Arthritis - joint inflammation, "synovitis"

Definition

Arthritis is inflammation of one or more joints (mono- and polyarthritis, respectively), either large joints (knees, hips, shoulders, elbows) or small joints (fingers, toes, jaw joints)

• "Synovitis" actually describes the rheumatic inflammation that can be seen by tissue sample (biopsy) from the inside of an arthritis joint. In practice, the word "synovitis" is also used for joint inflammation / arthritis
• In Norwegian, we separate "arthritis" from Osteoarthrtitis (English: osteo-arthritis)
  • Osteoarthritis has less inflammation than arthritis
• Most forms of arthritis are caused by a autoimmune attack from our own immune system. The triggering cause is most often unknown
• Septic (infectious) arthritis is caused by infection, most often bacteria

Symptoms of arthritis - inflamed joints

• Joint pain (arthralgia)
• Joint stiffness
• Joint swelling
• Increased heat in the skin over the joint
• Redness (erythema) may occur, especially in acute conditions there gout or Septic arthritis should be suspected

Arthritic Diseases (Arthritis)

Adult Stills disease

• High and variable fever, arthritis, rash in fever, high ferritin in blood test

Childhood arthritis (juvenile arthritis)

• A special group of chronic diseases among children of all ages (but can continue into adulthood)

Connective tissue disorders (please see below)

Ankylosing spondylitis (Ankylosing spondylitis)

• Chronic back pain, most evident in the morning, minor symptoms after physical activity
• Can also cause arthritis, most often in the hip and knee joints
• Some have concomitant chronic inflammation of the gut (Ulcerative colitis or Crohn's disease)
  • More on rheumatic manifestations of chronic inflammatory bowel disease here
• About 25% get eye inflammation (uveitis, iridocyclitis).
• Ankylosing spondylitis is detected by radiological examination of "sacroiliac joints” between the pelvis and spine

Familiar Mediterranean Fever (FMF)

• Ethnic from the Mediterranean and North Africa, family history
• Acute self-limiting seizures with arthritis and inflammation of the pericardium og lung membranes / serositis)

Infections (please see below)

Cancer treatment (please see below)

Arthritis / Rheumatoid Arthritis (RA)

• Symptoms lasting two weeks or more
• Swollen fingers / toes
• Hard to tie hands, especially in the morning
• The feeling of "walking on pillows", especially in the morning
• Blood samples with increased CRP, Rheumatoid factor (RF) and anti-CCP

Psoriatic arthritis

• Occurs among 5-10% of those who have Psoriasis of the skin

Reactive arthritis

• Severe joint inflammation (knees, ankles and hips)
• Begins a few weeks after infection, often chlamydia, yersinia, salmonella or campylobacter- bacteria (from the urinary tract or intestine).
• Knee joints are most often attacked. Eye disorders (uveitis, iridocyclite) occurs
  • Reiter's syndrome: Arthritis + urethral inflammation + eye inflammation)

Reticulo-histiocytosis

• • A rare form of arthritis with joint destruction, mostly in finger joints (mutilating). Similar to arthritis in the form of multicentre reticulohistiocytosis

Sarcoidosis

• Løfgren Syndrome
  • Both ankles, erythema nodosum / nodule and swollen hilus lymph nodes in the lungs

Still's disease (systemic childhood arthritis in children, Adult Stills disease among adults)

• Typically, high fever, arthritis and varying mild rashes

Intestinal inflammation

• Ulcerative colitis or Crohn's disease (chronic intestinal inflammation).
• Most often knees and / or ankles and with active bowel inflammation

Vasculitis, systemic (please see below)

Gout

• Caused by uric acid crystals

Infections

• Borrelia arthritis (Lyme disease) is a special form of septic arthritis that can attack the knee or other joints a few weeks or months after tick bite. The fewest tick bites lead to infection. If a tick has sucked blood for a long time, it increases the risk of infection
• Septic arthritis caused by infection (mostly bacteria)
• Whippel's disease (arthritis can precede other symptoms for several years)

Connective Tissue Diseases

Arthritis commonly occurs in Systemic connective tissue diseases:

• SLE
• Sjögren's syndrome
• Systemic sclerosis (systemic scleroderma)
• Myositis
• MCTD

Vasculitis diseases

Vasculitis diseases can also cause arthritis, most often at the onset of illness

• GPA (Wegener's granulomatosis)
• Takayasu arteritis
• Giant cell arteritis (temporal arteritis)
• Behcet's disease
• Relapsing polychondritis

Arthritis during cancer treatment

• Immunological checkpoint inhibitors (provisional anti PD-1 such as pembrolizumab and nivolumab and anti PDL-1 such as atezolizumab, avelumab and durvalumab) are effective against several types of cancer. However, they increase risk of autoimmune disease that Rheumatoid arthritis (RA) og Polymyalgia rheumatica (PMR) (Reference: Belkhir R, 2017)
  • Separate page about rheumatic side effects of checkpoint inhibitors here
• BCG treatment against urinary bladder cancer can cause joint pain and arthritis (arthritis), usually 2-4 weeks after treatment. Knees and ankles are most often attacked. The symptoms usually last for 6 months
• Granulocyte and granulocyte macrophage colony stimulating factor (G-CSF / GM-CSF) is used as a supplement for some chemotherapy. The treatment may lead to acute, symmetrical arthritis in several joints. Symptoms usually occur within a few days after the end of treatment.

Diagnosis arthritis - inflammation of joints

An experienced doctor will recognize arthritis by clinical examination of joints

• Blood tests usually show elevated CRP and erythrocyte sedimentation rate (ESR)
• By Rheumatoid arthritis (RA), SLE and some vascular diseases are often characteristic Antibodies present
• Gout usually show markedly elevated uric acid levels in blood and typical crystals by joint fluid examination (via rheumatologist)
• Septic arthritis is diagnosed by joint fluid examination and / or PCR technique
• Ultrasound and MRI examination of joints can detect early signs of arthritis
• X-ray changes occur in later stages of disease

Treatment of arthritis - inflammation of joints

In chronic rheumatoid arthritis, the hyperactive immune system is calmed with immunosuppressive drugs to prevent the development of joint injury

• Initially can Prednisone and / or aspiration of joint fluid be applicable
• Aspiration of joint fluid (arthrosentesis) and joint injection with a cortisone drug is often used for knees and other large joints
• In case of chronic arthritis diseases like Rheumatoid arthritis (RA), SLE and similar conditions are often complementary Methotrexate tablets or injections necessary
• If the disease is still active, treatment may be supplemented with "biological drugs" as Remsima / Inflectra/ Remicade, Enbrel, Humira, MabThera and other
• Gout can be prevented with Allopur tablets, Zyloric and other medications
• Septic arthritis and Borrelia arthritis must be treated with antibiotics

Referral to rheumatologist

If arthritis is suspected - arthritis, the general practitioner usually chooses to refer to the rheumatologist or rheumatology department after preliminary examinations (assessment of affected joints, blood and urine tests).

• In Oslo, arthritis diseases are managed by Diakonhjemmet hospital (Rheumatology department), while connective tissue diseases and systemic vasculitis are handled at Rikshospitalet (Rheumatology department of Oslo University Hospital). More about referral routines can be found here.

You can read about your rights in arthritis disease here (Norsk Revmatikerforbund)

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