Symposium-Rheumatology

An approach to monoarthritis
Molly Mary Thabah, Maj. Gen. Ved Chaturvedi1

Abstract
Monoarthritis can be inflammatory or non-inflammatory, and can be acute or chronic. A thorough history and
physical examination can differentiate inflammatory from non-inflammatory monoarthritis. The most common
causes of acute inflammatory monoarthritis are infectious arthritis, crystal induced arthritis (gout and pseudogout).
Examination of synovial fluid often is essential in making a definitive diagnosis. Immunoinflammatory diseases
like rheumatoid arthritis, systemic lupus erythematosus, spondyloarthritis, Behçet’s disease, and reactive arthritis
can all begin as acute inflammatory monarthritis. Synovial biopsy is useful to diagnose chronic infections like
tuberculosis and brucellosis. In order to arrive at a final diagnosis other organ systems should be thoroughly
reviewed, because other systemic illness like sickle cell disease, thalassemia, sarcoidosis can all cause
monoarthritis.

Keywords: Monoarthritis, monoarticular pain, crystal induced arthritis, gout, pseudogout

Introduction 1. Therefore the first step in approach to a patient

with musculoskeletal complaints is to separate
Musculoskeletal diseases are among the most systemic, serious, life-threatening illness from
common reasons for which medical help is sought. local, regional and mechanical problems.[3] Patients
Anywhere between 25% and 30% individuals will with musculoskeletal problems could have any of
have a musculoskeletal complaints in their life time. the following presenting complaints.
[1,2]
A significant proportion of patients who present • Joint pain/arthralgia.
with musculoskeletal complaints have in fact systemic • Arthritis.
illness such as rheumatoid arthritis (RA), systemic lupus • Diffuse pain.
erythematosus (SLE) etc. which may be potentially • Stiffness of joints.
life-threatening if not detected, correctly diagnosed • Back pain.
and treated. These conditions have to be distinguished • Constitutional symptoms.
from other musculoskeletal conditions, which have no • Symptoms of systemic organ, muscular or
systemic component, are mechanical in origin and are cutaneous involvement.
referred to the orthopedic department.[3] 2. The next step in approach to a patient with
musculoskeletal complaints is to find out from which
Access this article online
structure this pain is arising from (anatomical basis).
Quick Response Code: Pain could arise from the joint or from periarticular
Website:
www.jmgims.co.in
structures (articular versus non-articular). Articular
structures include the synovium, synovial fluid,
articular cartilage, intra-articular ligaments, joint
DOI:
10.4103/0971-9903.126229 capsule and juxta-articular bone. Non-articular (or
peri-articular) structures, such as supportive extra-

Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 1 Consultant
Rheumatologist, AMC Centre and College, Lucknow, Uttar Pradesh, India

Address for correspondence:

Dr. Molly Mary Thabah, Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research,
Puducherry - 605 006, India. E-mail: mthabah@yahoo.com

Journal of Mahatma Gandhi Institute of Medical Sciences March 2014 | Vol 19 | Issue 1
Thabah and Chaturvedi: Monoarthritis 13

