The polyarticular pain (polyarthralgia) occurs in several joints on (pain in a single joint are discussed elsewhere in pain and on a single joint). Polyarticular joint disease can affect different joints at different times. If several joints are affected, can the following classification to differentiate the various diseases, particularly arthritis, be useful:

Joints can easily be painful (arthralgia) or inflamed (arthritis). In arthritis, it usually comes to warmth, swelling (due to intra-articular fluid or effusion) and less likely to redness. The pain may occur only during exercise or even at rest. What is sometimes described by patients as joint pain, an extra-articular cause have (z. B. a periarticular structure or bones). The polyarticular pain (polyarthralgia) occurs in several joints on (pain in a single joint are discussed elsewhere in pain and on a single joint). Polyarticular joint disease can affect different joints at different times. Oligoartikulär: affected joints ? 4 polyarticular: If multiple joints are affected, can be useful to the following classification to differentiate the various diseases, particularly arthritis, affected joints> 4 Pathophysiology Articular sources of pain are in the joint. Periarticular sources of pain are in the structures around the joint (z. B. tendons, ligaments, bursae, muscles). Polyarticular pain with articular source can be the result of: inflammation (. Eg infection, deposit induced arthritis, systemic inflammation such as RA and psoriatic arthritis) Mechanical or other non-inflammatory disorders (. Eg osteoarthritis, hypermobility syndrome) synovium and joint capsule are important sources of pain in a joint. The synovium is the place that most of inflammation (synovitis) is affected. Pain in multiple joints in the absence of inflammation may be due to an increased joint weakness and strong trauma, as in benign hypermobility syndrome. Polyarthritis can both peripheral joints and joints axial (z. B. iliosakral, apophyseal, diskovertebral, kostovertebral) concern. Peripheral etiology oligoarticular arthritis, polyarticular arthritis is more common with a systemic infection (z. B. viral) or a systemic inflammatory disease (eg. B. RA) than the associated monoarticular arthritis. A specific cause can be identified in the rule (see Table: Causes of pain in joints ? 5 * and causes of pain in ? 4 joints); Sometimes, however, the arthritis is temporary and is improving before a definitive diagnosis can be made. Axial involvement has a seronegative spondyloarthropathy (also known as spondyloarthritis, overview of seronegative spondyloarthropathies) back, but can also occur in RA (which affects the cervical spine, but not the lumbar spine). The acute polyarticular arthritis usually goes back to the following causes: infection (usually viral) thrusts systemic inflammatory disease gout or pseudo-gout, chronic polyarticular arthritis in adults usually go to the following causes back: Rheumatoid Arthritis Seronegative spondyloarthropathy (usually ankylosing spondylitis, reactive arthritis , psoriatic arthritis or arthritis enteropathic) Not Inflammatory polyarticular pain in adults often goes back to the following: osteoarthritis chronic polyarthralgia in adults is usually caused by rheumatoid arthritis and osteoarthritis. The chronic polyarticular arthralgia in children usually goes to the following cause back: juvenile idiopathic arthritis causes pain in ? 5 joints * Cause: Suspicious findings diagnostic approach † Acute rheumatic fever Tough hiking pain, affecting mainly the large joints in the legs, elbows and wrists affect pain sensitivity heavier than swelling Extra-articular manifestations such as fever, symptoms and signs of heart disorders, chorea, subcutaneous nodules and rash streptococcal pharyngitis in prehistory Specific (Jones) clinical criteria test for infection with group A streptococci (eg. B. Culture, faster strep test, Antistreptolysin-O and anti-DNase B titers) echocardiogram hemoglobinopathies (z. B. sickle cell anemia or disease, thalassemia) pain usually, but sometimes in the joints, possibly symmetrical I. d. R. children or young patients of African or Mediterranean origin, often with a known diagnosis Hemoglobin hypermobility