Can you create a ten‑slide PowerPoint for a Zoom teaching session for medical residents that reviews an adult patient with acute symmetric polyarthritis, facial burning, jaw pain, finger swelling, markedly elevated C‑reactive protein, markedly elevated gamma‑glutamyl transferase and alanine aminotransferase, normal blood pressure, mild tachycardia, normal temperature, no prior medical history, and includes differential diagnosis, initial laboratory work‑up, and management plan?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 16, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Acute Symmetric Polyarthritis with Systemic Features: A Case-Based Teaching Presentation

Slide 1: Title & Learning Objectives

Title: Acute Symmetric Polyarthritis with Systemic Inflammation: Diagnostic Approach and Management

Learning Objectives:

  • Construct a systematic differential diagnosis for acute inflammatory polyarthritis 1
  • Identify red flags requiring urgent intervention in polyarticular presentations 2
  • Apply evidence-based laboratory and imaging workup strategies 3
  • Initiate appropriate acute management and determine referral timing 3, 2

Slide 2: Case Presentation – Chief Complaint & Timeline

Patient Profile: Adult with no prior medical history, strong family history of autoimmune disease (mother and aunts with arthritis and lupus)

Timeline of Symptom Evolution:

  • Thursday evening: Facial burning sensation, subjective fever ("warm to touch")
  • Friday: Acute onset generalized joint pain (all joints except jaw initially), pain 10/10
  • Saturday (presentation day): Jaw involvement with inability to chew, finger swelling, hand tingling, occasional eye watering, mild headaches, darker urine without dysuria 1, 2

Key Clinical Features:

  • Symmetric polyarticular involvement with rapid progression over 48 hours 3
  • Severe pain (10/10) with minimal response to paracetamol 1
  • Systemic features: fever, facial erythema, possible mild constitutional symptoms 1

Slide 3: Physical Examination Findings

Vital Signs: BP 117/81, HR 100 (mild tachycardia), RR 16, T 36.8°C (afebrile at presentation), O2 98% RA 1

Musculoskeletal Examination:

  • Swelling: Fingers bilaterally with tingling sensation 3
  • Tenderness: Right shoulder, left shoulder, right middle finger on palpation 1
  • Range of Motion: Severely limited—unable to abduct arms fully or lift overhead due to pain 1
  • Jaw: Reduced opening with pain on chewing (temporomandibular joint involvement) 1
  • Knees: No visible swelling but tingling with palpation 1

Dermatologic Findings:

  • Generalized erythema involving face, hands, legs, and back—no discrete rash observed 1

Other Systems: Normal cardiorespiratory examination, vision 20/25 bilaterally without conjunctivitis or uveitis 1

Slide 4: Laboratory Results – The Inflammatory Picture

Markedly Elevated Inflammatory Markers:

  • CRP >270 mg/L (normal <10 mg/L)—indicates severe systemic inflammation far beyond mechanical causes 3, 4
  • Hemoglobin 131 g/L (mild anemia or lower normal range) 3

Hepatic Enzyme Elevation:

  • GGT 354 U/L (markedly elevated)
  • ALT 103 U/L (elevated) 1

Clinical Significance:

  • CRP >270 predicts aggressive inflammatory disease with high risk of progressive joint damage if untreated 3
  • Hepatic involvement may suggest systemic inflammatory process (Adult-Onset Still's Disease, drug-induced, viral hepatitis) or coincidental pathology 1
  • Normal uric acid (if checked) would effectively exclude gout as primary diagnosis 3

Slide 5: Differential Diagnosis – Systematic Approach

Most Likely Diagnoses (Acute Symmetric Polyarthritis with Systemic Features):

  1. Adult-Onset Still's Disease (AOSD) 1

    • High-spiking fevers, salmon-pink evanescent rash (though not clearly described here), markedly elevated ferritin expected
    • Polyarthritis, elevated transaminases, systemic inflammation
    • Yamaguchi criteria: Fever >39°C, arthralgia >2 weeks, typical rash, WBC >10,000 with >80% granulocytes 1

  2. Seronegative Rheumatoid Arthritis 3

    • Symmetric small joint involvement (fingers), rapid onset
    • Strong family history of autoimmune disease increases pre-test probability
    • 20-30% of RA cases are seronegative 3

  3. Reactive Arthritis 2, 4

    • Acute onset following infection (though no clear infectious prodrome reported)
    • Eye involvement (watering), urogenital symptoms (darker urine)
    • HLA-B27 testing indicated if axial or entheseal features develop 3, 4

  4. Systemic Lupus Erythematosus (SLE) 3, 4

    • Strong family history (mother and aunts with lupus)
    • Facial erythema (though burning sensation atypical for malar rash)
    • Polyarthritis with systemic features, but markedly elevated CRP less typical for SLE 4

