What are the typical presentations of migratory polyarthritis?

Migratory Polyarthritis: Clinical Presentation and Characteristics

Migratory polyarthritis typically presents as joint pain and swelling that moves from one joint to another over time, most commonly affecting large joints such as knees, ankles, elbows, and wrists, with rapid response to anti-inflammatory medications being characteristic. 1

Key Clinical Features

• Migratory pattern: Pain and swelling move from one joint to another, with previous joints improving as new joints become affected 1
• Predominant involvement of large joints (knees, ankles, elbows, wrists) 1
• Self-limited course, typically lasting approximately 4 weeks even without therapy 1
• Rapid improvement with salicylates or nonsteroidal anti-inflammatory drugs (NSAIDs) 1
• Absence of long-term joint deformity 1
• Less common involvement of small joints of hands, feet, and spine compared to other arthritic conditions 1

Common Etiologies

Acute Rheumatic Fever (ARF)

• Classic cause of migratory polyarthritis, especially in moderate to high-risk populations 1
• Follows group A β-hemolytic streptococcal infection 1
• Often accompanied by other manifestations (carditis, chorea, erythema marginatum, subcutaneous nodules) 1
• Morning stiffness may be present but is typically mild and brief 1

Post-Streptococcal Reactive Arthritis

• Similar to ARF but may not fulfill all Jones criteria 1
• May later develop into full ARF or rheumatic heart disease in some cases 1
• Controversy exists regarding need for secondary prophylaxis 1

Familial Mediterranean Fever (FMF)

• Can present with recurrent episodes of migratory polyarthritis 2
• Episodes are typically self-limited but recurrent 2
• May be misdiagnosed as infectious arthritis, leading to inappropriate antibiotic treatment 2

Lyme Disease

• Can present with migratory joint pain and swelling 3
• Often preceded by erythema migrans rash in 60-80% of cases 1
• Predominantly affects large joints, particularly knees 3
• History of tick exposure in endemic areas is common 1

Atypical Presentations of Other Rheumatic Diseases

• Rheumatoid arthritis occasionally presents with migratory pattern before settling into its more typical symmetric polyarthritis 4
• Viral arthritis can present with acute, self-limited migratory polyarthritis 5
• Crystal-induced arthropathies may occasionally present with migratory pattern 5

Laboratory and Imaging Findings

• Inflammatory markers (ESR, CRP) are typically elevated 5
• Specific serological tests depend on suspected etiology:
  • Anti-streptolysin O (ASO) titers for ARF and post-streptococcal reactive arthritis 1
  • Anti-CCP antibodies and rheumatoid factor for atypical rheumatoid arthritis 4
  • Lyme serology for Lyme arthritis 1
• Plain radiographs may be normal early in the disease process 5
• Joint aspiration may reveal inflammatory synovial fluid without crystals or organisms 5

Differential Diagnosis Considerations

• Inflammatory arthritides (rheumatoid arthritis, psoriatic arthritis) 1
• Crystal arthropathies (gout, pseudogout) 1
• Septic arthritis (requires urgent exclusion) 1
• Viral arthritis 5
• Serum sickness reactions 5
• Immune checkpoint inhibitor-induced arthritis 1

Clinical Pearls and Pitfalls

• The migratory nature of joint pain can lead to misdiagnosis as separate episodes of monoarthritis 2
• Premature use of antibiotics without proper diagnostic evaluation can delay correct diagnosis 2
• In adults over 40 years, degenerative joint disease may coexist and complicate the clinical picture 4
• Careful assessment of extra-articular manifestations is crucial for narrowing the differential diagnosis 5
• Recurrent episodes of migratory polyarthritis should prompt consideration of underlying systemic disease rather than repeated infections 2, 6