved. The arthritis can lead to bone destruction and disorganization of joints. Apart from replacement of factor VIII, affected joints require initial immobilization followed by physiotherapy to restore movement and measures to prevent and correct deformities. Sickle cell crises are often accompanied by joint pain that particularly affects the hands and feet in a bilateral, symmetrical distribution. Affected joints usually look normal but are occasionally swollen. This condition may also be complicated by avascular necrosis and by Salmonella osteoarthritis.
Arthritis can also occur in acute leukaemia; it may be the presenting feature in childhood. The knee is particularly affected and is very painful, warm and swollen. Treatment is directed at the underlying leukaemia. Arthritis may also occur in chronic leukaemia, with leukaemic deposits in and around the joints.
Endocrine and metabolic disorders
Hypothyroid patients may complain of pain and stiffness of proximal muscles, resembling polymyalgia rheurnatica. They may also have carpal tunnel syndrome. Less often, there is an arthritis accompanied by joint effusions, particularly in the knees, wrist and small joints of the hands and feet. These problems respond rapidly to thyroxine. In acromegaly an arthritis occurs in about 50% of patients. It resembles OA and particularly affects the small joints of the hands and knees. It may be associated with the carpal tunnel syndrome. Diabetes mellitus-related joint disorders are described.
Familial hypercholesterolaemia is associated with oligoarthritis or polyarthritis usually with tendon xanthomata. Arthritis also occurs in combined hyperlipidaerma,