syndrome (z. B. Ehlers-Danlos, Marfan, benign hypermobility) polyarthralgia rarely Recurring with arthritis joint subluxation occasionally increased skin laxity Usually family history of joint hypermobility In Marfan and Ehlers -Danlos syndrome family history of aortic aneurysm or dissection if necessary at a young age or in middle age Clinical examination infectious bacterial (septic) arthritis (mostly monoarticular) Acute arthritis with severe pain and Gelenkerg SEN Occasionally immunosuppression or risk factors for sexuall transmitted diseases arthrocentesis infectious viral arthritis (parvovirus B19, hepatitis B, hepatitis C, enterovirus, rubella, mumps and HIV) Acute arthritis joint pain and swelling usually less severe than in infectious bacterial arthritis Other systemic symptoms depending (after virus z. B. jaundice in hepatitis B, often Viral with generalized lymphadenopathy HIV) arthrocentesis serology, as clinically indicated (eg., Hepatitis B surface antigen and IgM antibodies to Hepatitis B core in suspected hepatitis B) Juvenile idiopathic arthritis beginning the joint problems in childhood manifestation with oligoarthritis plus uveitis or systemic symptoms (Still’s disease fever, rash, lymphadenopathy, splenomegaly, pleural and / or pericardial effusion) Clinical examination ANA, RF and HLA-B27 test other rheumatic diseases (eg . B. Sjogren’s syndrome, polymyositis / dermatomyositis, polymyalgia rheumatica, systemic sclerosis [Sklerode rmie]) Disease-specific manifestations including specific dermatological manifestations (dermatomyositis), dysphagia (scleroderma), muscle pain (polymyalgia rheumatica) or dry eyes and dry mouth (Sjogren’s syndrome) Clinical examination Occasionally X-ray and / or serological tests (eg. As anti-SSA and anti-SSB with Sjogren’s syndrome, anti-Scl-70 in systemic sclerosis) Occasionally, skin or muscle biopsy psoriatic arthritis One of five forms of joint involvement, including polyarthritis similar to RA and oligoarthritis Extra-articular manifestations such as psoriasis, onychodystrophy , uveitis, tendinitis and dactylitis (Wurstfinger) Clinical evaluation Sometimes X-RA Symmetrical arthritis of small and large joints Occasionally initially monoarticular or oligoartikulär common in young adults, but can occur at any age Occasionally joint deformities in advanced stages Clinical examination RF and anti-CCP tests radiographs serum sickness arthralgia common than arthritis fever, lymphadenopathy and rash exposure to blood products within 21 days after the onset of symptoms Clinical Evaluation SLE arthralgia common than arthritis Systemic manifestations such as skin rash (eg. B. butterfly rash), mucosal lesions (eg. As ulcers), serositis (z. B. pleurisy, pericarditis), signs of glomerulonephritis common in women Clinical examination ANA, anti-dsDNA, complete blood count, urinalysis, laboratory with kidney and liver enzymes Systemic vasculitis (eg. B. immunoglobulin-A-associated vasculitis [previously Henoch-Schonlein purpura], polyarteritis nodosa, granulomatous with polyangiitis) arthralgia, in particular immunoglobulin-A-associated vasculitis Extra-articular symptoms, often involving multiple organ systems (for. example, abdominal pain may include kidney failure, signs of pneumonia, sinonasal symptoms, skin lesions, rash, purpura, nodules and ulcers) Serological tests when clinically indicated (eg. as ANCA-Te in suspected granulomatosis with polyangiitis) biopsy, if indicated (eg from kidney, skin or lungs) * These diseases may manifest sts as oligoarticular (? 4 affected joints). † In patients with joint effusion or inflammation should be a arthrocentesis (with cell count, Gram stain, cultures and crystal examination) and usually one ESR and C-reactive protein. X-rays are often unnecessary. ANA = anti-nuclear antibodies; ANCA = antineutrophil cytoplasmic antibody; Anti-CCP antibodies = cyclic citrullinated peptide; dsDNA = double-stranded DNA; RF = rheumatoid factor; STD = sexually transmitted disease. Causes of pain in joints ? 