Approach to Arthritis

Sabrina Fallavollita

Outline
Inflammation
The Rheumatologic History
Sinovial Fluid Analysis
Rheumatologic Antibodies
Approach to Acute Monoarthritis
Septic Arthritis
Crystal Arthropathies
Approach to Polyarthritis
OA
RA
Approach to SLE
Approach to Seronegative Arthropathies
Approach to Chronic Pain Disorders

Epidemiology

The Rheumatologic History

Sinovial Fluid Analysis

Approach To Monoarthritis

CAUSES: SINGL JOINT

Septic Arthritis

Bacterial arthritis
Fungal arthritis
Parasitic arthritis
Internal derangement or
trauma
Meniscus Injury
Ligament tears
Neuropathy (Charcot's
Joint)
Gout, Pseudogout and
other crystal-induced
arthritis
Lyme Disease

Juvenile or adult Rheumatoid

Arthritis
Osteitis Deformans (Paget's
Disease)
Osteoarthritis
Osteomyelitis
Ischemia or infection
Ischemic bone (avascular
necrosis)
Acute Retroviral Syndrome
(initial HIV Presentation)
Neoplasms
Osteoid Osteoma
Villonodular synovitis
Trauma
Overuse injury
Fractures
Hemarthrosis

Septic Arthritis

Septic Arthritis: Risk Factors

Prosthetic hip joint

Prosthetic knee joint
Skin Infection
Joint surgery
Rheumatoid Arthritis
Elderly patients over age 80 years old
Diabetes Mellitus
Intravenous drug use (unusual joints affected)
Large vein catheterization (unusual joints
affected

Signs and Symptoms

Rapid onset monoarticular joint inflammation

Joint Pain

Joint swelling

Joint warmth and erythema

Significantly decreased joint range of motion

Limb paralysis from inflammatory neuritis

Joints affected in bacterial infection

Septic Knee (50% of cases)

Septic Hip (especially in young children)

Septic Ankle

Septic Shoulder
Joints affected with intravenous Drug Abuse

Sacroiliac joint

Sternoclavicular joint

Symphysis pubis

Vertebral disc spaces

Causes
Young sexually active adults

Neisseria gonorrhoeae (most common)

More common in women by a factor 3-4
Staphylococcus aureus
Streptococcus
Older adults
Staphylococcus aureus (50%)
Streptococcus species
Gram Negative Bacilli

Sinovial Fluid Analysis

Bacterial arthritis

Opaque to turbid Synovial Fluid

Synovial Fluid WBC: >50,000 (>90% PMNs)
Gram Stain positive in 50% of cases
Culture positive in 30-50% (75% polyarticular)
Gonococcal Arthritis
Clear to opaque Synovial Fluid
Synovial Fluid WBC: 30,000 to 100,000 (>80% PMNs)
Gram Stain positive in <25% of cases
Culture positive in <50% of cases
Tuberculous Arthritis
Opaque Synovial Fluid
Synovial Fluid WBC: 10,000 to 20,000 (>50% PMNs)
Gram Stain positive in <20% of cases
Culture positive in 80% of cases

Crystal Arthropathies

Gout: Uric Acid Crystals Risk Factors

Obesity
Diabetes Mellitus
Hyperlipidemia
Hypertension
Atherosclerosis
Alcohol use
Thiazide Diuretics
Renal insufficiency
Myeloproliferative disease

Signs And Symptoms

Acute onset of lower extremity joint pain

First Metatarsophalangeal joint (great toe)

Involved most commonly

Affected in 50% of first gout attacks

Excruciating, crushing type pain

Wakens patient from sleep

Unable to bear weight
Chills
Fever as high as 104 F (40 C)
Joint Inflammation
Erythema, tenderness and swelling at affected joint

Pain extends well beyond joint

Entire foot involved in some cases

Asymmetric joint involvement

May only involve one side with the first attack

Skin over joint is tense and shiny

Gout
Sinovial Fluid
Polarizing Microscopy
Negatively birefringent
Needle shaped Uric
Acid crystals
Gram Stain and Culture
Rule out Septic Arthritis

Treatment
Indomethacin

Start: 50mg PO tid for 2-3 days

Then: 25mg PO tid for 4-10 days
Colchicine
Use as an alternative agent due to GI toxicity
Systemic Corticosteroids
Effective alternative to NSAIDs (less risk of ulcer)
Dose
Oral: Prednisone 30 mg PO qd taper off over 1 week
IV: Methylprednisolone 40 mg (NPO in hospital)
IM: Triamcinolone 40 mg IM
Intra-articular Corticosteroid
Large joints and refractory cases to other treatment
Rule-out Septic Arthritis first

Polyarthritis

Polyarthritis
Acute Polyarthritis (inflammation in more

than 4 joints)
Viral (MMR, Parvovirus, enterovirus)
Borrelia burgdorferi
Chronic Polyarthritis: Symptoms of joint
pain and swelling lasting >6 weeks
<50: RA, SLE, psoriatic arthritis, other
spondyloarthropathies
>50: MOSS (mature onset seronegative
spondyloarthropathy) and Crystal induced