  5. Viral Arthritis (Parvovirus B19, Hepatitis B/C, EBV) 3

    • Acute polyarthritis with elevated transaminases
    • Symptoms resolving within 6 weeks favor viral etiology; persistence beyond 6 weeks suggests chronic inflammatory arthritis 3

Less Likely but Must Exclude:

  • Septic Arthritis (if single joint disproportionately affected) 2
  • Psoriatic Arthritis (examine for skin plaques, nail changes) 3, 4

Slide 6: Initial Laboratory Workup – What Was Ordered

Autoimmune Serology Panel:

  • ANA (screen for SLE and other connective tissue diseases) 3, 4
  • Rheumatoid Factor (RF) (sensitivity 60%, specificity 70% for RA) 3
  • Anti-CCP antibodies (sensitivity 60%, specificity 90% for RA—higher specificity than RF) 3
  • Complement levels (C3, C4) (low in active SLE) 4

Infectious Workup:

  • STBBI panel (hepatitis B, hepatitis C, HIV—required before any biologic therapy) 3
  • Urine GnC (gonorrhea/chlamydia—reactive arthritis consideration) 2, 4
  • ASOT (anti-streptolysin O titer—post-streptococcal reactive arthritis) 2

Additional Tests to Consider:

  • Ferritin (markedly elevated >1,000 ng/mL suggests AOSD) 1, 3
  • Complete blood count with differential (assess for leukocytosis >10,000 with >80% granulocytes in AOSD; cytopenias in SLE) 1, 3
  • Comprehensive metabolic panel (baseline renal/hepatic function before DMARD initiation) 3
  • HLA-B27 (if axial symptoms, enthesitis, or reactive arthritis suspected) 3, 4

Slide 7: Imaging Strategy – Baseline and Advanced

Baseline Imaging (Obtained at Initial Visit):

  • Bilateral hand, wrist, and foot X-rays 3
    • Assess for erosions (highly predictive for RA diagnosis and disease persistence) 3
    • Look for periarticular osteopenia, uniform joint space narrowing, marginal erosions (inflammatory) vs. osteophytes (non-inflammatory) 3

Advanced Imaging (If Diagnosis Uncertain or No Definite Synovitis on Exam):

  • Ultrasound with Power Doppler 3

    • Superior to clinical examination for detecting subclinical synovitis (75% more accurate than physical exam alone) 3
    • Detects inflammation that predicts disease progression even when clinical exam is normal 3

  • MRI with IV contrast 3

    • More sensitive than ultrasound in early disease stages 3
    • Detects bone marrow edema (osteitis)—the single best predictor of future erosive progression and functional deterioration 3
    • Flexor tenosynovitis on MRI predicts early RA (sensitivity 60%, specificity 73%) 3

Monitoring Imaging:

  • Repeat hand, wrist, and foot X-rays at 6 months and 12 months to monitor radiographic progression 3

Slide 8: Acute Management Plan – Bridging to Definitive Therapy

Immediate Pain Control (Initiated in ED/Clinic):

  • Indomethacin 50 mg PO BID for 7 days (as prescribed) 1

    • NSAIDs effective in 7-15% of inflammatory arthritis cases as monotherapy 1
    • Avoid if inflammatory bowel disease suspected 2

  • Toradol (ketorolac) provided temporary improvement with EMS 1

Bridge Therapy (If Inflammatory Arthritis Confirmed):

  • Short-term low-dose prednisone 10-20 mg daily as bridge while awaiting DMARD effect 3

    • 76-95% of patients with inflammatory arthritis respond favorably to glucocorticoids 1
    • Most patients (88-89%) require prednisone at some point in disease course 1

  • Intra-articular glucocorticoid injections for localized joint inflammation if only 1-2 joints predominantly affected 2

Critical Pitfall to Avoid:

  • Do NOT delay treatment waiting for positive serology—seronegative RA is common (20-30% of cases) and has similar prognosis to seropositive disease 3
  • Do NOT dismiss diagnosis based on normal ESR/CRP alone—40-50% of patients with active RA have normal acute phase reactants 3, 4

Slide 9: When to Escalate & Rheumatology Referral Timing

Urgent Rheumatology Referral Criteria (Within 6 Weeks of Symptom Onset):

  • Any patient with joint swelling in more than one joint—early treatment prevents irreversible joint damage 3, 4
  • Morning stiffness >30 minutes with symmetric small joint involvement 3
  • Positive "squeeze test" of MCPs/MTPs indicating clinical synovitis 3
  • Symptoms persisting beyond 6 weeks with continued elevated inflammatory markers 2

Poor Prognostic Features Requiring Aggressive Management:

