Approach to case of arthritis
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APPROACH TO ARTHRITISGuide:Dr.Sanjay Dubey
Canditate:Dr.Sarath Menon.R DEPT.MEDICINE,RHEUMATOLOGY DIVISION,
MGM MEDICAL COLLEGE ,INDORE.
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OUTLINE
Rheumatological history and clinical examination
Inflammatory /non-inflammatory arthritis Mono/ Oligo arthritis Polyarthritis Soft tissue rheumatism Lab investigations Synovial fluid analysis Imaging
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EVALUATION OF A PATIENT WITH ARTHRITIS IN RHEUMATOLOGY OPD
Articular or non articular Inflammatory or non inflammatory Acute or chronic Monoarticular or polyarticular Extra articular signs
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ARTICULAR
- Deep or diffuse pain.- Painful or limited range of
movemnt - both active and passive
- Swelling of joint- Crepitation.- Joint instability.- Locking of joint.- Deformity.
NONARTICLAR
- localised pain- Point or local tenderness - Painful active movements
but not on passive - Physical findings are
remote from joint capsule.- swelling,crepitation,joint
instability, deformity are rare.
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ARTHRITIS
Cardinal signs Systemic symptoms Stiffness- >1 hr - prolon.
rest Lab evidences ESR CRP
NO signs Stiffness-<60 mnt -
intermittent -brief rest Trauma,rept.use, Degenerative,tumor
inflammatory Non- inflammatory
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THE RHEUMATOLOGIC HISTORY h/o presenting complaints - Onset - progression - distribution of disease - stiffness - aggravating or relieving factor - diurnal variation - other systemic feature
- functional disability
General systematic medical history. Past medical and surgical history. Family history. Drug history.
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RHEUMATIC DISEASE SIGNS
Swelling Posture of joint Deformity Warmth Redness Tenderness Limitation of joint movement Crepitus Stability Function
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EXTRA ARTICULAR SIGNS & SYMPTOMS
Constitutional symptoms Skin rashes Mucous membrane lesions Ocular Nails Raynauds Serositis
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CHRONOLOGY OF COMPLAINTSA. ONSET- acute- < 6 wks eg.infectious arthritis crystal arthropathy reactive arthritis.
Chronic - >6 wks eg. Non inflamatory arthritis (OA)
Inflammatory arthritis(RA)
Fibromyalgia.
B. EVOLUTION – chronic eg.OA intermittent eg. Crystal / lymes
arthritis
migratory arthritis eg.Rheumaticfever, Gonococcal, viral
arthritis
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CHRONOLOGY OF COMPLAINTS
C. Extent of articular involvement
- Monoarticular (one joint involved)
- Oligo or pauciarticular (two or three joint)
- Polyarticular (> 3 joints)
D. Distribution of joint involvement -symmetrical- upper and lower limb eg. RA,
SLE
-Asymmetrical-eg. psoriatic arthritis,
spondyloarthropathy,
gout
-Involvement of axial skeletal-eg AS, OA,
RA(only cervical spine)
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History and physical examination
Is it articularTrauma/fractureSoft tissue rheumatism
no
> 6 weeks
yes
Chronic
yes
Acute Infectious arthritris
Crystal inducedReactive arthritis
No
Signs of inflammation
Chronic noninflamatory
arthritis
DIP, CMC1,Hip ,Kne
e joint
osteoarthritis
yes
Osteonecrosis
Charcots joint
no
yesChronic
inflammatory arthritis
Joints involved
1-3
Psoriatic Pauci JA
symmetrical
>3
Psoriatic Reactive
no
yes PCP,MCP/
MTP
yes
Rheumatoid
no
SLE/Scleroderma
no
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CAUSES:MONO/ OLIGO ARTHRITIS
• Septic Arthritis–Bacteria,fungal,parasitic arthritis
• Internal derangement or trauma –Meniscus Injury –Ligament tears - hemarthrosis crystal-induced arthritis Charcot joint Psoariatic arthritis Juvenile Rheumatoid Arthritis(pauci articular) Mono art.presentation of c/c arthritis Ischemic bone (avascular necrosis Neoplasms –Villonodularsynovitis
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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).
