Continuing Medical Education: Synovitis.

Making sense of the swelling

Laboratory testing

Finally, after having gone through the above process, you are ready for some directed laboratory testing.

Try to select your tests based on your history, review of systems, and examination. Avoid the "Arthritis Panel" approach to patients with arthritis. This can give you information you don't need and may misdirect your evaluation. Remember in most cases, time is on your side and all tests don't have to be ordered at once. Concentrate on the potentially most serious conditions and those most easily tested for and add tests as needed. I have included a handout on laboratory testing at the end of this section that might be helpful.

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• Arthritis Case Histories (PDF) (0.01 MB)

"Newer" forms of arthritis

Parvovirus arthropathy is a recently recognized cause of acute and chronic joint symptoms. In 1975, the parvovirus was isolated from human tissue. In 1981, this virus was associated with aplastic crisis in people with hemaglobinopathies, 1n 1983, with 5th disease, 1984 with nonimmune hydrops in prognancy, 1985 with an acute and chronic arthropathy, and 1987 with bone marrow suppression in immunocompromised individuals. The virus is a small, single stranded DNA virus that grows in erythrocyte precursor cells. Presently, detection of infection depends on serologic confirmation of an IgM response to the virus and one need to check for infection within the first 8 weeks. Newer methods of detection are being developed as is a method for culture.

The acute arthropathy consists of polyarthralgias/polyarthritis that may come on over night. There is usually significant stiffness and pain and only mild synovitis. Joint symptoms are much more common in adult women than men and the characteristic rash of childhood 5th disease is unusual in adults but a fine evanesent macular is frequently present on the extremities and trunk. The symptoms last 1-3 weeks and in most cases dissappear without sequela. In up to 1/3 of affected females the symptoms may continue or recur at various intervals. Symptoms have been recorded up to 4 years to date. One can usually treat the symptoms with NSAIDs. It is important to ask individuals with chronic or recurring inflammatory sounding arthralgias about possible exposure to the virus ie exposure to 5th disease. There is some interest in the parvovirus as a possible trigger of rheumatoid arthritis or systemic lupus erythematosus.

PMR with synovitis or seronegative rheumatoid arthirtis. In recent years, it has become evident that there is a group of individuals over the age of 60 who present with symmetrical polyarthritis, are seronegative for rheumatoid factor, and present with considerable shoulder and hip stiffness. This group has an excellent response to low dose steroids and do not show the progressive destructive course so common of true rheumatoid arthritis. Their symptoms resemble more the course of polymyalgia rheumatica (PMR). It is well recognized that PMR can have have coexixting joint effusions often pauciarticular, but this group who are between RA and PMR, have a polyarticular presentation. The response to low dose steroids is as dramatic as that for PMR and relapses can occur as well as actual temporal arteritis. Besides the absence of rheumatoid factor, another clue to help distinguish this syndrome from RA is the lack of involvement of the MTP joints.

Surgery for arthritis at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington

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