Osteoarthritis

Osteoarthritis
Most common form of arthritis
Associated functional Impairment

increases with age

Prevalence directly increases with age
Age over 40 years: 70% of U.S.
population
Age over 65 years: 80% of U.S.
population

Pathophysiology
Primary lesion resides in the articular cartilage
Abnormal cartilage repair and remodeling
Chondrocytes produce proteolytic enzymes
Proteolytic enzymes destroy cartilage
End result
Asymmetric joint cartilage loss
Subchondral sclerosis (bone density increased)
Subchondral cysts
Marginal osteophytes

Signs

Morning stiffness of short duration (<30 minutes)

Pain on motion that worsens with increasing joint
usage
Slowly progressive deformity and possibly pain
Initial high-use joint pain relieved with rest
Next, pain is constant on affected joint usage
Eventually pain occurs at rest and at night
No systemic manifestations
No Fatigue
No generalized weakness
Associated muscle spasm, contractures and
atrophy
Symptoms uncommon before age 40

Distribution of Osteoarthritis

Joints spared

Wrist spared

Metacarpal-phalangeal
joints spared (except
thumb)

Elbow spared

Ankle spared
Joints commonly involved
Knee , Hip Foot Osteoarthritis
hand

Distal interphalangeal
joints (Heberden's
Nodes)

Proximal interphalangeal
joints (Bouchard's
Nodes)

First carpometacarpal
joint (thumb)
Cervical and lumbar spine

Pharmacologic Treatment
Acetaminophen 1 gram PO qid
NSAIDs (cautious use in the elderly)
Avoid Feldene - higher risk of GI toxicity
Be cautious due to CNS effects (esp.
Indomethacin
Intra-articular Corticosteroid injection
Avoid more than 3-4 times per year
Sodium hyaluronate (Synvisc) in Knee
Osteoarthritis
Topical Capsaicin cream for refractory joint pain

Rheumatoid Arthritis

Rheumatoid Arthritis
Affects all ethnic groups
Peak incidence 4-6 th decades
Most widely used criteria ACR
Diagnosis is based on the clinical

criterion and can not be made until

symptoms present for several weeks
+ve RF supports Diagnosis (30% have
normal RF)

Distribution of Rheumatoid Arthritis

Affects small and

medium sized joints

Typical patient has
symmetrical
inflammation in the
wrists and/or MCP
joints
Spares DIP
Morning stiffness,
inactivity stiffness

ACR Rheumatoid Arthritis Criterion

Need to have 4 of 7
Morning Stiffness

In and around joints lasting 1hr to max improvement

Arthritis of 3 or more joint areas
as witnessed by a physician
Arthritis of the Hands
In wrist MCP or PIP
Symmetric Arthritis
Rheumatoid Nodules:
over bony prominences, extensor surfaces, juxtaarticular regions
Serum RF
Radiographic changes: on hand and wrist Xray

Treatment

Systemic Lupus Erythematosus

 Immune complex deposition disease,

involving many organs

Female:Male 10:1
ANA and other criterion will make the
diagnosis
Named in 1851 for wolf (lupus) bitelike facial rash

Epidemiology/ Etiology

Prevalence

U.S.: 40 to 50 per 100,000

persons

England: 200 per 100,000

women aged 18 to 65 years
Over-diagnosed in United States

Of 2 million U.S. cases, only

25% have true disease
Age distribution: Young adults
with onset under age 60
More common in women by ratio
of 9:1
Ethnic predisposition

Native American

African American

Hispanic

Chinese

Filipino

Etiology
Idiopathic
Drug Induced
Procainamide
Isoniazid
Hydralazine
Minocycline
Phenytoin
Ethosuximide
D-Penicillamine

Criterion For Diagnosis of SLE

Need 4 out of 11 to make the
diagnosis

Malar Rash :Rash spares nasolabial folds

Discoid Rash
Photosensitivity
Oral Ulcers: Painless observed by physician
Arthritis: Nonserosive 2 or > joints
Serositis: Pleuritis, Pericarditis
Renal Disorder: Proteinuria > o.5g/day or casts
Neurologic Disorder: seizures/ psychosis
Hematologic Disorder: Hemolysis, Leukopenia<4,
Lymphopenia, Thrombocytopenia <100
ANA
Immunologic disorder: Anti-DNA, Anti-Sm, APS

Management
Reevaluate every 3-6 months
Employ measures to relieve Fatigue
Sunscreen and other protection due to

photosensitivity
Reduce risk of infection (e.g.
Immunizations)
Birth Control is critical during
exacerbations

Spondyloarthropathies

Clinical Features: Common to every

spondyloarthropathy
Inflammatory back pain
Dactylitis

Inflammation of entire digit

Enthesitis
Inflammation of tendon and ligament bony
attachments
Common areas of involvement
Achilles tendon insertion (calcaneus)
Platar fascia insertion (calcaneus)
Patellar tendon insertion (tibial tubercle)
Patella margin (superior and inferior)
Metatarsal heads
Spinal ligament insertion (vertebral body)