articular ligaments, tendons, bursa, muscle, fascia, Therefore, monoarthritis which is arthritis of a single
bone, nerve and overlying skin, may be involved in joint can either be acute or chronic or be either
the pathologic process. inflammatory or non-inflammatory.
Articular disorders may be characterized by deep or
diffuse pain, pain on active and passive movement and Acute Inflammatory Monoarthritis
swelling (caused by synovial proliferation, effusion,
or bony enlargement), crepitation, instability, or Acute inflammatory monoarthritis is a rheumatology
deformity. By contrast, non-articular disorders tend emergency. The most important causes are infectious
to be painful on active, but not passive movement, (septic) arthritis, acute gouty arthritis, pseudogout,
demonstrate focal tenderness and swelling away from reactive arthritis and initial presentation of a
the joint line. Moreover, non-articular disorders may polyarthritis.[4] The diagnosis of septic arthritis should
rarely have synovitis, swelling, crepitus, instability, or not be missed as delay in initiating antibiotic therapy
deformity of the joint itself. can lead to permanent damage to the cartilage of
Pain caused by bone diseases can be difficult to the joint. History must include history of fever and
distinguish from that from the joints. Examples of involvement of other joints. Presence of classical
diffuse bone diseases are metabolic bone disease, signs of inflammation-red hot swollen and tender joint
multiple myeloma and multi focal osteomyelitis. makes it easy to label acute inflammatory arthritis.
In general bone diseases cause pain which is much Synovial fluid analysis is the single most important test
worse at night. This category must also be considered in the emergency evaluation of acute monoarticular
in differential diagnosis of musculoskeletal pain. arthritis.[5] Synovial fluid should be sent for cell count,
3. Once articular origin of the pain is established, the gram stain, bacterial culture and also examined for
other relevant features include the duration (acute crystals under polarized light microscope.
<6 and chronic >6 weeks); the number (mono, a. Non gonococcal bacterial arthritis (septic
oligo (≤3), or polyarthritis), and distribution arthritis) — Septic arthritis is a true rheumatology
of joint involvement, and whether the pain is emergency because it can rapidly destroy the
inflammatory (morning stiffness >30 min, systemic articular cartilage.[6] Septic arthritis may develop
symptoms, local inflammatory signs, laboratory in a fulminant fashion with high grade fever,
evidence of inflammation- (elevated ESR/ CRP, confusion and marked toxicity or may be subacute
thromobocytosis, anaemia of chronic disease, etc.) with little or no fever. The knee joint is the most
or non-inflammatory. common joint to be involved, followed by hip and
Therefore a patient with arthritis (joint pain and less commonly are the shoulder, wrist and elbow.
swelling) can be classified in one of the categories Patients with RA are at increased of developing
as given in Table 1.[3] septic arthritis.[7] Prior joint abnormality, prosthetic
joint also significantly increases the likelihood
Table 1: Shows a broad classification of the causes of developing septic arthritis.[8] It is important
of arthritis with a focus on major causes to rule out septic arthritis in any patient of RA
of monoarthritis who presents with a red hot and swollen joint.[8]
Acute arthritis Chronic arthritis Synovial fluid typically reveal white cell count of
Inflammatory
>50,000 cells/µL. Staphylococcus aureus is still
Monoarthritis Monoarthritis
Crystal induced arthritis Tubercular arthritis the most common cause of non-gonococcal septic
(gout and pseudogout) Fungal arthritis arthritis. Other pathogens include Streptococcus
Septic arthritis Other infections (e.g Brucellosis)
Gonococcal arthritis Immunoinflammatory arthritis
pneumoniae and Gram-negative bacilli. Reports
Acute onset of inflammatory Crystal induced arthritis in the literature show an increased incidence of
polyarthritis (like RA, SLE) methicillin-resistant S. aureus.[9]
Polyarthritis (e.g., acute onset Polyarthritis (e.g., RA, psoriatic
of polyarthritis, reactive arthritis) arthritis, spondyloarthritis)
Treatment for septic arthritis consists of hospital
Non-inflammatory admission and appropriate empirical intravenous
Monoarthritis Monoarthritis (IV) antibiotics (also to cover for S. aureus) should
Hemarthrosis Single joint osteoarthritis be started once samples for gram stain and culture
Trauma Neuropathic arthropathy
Osteonecrosis has been obtained to avoid joint destruction. Daily
Pigmented villo nodular synovitis aspiration should be done for accessible joints like
Polyarthritis Polyarthritis (e.g., osteoarthritis) the knee. Orthopedic consultation should be sought