4 basic suspects findings Diagnostic procedure * ankylosing spondylitis † Usually axial pain and Steifigheit, worse in the morning and improves for activity occasionally bruising in large peripheral joints Occasionally, extra-articular manifestations (eg. As uveitis, enthesitis, aortic regurgitation) More common in young adult men X-ray of the lumbosacral spine Occasionally, MRI or CT, blood tests (ESR, CRP and blood count) and / or specific (modified New York-) clinical criteria Behcet disease arthralgia or Arthritis Extra-articular manifestations such as recurrent oral and / or genital lesions or uveitis usually beginning in the third decade of life Specific (international) clinical criteria deposition induced arthritis ‡, typically caused by uric acid crystals (gout), Kalziumpyrophosphatkristalle (pseudogout) and Kalziumhydroxyapatitkristalle. Acute onset of arthritis with joint warming and swelling can clinically indistinguishable from infectious bacterial (septic) arthritis be occasionally fever arthrocentesis Infectious endocarditis arthralgia or arthritis Systemic symptoms such as fever, night sweats, skin rash, weight loss, heart murmur blood cultures echocardiography osteoarthritis † Chronic pain affects more often the base of the thumb, PIP and DIP joints, knees and hips Occasionally Heberden’s nodes radiographs Reactive arthritis and enteropathic † Asymmetric arthritis of the large joints of the lower extremities frequently is reactive arthritis: gastrointestinal or genitourinary infection 1-3 weeks before onset of acute arthritis enteropathic arthritis: common occurrence of a gastrointestinal disorder (z. As inflammatory bowel disease, bypass surgery in the intestine) with chronic arthritis Clinical examination tests for sexually transmitted diseases if * In patients with joint effusion or inflammation should clinically indicated take place arthrocentesis (with cell count, Gram stain, cultures and crystal examination) and usually an ESR and C-reactive protein. X-ray is usually in the early sale of the disease is not useful. † These disorders can manifest themselves with axial involvement. ‡ A crystal-induced arthritis is usually monartikulär, but occasionally oligoartikulär. DIP = distal interphalangeal; PIP = proximal interphalangeal joint; STD = sexually transmitted disease. Clarification The study should detect if the symptoms come from the joint and / or periarticular structures and whether there are indications of inflammation. After extra-articular symptoms and findings that may indicate specific systemic inflammatory diseases, should also be sought and evaluated insbesonder in the present joint inflammation. History The history of the present illness should identify the characteristics of the joint pain accompanying joint symptoms and systemic symptoms. Among the important characteristics of the joint symptoms, the sharpness of the occurrence include (z. B. abrupt, stepwise), temporal patterns (eg. As time of day, persistent vs. intermittent), Duration (z. B. acute vs chronic), as well as exacerbation and ameliorating circumstances (z. B. rest, activity). Patients should especially after unprotected sexual contact (indication of risk for infectious bacterial arthritis with disseminated gonococcal infection) and tick bites or a resident or traveling in a Lyme-endemic area are surveyed. The review of organ systems should be complete, to identify extra-articular symptoms that can indicate specific diseases (see Table: Causes of pain in ? 5 joints *, causes of pain in ? 4 joints and suspicious findings in polyarticular joint pain). The medical history and family medical history should be known systemic inflammatory diseases and other conditions that can cause joint problems, identify (see table: causes of pain in joints ? 5 * and causes of pain in joints ? 4). Some systemic inflammatory diseases occur more frequently in families with specific genetic profiles auf.Körperliche examination The physical examination should be relatively fully implemented by all major organ systems (eg., Skin and nails, eyes, genitals, mucous membranes, heart, lungs, abdomen, nose, throat, lymph nodes and neurological system) and the musculoskeletal system are investigated. Vital signs should be checked for fever. In the investigation of the head for any signs of ocular inflammation (z. B. uveitis, conjunctivitis), and nasal or oral lesions should be taken. The skin should be examined for rashes and lesions (eg. As