Distribution of Spondyloarthritis

Psoriatic, reactive arthritis,

Ankylosing spondylosis, IBD
Assymetric arthritis involving
the axial spine and joints of
the lower limb
Soft tissues are involved
aswell as the joints
Bursitis, enthesitis, achilles
tendonitis, epichondylitis,
plantar fasciitis
No diagnostic lab tests (HLA
B 27)
These Patients respond well
to NSAIDS

Criteria for the Diagnosis of

spondyloarthropathies

Inflammatory Spinal Pain (onset before 45, insidious,

improved with exercise, AM stiffness, 3 months)
OR
Synovitis: Assymetric or in lower limb
AND one or more of following
Positive Family History
Psoriasis
IBD
Urethritis, cervicitis, or acute diarrhea
Buttock pain alternating between right and left gluteal
area
Sacroileitis

Fibromyalgia

Epidemiology
Women account for 75% of fibromyalgia
patients
Peak Incidence: ages 20 to 60 years old
Most common rheumatic cause of chronic
diffuse pain
Incidence
Rheumatology patients: 15%
General medical patients: 5%
General population: 2%

Distribution of Fibromyalgia
( 11/18 tender points)

Widespread musculoskeletal pain ("I

hurt all over")
Regional: Each of 4 body quadrants
involved

Pain on left and right side of

body

Pain above and below waist

Axial skeleton pain present

Cervical spine

Anterior chest

Thoracic spine

Low back
Pain worse in the morning and at the
end of the day
Symptoms persist at least 3 months

Associated Conditions

Severe Fatigue (81%)

Morning stiffness longer
than 15 minutes (77%)
Sleep Disorder (75%)

Non-restorative sleep
(alpha-delta sleep)

Sleep Apnea

Nocturnal myoclonus

Restless Leg
Syndrome
Atypical Paresthesias
(63%)
Anxiety (48%)

Dry Mouth (36%)

Recurrent Headaches (53%)
Dysmenorrhea (41%)
Past History of Major
Depression (31%)
Irritable Bowel Syndrome
(30%)
Urinary urgency (26%)
Cold sensitivity or Raynaud's
Phenomenon (17%)
Reduced functional ability
Aerobic deconditioning

Rheumatology Lab Tests

Rheumatology Lab Tests

ESR
Acute phase reactants (fibrinogen, Igs) Interact with RBCs
causing the cells to stick in stacks (rouleaux) --> sediment
more rapidly in column of blood
Elevated: Inflammatory process, crude marker of
inflammation
CRP
Synthesized in liver promptly after tissue injury.
Levels increase as early as 4-6hrs post injury, peak 24-72
hrs, and return to N w/in 1 week.
Synthesis depends on cocentration of inflammatory
mediators reaching the liver Therefore N level not =
abscense of inflammation
More timely indicator of diisease activity than ESR

Rheumatoid Factor
Ig that binds to the constant portion of

IgG. IgM isotype most easily detected in

serum
Latex Fixation Test. Positive >1/20
1-2% healthy people have serum RF,
75% RA patients aswell

Anti Nuclear Antibodies

Autoantibodies that react with a variety of nuclear

antigens, nucleic acids, histones, centromere
Homogeneus: SLE, Drug effect
Speckled: MCTD, SLE, Sjogrens, Myositis,
Infection, Neoplasm
Nucleolar: Scleroderma
Peripheral (Rim): SLE
Centromere: CREST
Senstitive Markers for SLE > 95% of patients
Also in 5% of healthy people
Specificity low Pattern determination subjective

Anti Neutrophilic Cytoplasmic

Antibodies
Autoantibodies directed against primary granule
components of neutrophils and monocytes
C-ANCA:
cytoplasmic against the antigen serine
protease 3 PR3
Best with active widespread Wegners
P-ANCA:
perinuclear against the antigen
myeloperoxidase MPO
Microscopic polyangitis, but also other
vasculitis IBD ID#s and medications

Complement
30 blood proteins that serve as

mediators and amplifiers of

inflammatory response
Decreases--> Increased utilisation
during active immune complex
disease (SLE, Endocarditis, Post strep
GN)
Defficiencies --> Increased risk of
Neisserial infections

Cryoglobulins
Igs that precipitate when serum <4C
Type I --> monoclonal IgM,

Lymphoproliferative disease
Type II--> monoclonal IgG,
Type III --> polyclonal
Type II + III --> chronic infection Hep
C, vasculitis, Infectious Diseases

Extractable Nuclear Antigens

Anti-dsDNA: Abs to double stranded DNA, specific for SLE

Anti-Histone: SLE, Drug induced lupus
Anti-ENA: Extractable Nuclear Antigens Smith + RNP: SLE
MCTD
Anti SS-A/Ro: Ribonucleoprotein, Subascute subcutaneous
lupus, neonatal lupus, Sjogrens
Anti SS-B/La: Ribonuclear proteins, Sjogren"s, SLE
Anti-Centromere: CREST
Anti-Scl 70: Ab to topoisomerase I, diffuse scleroderma
Anti-Jo 1: Ab to Transfer RNA synthase,
Poly/dermatomyositis
Anti-PM-SCL: Ab to nucleolar granular component,
Polymyositis/scleroderma overlap
Anti-Mi-2: Dermatomyositis

Questions?