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14 Thabah and Chaturvedi: Monoarthritis

because certain joints such as shoulder and hip may spontaneously within 3 to 10 days and most of the
require arthrotomy and open drainage. There is no patients have intervals of varying length with no
role of intra-articular antibiotics. residual symptoms until the next episode. Later
b. Gonococcal arthritis is main cause of infectious attacks may be monarticular or polyarticular.
arthritis in young persons (<40 years of age).[10] Certain events may precipitate acute gouty
The causative organism is Neisseria gonorrhoeae arthritis-these include excessive alcohol intake,
and arthritis is a consequence of bacteremia arising dietary excess, trauma and surgery.
from gonococcal infection or, more frequently, from d. Pseudogout — Calcium pyrophosphate dihydrate
asymptomatic gonococcal mucosal colonization crystals can cause monoarthritis that is clinically
of the urethra, cervix, or pharynx. Women are at indistinguishable from gout and thus is often called
greatest risk during menses and during pregnancy pseudogout. Pseudogout is most common in the knee
and overall are two to three times more likely than and wrist, but it has been reported in a variety of
men to develop disseminated gonococcal infection other joints, including the first metatarsal phalangeal
(DGI) and arthritis. joint (MTP) joint. Among other crystals known to
DGI is a syndrome of fever, chills, rash and arthritis cause acute mono-arthritis are apatites, calcium
which is migratory, with prominent tenosynovitis of oxalate and liquid lipid crystals.
the knees, hands, wrists, feet and ankles. Important
findings on the skin of the trunk and extensor Chronic Inflammatory Monoarthritis
surface of extremities are papules that progress to
hemorrhagic pustules. The causes of chronic inflammatory monoarthritis
True gonococcal septic arthritis is a monoarthrits of are indolent infections such as tuberculosis (TB),
hip, knee, ankle, or wrist. Gonococcal septic arthritis brucellosis, fungal infections and rare parasitic
is less common than the DGI syndrome and always infections. Any patient who presents with the chronic
follows DGI, which is unrecognized in one-third of inflammatory monoarthritis must undergo synovial
patients. Synovial fluid, typically contains >50,000 fluid analysis especially for microbiological analysis
leukocytes/L; the gonococcus is only occasionally and/or synovial biopsy must be done in order to get
evident in gram-stained smears and cultures of a correct diagnosis. Other important causes of chronic
synovial fluid are positive in <40% of cases. Blood inflammatory monoarthritis are tophaceous gout and
cultures are almost always negative. Treatment immunoinflamatory arthritis due to autoimmune
consists of ceftriaxone (1 g IV or intramuscular conditions like spondyloarthritis (SpA), SLE or RA.
every 24 h) to cover possible penicillin-resistant By and large this category remains a diagnosis of
organisms, until resolution of local and systemic exclusion.
signs. This can be followed by oral ciprofloxacin a. Tubercular arthritis — Approximately 10-11%
(500 mg twice daily) to complete 10-14 day course. of extrapulmonary TB involves bone and joints
c. Crystal induced arthritis — Gout, which is caused (osteoarticular TB).[13] The most common site of
by monosodium urate crystals, is the most common osteoarticular TB is the spine, followed by peripheral
type of inflammatory monarthritis.[11, 12] Gout occurs tubercular arthritis.[14] Tubercular arthritis occurs
almost always in a man above the age of 40 years. mainly as a chronic monoarticular arthritis of a hip
In general, only one joint is affected initially, but or knee (about 85%), but may involve other joints.
polyarticular acute gout can occur in subsequent [14]
The onset of tubercular arthritis is typically
episodes. The metatarsophalangeal joint of the insidious with pain and swelling of a single
first toe often is involved, but tarsal joints, ankles joint, but signs of inflammation may be limited.
and knees also are affected commonly. The first Tubercular arthritis is usually due to reactivation
episode of acute gouty arthritis frequently begins of a hematogenously seeded focus and need not
at night with dramatic joint pain and swelling. be associated with active disease elsewhere; it
The pain may be so excruciating that the patient can also spread from adjacent osteomyelitis. The
may not even tolerate the touch of the bed clothes. risk factors for development of osteoarticular TB
Joints rapidly become warm, red and tender and and include individuals who are from low socio-
there may be peeling of skin overlying the affected economic status, alcoholics, diabetes mellitus, HIV
joint with a clinical appearance that often mimics infection, corticosteroid therapy and other chronic
that of cellulitis. Early attacks tend to subside illnesses.

