Intended for healthcare professionals

Practice Rational Testing

Investigating symmetrical polyarthritis of recent origin

BMJ 2010; 340 doi: (Published 30 June 2010) Cite this as: BMJ 2010;340:c3110
  1. Allan Binder, consultant rheumatologist,
  2. Spencer Ellis, consultant rheumatologist
  1. 1East and North Hertfordshire NHS Trust
  1. Correspondence to: A Binder, Lister Hospital, Stevenage SG1 4AB allan.binder{at}

    What are the key tests for someone with polyarticular symptoms and at what point do you refer? This article goes through the diagnostic steps

    Learning points

    • Patients with polyarticular joint symptoms need urgent referral to a rheumatologist without awaiting radiography results

    • Positive anticyclic citrullinated peptide (anti-CCP) antibodies have greater specificity than rheumatoid factor for rheumatoid arthritis, although at high titre both suggest an unfavourable outcome

    • Radiographic changes are often seen late in rheumatoid arthritis; high resolution Doppler ultrasound or magnetic resonance imaging aid early diagnosis

    • The classification criteria for rheumatoid arthritis are unhelpful in the early stages of the disease, but the need for disease modifying antirheumatic drugs can be accurately predicted by clinical and laboratory factors at presentation

    A 32 year old woman presents to her general practitioner with a month’s history of painful wrists and feet and increased tiredness, which she attributes to carrying and looking after her 6 month old son. When asked, she describes early morning stiffness for an hour and finds that over the counter ibuprofen eases the pain. She has no clinically significant history, such as psoriasis, recent infection, or diarrhoea. On examination, she has mildly swollen wrists and tenderness on compression of her metatarsophalyngeal joints.

    What are the next investigations?

    Given the polyarticular joint involvement, morning stiffness, and response to anti-inflammatory agents in our patient, inflammatory arthritis needs to be considered, although the course of early inflammatory arthritis is highly variable. In a prospective population based study in Sweden, 151 new cases of recent onset undifferentiated inflammatory arthritis were identified over a period of one year. When reviewed a year later, 21% of these patients …

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