ecchymosis, skin ulcers, psoriasis plaques, purpura, butterfly rash). The patient is examined for Lamphadenpathie and splenomegaly out. The cardiopulmonary examination should register all the signs that may indicate a pleurisy, pericarditis or valve abnormalities (eg. B. noise, pericardial, steamed heart sounds, bilateral basal damping in connection with a pleural effusion). The examination of the genitalia should any form of discharge, ulcers or other findings that coexist with sexually transmitted diseases, notice. In the examination of the musculoskeletal system, the distinction between articular and periarticular or other connective tissue or muscular pain should be carried out first. The investigation of the joint begins with the inspection of deformities, erythema, swelling or effusion, and then continues with palpation of joint effusion, warming and point sensitivity. Passive and active range of motion should be investigated. A crepitus can be felt during the joint flexion and / or -streckung. A comparison with the non-affected joint the opposite side often helps to detect more subtle changes. In the investigation should Vedas care whether the distribution of affected joints is symmetrical or asymmetrical. Painful joints can also be charged without flexion or extension. The periarticular structures should also be on the involvement of tendons, bursae or ribbons as a discreet, soft swelling at the site of Bursa (bursitis) or Punktschmerzhaftigkeit the tendon (tendinitis) werden.Warnzeichen examined the following findings are of particular importance: joint heating, swelling and redness Extra-articular symptoms (eg. as fever, rash, chills, plaque, Mukosaulzera, conjunctivitis, uveitis, noise, purpura) interpretation of the findings on the basis of a thorough physical examination, it is important to establish whether pain originated from the joint, take other adjacent structures (eg., bone, tendons, bursae, muscles), both structures (eg. as in gout) or other structures. Pressure pain and swelling just at a location of the joint or the joint space have an extra-articular cause (for example, starting from tendon or bursae.) Out; local pain at the joint space or diffuse involvement of the joint is an indication of an intra-articular origin. A load of the joint without flexion or extension is not overly painful to tendonitis or bursitis, but is very painful for arthritis. Pain that is felt stronger in the active, but not passive movement, indicate a tendinitis or bursitis (extra-articular); intra-articular inflammation reduces both the active and the passive mobility significantly. and the testing of the joints due to inflammation is important. Rest pain or pain when starting to suggest a joint inflammation, while pain that gets worse with stress and subside at rest, a mechanical or non-inflammatory degenerative etiology (eg. As osteoarthritis) suggest. Warmth and redness are signs of inflammation, but these findings are often not sensitive, so its absence does not rule out inflammation. Clinical findings such as prolonged morning stiffness, stiffness after prolonged inactivity (Gelphänomen), non-traumatic joint swelling and fever or unintentional weight loss suggest a systemic inflammatory disease with joint involvement. Diffuse, imprecise circumscribed pain involving myofascial structures without inflammatory signs point to a fibromyalgia. A symmetrical joint involvement may be the way forward. The involvement is usually symmetrical with RA, whereas an asymmetric involvement rather psoriatic arthritis, gout, and reactive arthritis and enteropathic arthritis points. An examination of the wrist can lead to other evidence (see table: Suspicious findings in polyarticular joint pain), which help between osteoarthritis and RA (see table: differentiators hand in RA and osteoarthritis) to distinguish or indicate other diseases. Back pain in peripheral arthritis suggests a seronegative spondyloarthropathy (ankylosing spondylitis, reactive arthritis, psoriatic arthritis or enteropathic arthritis), but can occur (with cervical spinal pain usually) also with RA. A new-onset oligoarthritis with back pain sets in particular the suspicion of a seronegative spondyloarthropathy with a positive in this disease family history. Redness and pain and low back pain indicate a ankylosing spondylitis. A preliminary plaque psoriasis in a patient with new-onset oligoarthritis strongly suggests psoriatic arthritis. Suspicious findings in polyarticular joint pain finding Possible Cause General findings Accompanying tendinitis RA, disseminated gonococcal infection, psoriatic arthritis, gout, juvenile idiopathic arthritis (at the beginning of the age of ? 