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Thabah and Chaturvedi: Monoarthritis 15

TB of the hip usually presents with mild to Candida species can rarely cause septic arthritis.[17]
moderate pain in the groin, thigh or knee. Children Isolated monoarthritis is caused by the direct intra-
most commonly presents with a limp. At rest the articular inoculation of fungi that inhabit the skin or
hip is usually held in a flexed and abducted posture. as a complication of hematogenously disseminated
It is common to find atrophy of gluteal muscles and candidiasis. Disseminated candidiasis with its
tenderness in the groin. Plain radiographs in early accompanying arthritis is seen in patients with
stage of the disease are non-diagnostic, but in later serious underlying disorders, IV drug abusers or
stages of the disease there can be destruction of the after prolonged antibiotic therapy.[18] Rare cases have
femoral neck, acetabulum and cold abscess. been reported where direct inoculation is caused by
TB of the knee usually presents with insidious onset repeated injection of a joint or as a contaminant
pain, swelling and stiffness. Other presentations during joint surgery.[19,20] The causative organism
include a limp and reduction in motion of the knee. in 80% of cases is Candida albicans and remaining
The joint is usually warm to touch; synovitis and cases are caused by Candida tropicalis.[21] The knee
effusion are commonly present. Muscle spasm and is the most commonly affected joint in most cases,
synovial effusion result in flexion deformity. Plain though any other peripheral joint or the spine can
radiographs in the early stage of disease will show also be affected.[21] Most cases are monoarticular and
soft-tissue swelling subsequently damage to the osteomyelitis is often present. Diagnosis is achieved
articular cartilage will result in narrowing of the by isolating the organism by culture of the aspirated
joint space, irregularity of the cartilage surface and joint fluid or bone. Treatment with amphotericin B is
areas of destruction of the epiphysis. effective and joint destruction with loss of function
A high index of suspicion is necessary for early occurs only in a small percentage of affected
diagnosis. Yield of synovial fluid smear for acid individuals.
fast bacilli is only 20-40%, while culture may Coccidioides immitis, Blastomyces dermatitidis
become positive in up to 80% of cases.[13] Synovial and Histoplasma capsulatum are rare causes of
fluid analysis shows elevated cell counts with no chronic monoarthritis.[16] Arthritis due to these
specific distinguishing features. Very low glucose dimorphic fungus results from hematogenous
levels in synovial fluid may favor the diagnosis of seeding or direct extension from bony lesions in
TB. Synovial biopsy is a must in cases of chronic persons with disseminated disease.
monoarticular inflammatory arthritis where Infection with Sporothrix schenckii is common
diagnosis is in doubt. among gardeners and other persons who work
Treatment of tubercular arthritis is same as for with soil or sphagnum moss. Joint involvement is
other forms of TB. The intensive phase consists rare.[22] Articular sporotrichosis is six times more
of administration of rifampicin, isoniazid, common among men than among women and
pyrazinamide and ethambutol for 2 months, alcoholics and other debilitated hosts are at risk for
followed by a continuation phase of rifampicin polyarticular infection.[23] Tenosynovitis, with or
and isoniazid for 4 months. Intermittent short without carpal tunnel syndrome, is associated with
course chemotherapy has not been assessed in deep inoculations. If untreated, the infection will
osteoarticular TB. The optimal duration of therapy lead to osteomyelitis.
is also still unsettled.[13] Hence, each patient has c. Immunoinflammatory causes of chronic
to be individually assessed and where relevant, inflammatory monoarthritis. The SpA group
treatment duration may have to be extended for a of diseases consists of ankylosing spondylitis
given patient.[15] (AS), reactive arthritis, psoriatic arthritis (PsA),
b. Fungal infections — Fungal arthritis is a rare but arthropathies associated with inflammatory bowel
nevertheless an important differential diagnosis of disease (IBD) and undifferentiated SpA.[24] A
chronic monoarthritis. It usually follows a chronic pattern of peripheral arthritis which is asymmetrical,
indolent course of several months that leads to oligoarticular and predominantly of lower limb is
delays in diagnosis and to inappropriate treatment characteristic of this group of diseases.[24]
such as intra-articular and systemic steroids. Diagnosis of SpA in a patient with chronic
[16]
Various predisposing factors that depress the monoarthritis is suggested by presence
immune system have been implicated in patients inflammatory back pain or enthesitis or
developing fungal arthritis. dactylitis, with one SpA feature like; psoriasis,