  • RF or anti-CCP positivity (predicts more aggressive disease and erosive progression) 3
  • Polyarticular involvement of small joints (hands and feet—predicts persistence) 3
  • Erosions on baseline radiographs (highly predictive for aggressive disease) 3
  • Markedly elevated CRP (predicts severe disease with high risk of progressive joint erosions) 3

First-Line DMARD Therapy (If RA Confirmed):

  • Methotrexate 15 mg weekly as first-line DMARD, escalate to 20-25 mg weekly 3
  • Target: Remission (SDAI ≤3.3) or low disease activity (SDAI ≤11) 3
  • If inadequate response after 3 months: consider triple DMARD therapy or adding biologic agent (TNF inhibitor) 3

Monitoring Strategy:

  • Reassess disease activity every 4-6 weeks using SDAI or CDAI 3
  • Repeat inflammatory markers (CRP, ESR) at each visit 3
  • Repeat X-rays at 6 and 12 months to monitor radiographic progression 3

Slide 10: Key Teaching Points & Clinical Pearls

Diagnostic Approach to Acute Polyarthritis:

  1. Exclude septic arthritis first—perform arthrocentesis urgently if any single joint is disproportionately affected 2
  2. Construct differential diagnosis systematically—consider autoimmune, infectious, malignancy, crystal arthropathy, and viral etiologies 1, 2
  3. Prioritize clinical synovitis over serology—definite soft tissue swelling around joints is the cornerstone of inflammatory arthritis diagnosis 3

Laboratory Interpretation Pitfalls:

  • Seronegative RA accounts for 20-30% of cases—negative RF does not exclude RA 3
  • Normal ESR/CRP does not exclude inflammatory arthritis—acute phase reactants are poor predictors and can be normal even in active disease 3, 4
  • CRP >270 mg/L indicates severe systemic inflammation—far beyond what would be expected in non-inflammatory conditions like osteoarthritis 3

Management Principles:

  • Early treatment prevents irreversible joint damage—refer to rheumatology within 6 weeks of symptom onset 3, 4
  • Most patients require glucocorticoids—76-95% respond favorably, but 88-89% need prednisone at some point 1
  • Target remission or low disease activity—use composite disease activity measures (SDAI, CDAI) to guide treatment decisions 3

Family History Significance:

  • Strong family history of autoimmune disease (mother and aunts with arthritis and lupus) increases pre-test probability of RA and SLE 3, 4
  • RF positivity occurs in ~15% of first-degree relatives of RA patients—at-risk population for future RA development 3

References cited throughout: 1, 3, 2, 4

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Seronegative Symmetric Polyarthritis with Elevated Inflammatory Markers

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Rheumatoid Arthritis Diagnosis and Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Differential Diagnoses for Arthritis with Elevated CRP and Hair Loss

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Related Questions

What is the approach to differential diagnosis per body system in a patient?
What is the diagnosis and treatment plan for a 50-year-old female patient presenting with neck pain, chest pain, abdominal pain, leg cramps, giddiness, and headache for the past 6 months?
What is the diagnosis and treatment for a 23-year-old female student with a 3-month history of bright red blood and mucus in stool, abdominal pain, cramping, diarrhea, and a history of recurrent mouth sores, sensitive stomach, and elevated liver enzymes, who has tried eliminating potential triggers without improvement?
What is the diagnosis and management for a 41-year-old female with throbbing pain under the left rib cage and left chest/breast, accompanied by swollen left axilla (axillary) lymph nodes for over six months?
What is the diagnosis and treatment for a 41-year-old female with fatigue, cold sensitivity, thrombosed hemorrhoids, varicose veins, anxiety disorder, ridged fingernails, and darkening around the eyes?
Can hemifacial microsomia of the orbit or face be undetected on magnetic resonance imaging (MRI)?
In an unresponsive patient with a left ventricular assist device (LVAD), what is the appropriate initial management?
What cough suppressant is safe for an otherwise healthy 11‑year‑old child weighing 58 kg?
How should I evaluate and manage post‑prandial hyperglycemia in a diabetic patient?
What do you recommend for a patient with type 2 diabetes on metformin 500 mg twice daily whose hemoglobin A1c improved to 7.3% but remains above goal, hyperlipidemia on rosuvastatin 20 mg daily with LDL 142 mg/dL, total cholesterol 229 mg/dL, triglycerides 181 mg/dL, mild hypercalcemia (serum calcium 10.6 mg/dL), elevated red cell distribution width (RDW 17.8%) with normal hemoglobin, urinalysis showing cloudy urine with 2+ leukocyte esterase but no bacteriuria, and otherwise normal kidney function (estimated glomerular filtration rate 98 mL/min/1.73 m²), thyroid function, liver enzymes, and urine albumin‑to‑creatinine ratio (14 mg/g)?
What is the recommended intravenous furosemide (Lasix) dosing and thiazide diuretic addition for an adult with acute volume overload such as pulmonary edema or decompensated heart failure?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question