What is the initial approach to a patient presenting with joint pains and dyspnea (difficulty breathing)?

Differential Diagnoses for Joint Pains and Dyspnea

When a patient presents with both joint pains and dyspnea, immediately prioritize life-threatening cardiopulmonary causes first (acute coronary syndrome, pulmonary embolism, pericarditis), then systematically evaluate for systemic inflammatory conditions that affect both joints and lungs (rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis), followed by infectious etiologies (endocarditis with septic emboli, reactive arthritis with pneumonia). 1, 2

Life-Threatening Cardiopulmonary Causes (Rule Out First)

Cardiac Emergencies

• Acute coronary syndrome may present with dyspnea, diaphoresis, tachypnea, tachycardia, and hypotension; examination may be normal in uncomplicated cases, but joint pain is not typical unless there is referred pain or concurrent inflammatory condition 1
• Pericarditis causes chest pain that increases in the supine position, may be associated with a friction rub, and can present with pleuritic features; polyserositis can cause joint effusions in systemic inflammatory conditions 1
• Acute decompensated heart failure presents with "air hunger" and "inability to get a deep breath" due to restrictive mechanics and elevated filling pressures; peripheral edema may be mistaken for joint swelling 2

Pulmonary Emergencies

• Pulmonary embolism presents with acute dyspnea, pleuritic chest pain, tachycardia (>90% of patients), and hypoxemia; consider in patients with inflammatory arthritis due to increased thrombotic risk 1, 2
• Pneumonia presents with fever, productive cough, pleuritic chest pain, and focal crackles; reactive arthritis can follow respiratory infections 2
• Pneumothorax presents with sudden-onset dyspnea and pleuritic chest pain with decreased breath sounds; can occur in rheumatoid lung disease or Marfan syndrome with joint hypermobility 1, 2

Systemic Inflammatory/Rheumatologic Conditions

Autoimmune Diseases

• Rheumatoid arthritis with interstitial lung disease presents with progressive dyspnea, dry cough, bibasilar crackles, and symmetric polyarthritis; patients describe "air hunger" due to restrictive mechanics 2
• Systemic lupus erythematosus can cause pleuritis, pericarditis, pulmonary hemorrhage, and polyarthritis; serositis is a hallmark feature 2
• Sarcoidosis presents with hilar lymphadenopathy, interstitial lung disease, and arthritis (particularly ankles); Löfgren syndrome includes bilateral hilar adenopathy, erythema nodosum, and acute arthritis 2
• Systemic sclerosis causes pulmonary fibrosis and pulmonary arterial hypertension with progressive dyspnea, plus skin thickening and joint contractures 2

Vasculitis

• Granulomatosis with polyangiitis (Wegener's) causes pulmonary nodules/hemorrhage and arthralgias/arthritis; upper airway involvement is common 2
• Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) presents with asthma, eosinophilia, and migratory polyarthritis 2

Infectious Etiologies

• Infective endocarditis with septic pulmonary emboli causes dyspnea, fever, and septic arthritis or immune complex-mediated polyarthritis; look for new murmur and peripheral stigmata 1, 2
• Reactive arthritis following respiratory or gastrointestinal infection causes asymmetric oligoarthritis and can have concurrent pneumonia 2
• Disseminated gonococcal infection causes migratory polyarthritis, tenosynovitis, and rarely pneumonia 2
• Tuberculosis can cause Poncet's disease (reactive polyarthritis) with pulmonary TB causing dyspnea, cough, and night sweats 2

Other Multisystem Conditions

• Malignancy with paraneoplastic syndrome can cause hypertrophic osteoarthropathy (clubbing, periostitis, arthritis) with lung cancer causing dyspnea 2
• Amyloidosis causes restrictive cardiomyopathy with dyspnea and carpal tunnel syndrome or polyarthritis 2

Initial Diagnostic Approach

Immediate Assessment

• Perform focused cardiovascular examination to identify ACS, aortic dissection, PE, or pericarditis; assess for tachycardia, hypotension, new murmurs, friction rub, and accentuated P2 1
• Obtain 12-lead ECG immediately to detect ischemia, arrhythmias, or chamber enlargement 1, 2
• Measure pulse oximetry to assess for hypoxemia requiring supplemental oxygen 2

First-Line Testing

• Chest radiography is the initial imaging study to identify pneumonia, heart failure, pleural effusion, pneumothorax, masses, or interstitial lung disease 1, 2
• Complete blood count to assess for anemia, infection (leukocytosis), or thrombocytosis suggesting inflammatory conditions 2
• Inflammatory markers (ESR, CRP) are elevated in most systemic inflammatory conditions causing both joint pain and dyspnea 2
• BNP or NT-proBNP: levels <100 pg/mL or <125 pg/mL effectively exclude heart failure; use age-stratified cutoffs (NT-proBNP <125 pg/mL for age <75 or <450 pg/mL for age ≥75) 2
• Basic metabolic panel to evaluate for renal dysfunction (lupus nephritis, vasculitis), electrolyte abnormalities, and acid-base disturbances 2

Second-Line Testing (If Diagnosis Unclear)

• CT chest without IV contrast has higher sensitivity than chest radiography for detecting interstitial lung disease, pulmonary nodules, or early emphysema in patients with persistent symptoms 1
• Echocardiography to assess left ventricular function, valvular disease (endocarditis), right ventricular strain (PE, pulmonary hypertension), and pericardial effusion 2
• Rheumatologic serologies including rheumatoid factor, anti-CCP antibodies, ANA, anti-dsDNA, ANCA, and complement levels based on clinical suspicion 2
• Pulmonary function testing to characterize obstructive or restrictive patterns and assess diffusion capacity (DLCO reduced in interstitial lung disease and pulmonary vascular disease) 2
• Point-of-care ultrasonography (POCUS) improves sensitivity to detect heart failure, pneumonia, pulmonary embolism, pleural effusion, and pneumothorax; leads to statistically significantly more correct diagnoses than standard pathway alone 2

Critical Clinical Pearls

• "Chest tightness" is relatively specific for bronchoconstriction (asthma, COPD), while "air hunger" and "inability to get a deep breath" suggest restrictive mechanics (heart failure, pulmonary fibrosis, interstitial lung disease) 2
• Chest pain accompanied by painful, tympanic abdomen may indicate esophageal rupture, a life-threatening gastrointestinal emergency 1
• Chest tenderness on palpation or pain with inspiration markedly reduce the probability of ACS, but do not exclude it entirely 1
• History and physical examination alone have high specificity (96%) but low sensitivity (59%) for cardiac causes—do not rely on clinical assessment alone; always obtain objective testing 2
• Normal chest radiography does not exclude cardiac disease, particularly early heart failure or diastolic dysfunction, nor does it exclude early interstitial lung disease 2
• Sudden onset of severe chest pain or back pain with limb pulse differential suggests aortic dissection, though sensitivity of pulse differential alone is only 30% 1

When to Refer

• Specialty referral to rheumatology is indicated when systemic inflammatory disease is suspected based on elevated inflammatory markers, positive serologies, or multisystem involvement 2
• Pulmonology or cardiology referral is indicated when diagnosis remains elusive after initial workup or when advanced testing (cardiopulmonary exercise testing, right heart catheterization) is needed 2
• Consider palliative care consultation for refractory dyspnea with limited life expectancy 2, 3