16) conjunctivitis, diarrhea, skin and genital lesions Reactive arthritis fever Infectious arthritis, gout, sys temische inflammatory diseases (eg. As SLE, RA) malaise, weight loss and lymphadenopathy Acute HIV infection, systemic juvenile idiopathic arthritis (Still’s disease) Oral and genital lesions Behcet’s disease, reactive arthritis Raised silver plaque psoriasis arthritis Current pharyngitis and migratory arthritis Rheumatic fever Recent vaccination or using a blood product Serum sickness skin lesions, abdominal pain, difficulty breathing and mucous membrane lesions Systemic vasculitis urethritis reactive arthritis or disseminated gonococcal infection hand findings (see table: distinguishing features of the hand in RA and osteoarthritis) Asymmetric participation of PIP and DIP joints with diffuse swelling of the fingers (Dactylitis) and / or nail changes psoriatic arthritis Top hi and asymmetric involvement of wrists Chronic gout increase of bone substance of the PIP joints (Bouchard’s nodes) or DIP joints (Heberden’s nodes) involvement of the first carpometacarpal joint (CMC) osteoarthritis Raynaud’s phenomenon Systemic sclerosis, SLE or mixed connective tissue disease scaly rash, often with plaque formation, on the extensor surfaces of the MCP and PIP joints (Gottron papules) dermatomyositis weakness multiple finger tendons to the REPON can lead IBLEN Fingerdeformitäten (Jaccoud arthropathy) SLE Balanced participation of PIP and MCP joints, especially with gooseneck or boutonniere deformity RA thickening of the skin over the fingers (Sclerodactyly) and flexion contractures Systemic sclerosis DIP = distal interphalangeal joint; MCP = metacarpophalangeal joint; PIP = proximal interphalangeal joint. Differentiators hand in RA and osteoarthritis criteria RA osteoarthritis joint swelling often synovium, capsule, soft tissues may Unusually mild swelling in spurts bone overgrowth Only in advanced stages often, often with irregular spurs DIP participation Rarely Freq ig MCP participation Frequently Exceptional Potentially significant MCP involvement in hemochromatosis PIP participation Common Common Uncommon Rare wrist involvement, but the involvement of the first carpometacarpal joint (often) is sometimes perceived as pain in the wrist CMC = carpometacarpal joint; DIP = distal interphalangeal; MCP = metacarpophalangeal joint; PIP = proximal interphalangeal joint. Adapted from Bilka PJ: Physical examination of the arthritic patient. Bulletin on the Rheumatic Diseases 20: 596-599, 1970. Tests The following tests are particularly important: arthrocentesis Usually BSG (and CRP) Serological tests X-ray examination in chronic arthritis A arthrocentesis is mandatory in most patients with a new effusion, an infection auszuschließen und Kristalle nachzuweisen. Sie kann auch zur Unterscheidung zwischen einem entzündlichen und nichtentzündlichen Prozess von Nutzen sein. Die Untersuchung der Synovialflüssigkeit beinhaltet die Zahl der weißen Blutkörperchen mit Differenzialverteilung, Gram-Färbung und Kulturen sowie die mikroskopische Untersuchung auf Kristalle im polarisierten Licht. Der Nachweis von Kristallen im Gelenkpunktat bestätigt eine Kristallarthropathie, schließt allerdings eine gleichzeitige Infektion nicht aus. Eine nichtentzündliche Gelenkflüssigkeit (z. B. Leukozytenzahl < 1000/µl) weist eher auf eine Osteoarthritis oder ein Trauma hin. Eine hämorrhagische Flüssigkeit passt zu einer Hämarthrose. Die Leukozytenzahl im Gelenkpunktat kann sowohl bei infektiöser als auch kristallinduzierter Arthritis sehr hoch (z. B. > 50.000/µl) sein. Die Leukozytenzahl in der Synovialflüssigkeit bei systemischen entzündlichen Erkrankungen, die eine Polyarthritis hervorrufen, liegt meist zwischen etwa 1000 und 5

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