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16 Thabah and Chaturvedi: Monoarthritis

IBD, preceding infection, HLA-B27, uveitis, against any movement. Blood in the joint is resorbed
inflammatory sacroiliitis on magnetic resonance over a period of a week or longer and pain, swelling
imaging or plain radiographs.[25, 26] and tenderness decreases. Recurrent hemarthrosis
Peripheral arthritis in AS predominantly involves result in chronic arthritis, where swelling persists and
the lower extremities, especially the knee.[27,28] deformity of the joint develops.
Reactive arthritis commonly presents with
monoarthritis of ankle or knee. History of preceding The diagnosis of hemarthrosis should be considered
infection either urethritis can be elicited in 40% in a young male who presents with recurrent swollen
cases. Synovial fluid will not show any organism.[29] and painful joint, which gradually improves on its
Other immunoinflammatory systemic diseases that own overtime. The treatment of hemarthrosis consists
may be associated with chronic monarticular arthritis of immediate infusion of factor VIII or IX at the first
are RA, SLE, Behçet’s disease. sign of joint or muscle hemorrhage. Pain relief with
Therefore since indolent infections like TB, brucellosis paracetamol or Cox-2 inhibitors should be given,
and fungal infections constitute a major portion of non-selective nonsteroidal anti-inflammatory drugs
chronic inflammatory monoarthritis synovial fluid are generally avoided because of theoretical risk of
microbiology and/or biopsy must be performed to get potentiating the bleeding.
the actual diagnosis.
Chronic Non-inflammatory
Acute Non-inflammatory Monoarthritis Monoarthritis
The causes of acute non-inflammatory monoarthritis Under this heading is single joint osteoarthritis (OA),
would include trauma, bleeding in to the joint osteonecrosis, neuropathic joint and pigmented
(hemarthrosis) and palindromic rheumatism. villonodular synovitis (PVNS).
a. OA is the most common type of arthritis. World-
Trauma to a joint can lead to internal derangement, wide estimates indicate that 9.6% of men and 18%
hemarthrosis, or fracture. Such patients should be
of women >60 years have symptomatic OA.[1] It
evaluated with plain radiographs and referred to the
is a heterogeneous group of disorders with shared
orthopedic surgeon. Penetrating injuries from thorns,
clinical features that bind the group together. OA
wood fragments, or other foreign materials can cause
can be primary or secondary based on the presence
non-inflammatory monoarthritis.[30,31] There are case
or absence of an obvious cause. It can be localized
reports of foreign body in the joint (foreign body
or generalized based on the distribution between
synovitis) presenting like septic arthritis.
joints and numbers of joints involved. Knee OA
Hemarthrosis is very common and is often associated with
The most common causes of hemarthrosis is congenital disability.[33] Symptomatic hip OA is one-third as
disorders such as hemophilia.[32] Hemophilia is a sex- common as disease in the knee.
linked recessive genetic disorder characterized by the The two cardinal symptoms of OA are joint pain
absence or deficiency of factor VIII (hemophilia A, that worsens with use and difficulty initiating joint
or classic hemophilia) or factor IX (hemophilia B, or movement after inactivity (also known as gelling
Christmas disease). Spontaneous acute hemarthrosis of the joints).
occurs commonly with both types of hemophilia. The joint affected by OA generally has evidence of
Recurrent spontaneous accumulation of blood in to the mild to — moderate firm swelling around the joint
joint can lead to a deforming arthritis.[32] Hemarthrosis line due to osteophytes at the joint margin, palpable
is not common in other disorders of coagulation such as crepitus and restricted range of motion with pain
von Willebrand disease, factor V deficiency, warfarin at the end of the range. Other common findings on
therapy, or thrombocytopenia. clinical examination are weakness and wasting of
the muscles acting on the joint, tenderness around
Hemarthrosis occurs when the child begins to walk and the joint and deformities and instability of the joints
run. The joints most commonly affected are the knees, are seen in late stages.
ankles, elbows, shoulders and hips. In the acute stage b. Neuropathic arthropathy — Joint disease secondary
of bleeding the joint is warm, swollen and tender. The to neuropathy was first described by Jean Marie
patient holds the affected joint in flexion and guards Charcot, hence it also known as Charcot arthropathy.

