Approach patient with ARTHRITIS

DR. MOHAMMED O. AL-RUKBAN Assistant Professor Department of Family and Community Medicine College of Medicine King Saud University

Normal Joint..

Introduction..
Causes include various self-limited illness and disabling and lifethreatening. Is it Arthritis or Arthralgia? Musculoskeletal emergencies (infection, sepsis, compartment syndrome).

Arthralgia..
Fibromyalgia Bursitis Tendinitis Hypothyroidism Neuropathic pain Metabolic bone disease Depression

Monoarthritis..

Trauma Infection:

DGI Skin lesion. Nongonococcal bacterial infections: large joints. Mycobacterial and fungal infection.
Monosodium Urate crystals (MPJ) Ca pyrophosphate dihydrate crystals (knee)

Crystal induced arthritis

Lyme disease Systemic Rheumatoid diseases:

Seronegative spodyloarthropathy (Reactive arthritis, psoriatic arthritis, Inflammatory BD..) Sarcoid periarthritis RA

Osteoarthritis

Polyarthritis..
Rheumatoid Arthritis Systemic lupus Erythrematosus Viral arthritis Reiters disease Psoriatic arthritis Reactive arthritis

Migratory Arthritis..

Differential diagnosis:
Rheumatic

fever Gonococcemia Meningococcemia Viral Arthritis SLE Acute Leukemia

Rheumatic Fever..

Majer Criteria:
1- Carditis 2- Polyarthritis 3- Chorea 4- Erythema Marginatum 5- Subcutaneous nodules

Minor criteria:
1- Arthralgia (ESR, CRP). 2- Ferver 3- Acute phase reactant

4- Prolong PR interval 5- Evidence of group A streotococcal infection (AST, Throat culture)

History.. Age
<30= SLE, Ankylosis spodylitis, Reactive Arthritis. 30-50= RA, Systemic sclerosis, Gout. >50= OA, Pseudogout, PMR Any Age group= Psoriatic arthritis, Enteropathic arthritis

History.. Sex
>Female: SLE, RA, OA, Systemic sclerosis, Ankylosis spodylitis, PMR. Male=Female: Psoriatic arthritis, Enteropathic arthritis Pseudogout. >Male: Gout, Reactive Arthritis.

History.. Sx

Site:

Symmetrical= RA, SLE, Systemic sclerosis Asymmetrical=OA Large joints=OA DIP= OA, Psoriatic arthritis MCP, PIP= RA, SLE 1st MTP= Gout, OA Spine= OA, Ankylosis spodylitis, Psoriatic arthritis, Reactive arthritis Shoulder= PMR

History.. Sx

Pain character:

Aggravated by motion= Mechanical Relieved by motion= Inflammatory.

<6 wks= viral arthritis, systemic rheumatic diseases >6 wks=systemic rheumatic diseases

Duration:

Associated Sx:

Morning stiffness: >1hr= RA, PMR, Inflammatory >30 min= OA

History.. Sx

Associated Sx:

Multi-system involvement= Systemic rheumatic diseases.

Trauma, fracture, surgical procedures

Past Medical history:

Medication list:
Drug induced lupus. Diuretics.

Phy. Examination..

Joint:
Soft tissue swelling, warm, effusion= Inflammation. Inflammation signs extended= septic arthritis, crystal induced arthritis, fracture. Passive motion (N), active()= bursitis, tendinitis, muscle injury. Passive motion (), active()= Synovitis

Phy. Examination..

General Examination:

LAP, parotid enlargement, oral ulceration, heart murmurs, pericardial or pleural friction rubs, crackle= systemic disease. Fever= infection, reactive arthritis, RA, SLE, Crystal induced arthritis Subcutaneous nodules= RA, RHD, Gout (tophi) Skin manifestations= psoriasis, RA, SLE Eye disease (keratoconjunctivitis sicca, uveitis. Conjunctivitis, episcleritis)

Laboratory Studies..
Can be misleading. Basic: CBC, Urinalysis, U&E, LFT. Acute phase reactant: ESR, CRP. Antibody tests:

ANA= SLE Anti-dsDNA= SLE Anti-native DNA, anti-Sm= SLE RF= RA Anti-CCP antibody=RA

Rheumatoid Factor..

Rheumatoid Arthritis Connective tissue diseases Viral infection Leishmaniasis Leprosy Tuberculosis Sarcoidosis Liver diseases Subacute bacterial endocarditis

Laboratory Studies..
Uric acid concentration= Gout Synovial fluid analysis= infection, crystal induced arthritis, inflammatory.. Hepatitis B and C Parvovirus serology

Imaging Studies..

X-ray:
RA Chronic Gout OA Ankylosing spondylosis.

MRI:

Ankylosing spondylosis.

Rheumatoid Arthritis..

Epidemiology :

The world wide incidence of RA is approximately 3 cases per 10,000 population and the prevalence rate is approximately 1%

Rheumatoid Arthritis..

History..
Malaise fever fatigue weight loss myalgias difficulty performing activities of daily living

Examination..

Joint affected

swelling tenderness warmth decreased range of motion

Atrophy of the interosseous muscles deformities

Diagnosis..

Morning stiffness Arthritis of 3 or more joint areas Arthritis of hand joints of at least one area swollen in a wrist, MCP, or PIP joint Symmetric arthritis Rheumatoid nodules Serum RF Radiographic changes typical of RA

Deformities..

Extra-articular manifestations..

Rheumatoid nodule Cardiovascular Pulmonary GI & Renal Hematological Skin Vasculitis Neurological Ocular

Progression of RA..

Stage 1:
- no destructive changes. - Osteoporosis.

Stage 2:
- periarticular osteoporosis w/wo slight subchondral bone destruction. - joint mobility limit but no destruction. - adjacent muscle atrophy. - extra-articular soft tissue lesions.

Progression of RA..

Stage 3
- cartilage and bone destruction in addition to periarticular osteoporosis. - joint deformity w/wo fibrous or bony ankylosis. - extensive muscle atrophy. - extra-articular soft tissue lesions.

Stage 4
- criteria of stage 3. - fibrous or bony ankylosis.

Laboratory ..

Hematologic parameters
Anaemia Thrombocytosis Serum iron & IBC Serum globuline ALP Acute phase reactant

Immunological parameters Synovial fluid analysis

Prognosis..
40 % of patient become disabled after 10 years. Persistent active cases more than 1 year likely to lead to joint deformities. Periods of activity cases have better prognosis. Mortality rate 2.5 times than general population

Systemic Lupus Erythrematosis

Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis Renal disease (proteinuria, cellular cast) Neurologic disease (seizure, psychosis) Hematologic disease Immunologic abnormalities ANA

Summary..

Use of time. In one study: 60% of patients with early synovitis diagnosed as:

Rheumatoid Arthritis. Spondyloarthropathy.

20% had a self limited arthritis. 20% unclassifiable with good prognosis. In another study: 36% unclassifiable When to refer?