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Thabah and Chaturvedi: Monoarthritis 17

It was most commonly described in association who complaints of a traumatic swelling of a single
with tertiary syphilis, however nowadays it most joint.[38] The knee is involved 80% of the time. The
commonly occurs due to diabetic neuropathy.[34] synovial fluid is almost always gross red or bloody.
Other causes of neuropathic arthropathy are spinal Diagnosis is established by biopsy of the synovium,
cord diseases such as syringomyelia, spinabifida, which is defined by the presence of giant cells, foamy
spinal cord injuries.[35] The loss of pain sensation, cells and hemosiderin deposits in synovial tissue.
proprioception and abnormal muscular reflexes
that modulate joint movement leads to repeated Conclusions and Pearls for Diagnosis
trauma, resulting in progressive cartilage and bone
damage. • Pain and swelling (arthritis) of a single joint requires
Neuropathic arthropathy may present as an acute prompt evaluation to identify septic arthritis, crystal
or subacute monoarthritis with swelling, erythema induce arthritis and acute onset of inflammatory
and variable amounts of pain in the affected joint. polyarthritis.
Chronic presentation often mimics OA. The • Acute inflammatory monoarthritis is infection
most important clinical findings in neuropathic unless proved otherwise.
arthropathy are the presence of a significant • Synovial fluid analysis is the most important
sensory deficit and a degree of pain that is less than investigation in the evaluation of both acute and
would be expected considering the amount of joint chronic monoarthritis.
destruction evident on radiographs. • Septic arthritis can rapidly destroy the joint if not
The pattern of joint involvement depends on the detected and promptly treated.
location of the neurologic impairment and may • Septic arthritis can be superimposed on gout and
involve small as well as large joints. In diabetes, pseudogout.
the foot is most commonly involved. Patients • Gonococcal arthritis is seen in a young person.
with syringomyelia typically demonstrate upper • Serum uric is often normal during an acute attack of
extremity involvement.[36] gout; diagnosis of gout requires the demonstration
c. Osteonecrosis also known as avascular necrosis is of intracellular monosodium urate crystals in the
characterized pathologically by presence of dead joint fluid under polarized light microscope.
bone can present like arthritis. The most common • RA, SLE, IBD associated arthritis, PsA, Behçet’s
site for involvement is the femoral head. Other disease and reactive arthritis can all begin as acute
sites are knee, ankles, shoulders and elbows. inflammatory monarthritis.
The most common risk factor for osteonecrosis • Other systemic diseases associated with acute
is glucocorticoid use.[37] An important scenario inflammatory monoarthritis are sarcoidosis, sickle
is development of pain of the groin, typically a disease, hemoarthrosis due to hemophilia and
deep, throbbing pain in a patient with rheumatic arthritis associated with chronic viral infections.
illness who is on glucocorticoids. This pain which • Tuberculosis and other indolent infections should
is worse at night is usually intermittent and of be considered in the differential diagnosis of
gradual onset, occasionally appears abruptly. chronic inflammatory monoarthritis. Synovial
biopsy must be performed to get the diagnosis.
Osteonecrosis is often seen in RA, SLE, systemic
• Osteonecrosis, OA, neuropathic joint and PVNS
vasculitis and other rheumatic illness, the major risk
should be considered in the differential diagnosis
factor being glucocorticoid therapy. Other causes
of chronic non-inflammatory monoarthritis.
include fracture, dislocation, radiation injury,
pregnancy, sickle cell disease, coagulopathies,
hemoglobinopathies, organ transplantation,
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Source of Support: Nil, Conflict of Interest: None declared.
Infect Dis 2007;45:1255-65.

Journal of Mahatma Gandhi Institute of Medical Sciences March 2014 | Vol 19 | Issue 1