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CAUSES OF SEPTIC ARTHRITIS
Young sexually active adults –Neisseria gonorrhoeae (most common)
More common in women –Staphylococcus aureus–Streptococcus
Older adults –Staphylococcus aureus(50%) –Streptococcus species
-Gram Negative Bacilli
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SIGNS AND SYMPTOMS Rapid onset monoarticular joint inflammation
Joints affected in bacterial infection –Septic Knee (50% of cases),hip (children),
ankle, - shoulder
Joints affected with intravenous Drug Abuse –SI joint, SC joint.pubic symphysis,vertebral
spaces
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GOUT: URIC ACID CRYSTALS RISK FACTOR
-Obesity -Diabetes Mellitus -Hyperlipidemia -Hypertension -Atherosclerosis -Alcohol use -Thiazide Diuretics -Renal insufficiency -Myeloproliferativedisease
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GOUT :SIGN AND SYMPTOMS
•Acute onset of lower extremity joint pain –First Metatarsophalangeal joint (great toe)
- Affected in 50% of first gout attacks
•Fever and chills
•Joint Inflammation - Asymmetric joint involvement - May only involve one side with the first attack
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GOUTY ARTHRITIS
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GOUT
SynovialFluid
•Polarizing Microscopy
•Negatively birefringent Needle shaped Uric Acid crystals
• Gram Stain and Culture •Rule out Septic Arthritis
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POLYARTHRITIS
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POLYARTHRITIS
Acute Polyarthritis - < 6 wks
- Viral - Borrelia burgdorferi
Chronic Polyarthritis: - >6 weeks
<60yrs age : RA, SLE, psoriatic arthritis, spondyloarthropathies
>60yrs age : crystal induced, OA
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OSTEOARTHRITIS
• Most common form of arthritis.
• Associated functional.
• Impairment increases with age. • Prevalence directly increases with age
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PATHOPHYSIOLOGY
Primary lesion resides in the articular cartilage –Abnormal cartilage repair and remodeling –Chondrocytes proteolytic enzymes
destroy cartilage
subchondral subchondral
sclerosis cysts Marginal osteophytes
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OSTEOARTHRITIS
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SIGN AND SYMPTOMS• Pain on motion that worsens with increasing joint
usage • • Slowly progressive deformity and possibly pain
• No systemic manifestations
Associated muscle spasm, contractures and
atrophy
Symptoms uncommon before age 40 • Morning stiffness of short duration (<30 minutes)
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DISTRIBUTION OF OSTEOARTHRITIS
• Joints spared –Wrist –Metacarpal-phalangeal (except thumb) –Elbow –Ankle
• Joints commonly involved • knee • hip• foot • hand –DIP (Heberden'sNodes)
–PIP (Bouchard's Nodes) –First CMC jt(thumb) •Cervical and lumbar spine
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RHEUMATOID ARTHRITIS
Affects all ethnic groups Peak incidence 4-6th decades Most widely used criteria ACR Diagnosis is based on the clinical criterion
and cant be made until symptoms present for several
weeks
positive RF supports Diagnosis (20% are seronegative)
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ACR RHEUMATOID ARTHRITIS CRITERIA NEED TO HAVE 4 OF 7
1. Morning stiffness:-in and around the joint lasting 1 hr before maximal improvement.
2. Arthritis of 3 or more joint area observed by the physician. 14 possible joint
area involved are rt < PIP,MCP, wrist, elbow, knee, ankle and MTP joint.
3. Arthritis of hand joints- wrist,mcp &pip joint.
4. Symmetrical arthritis.
5. Rheumatoid nodule.
6. Serum Rheumatoid factor.
7. Radiographic changes – erosion or bony decalcification in or adjacent to involved joints.
Criteria 1 to 5 must be present for at least 6 wksCriteria 2 to 5 must be observed by physician
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GUIDELINES FOR CLASSIFICATION
1. Four of the seven criteri are required to classify a pts is having RA.
2. Pts with two or more clinical diagnoses are not excluded.
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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
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DEFORMITIES Z deformity
Swan neck deformity
Boutonniere deformity
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DEFORMITY- RA
Swan neck deformity
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Z - deformity Subcutaneous nodules
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SYSTEMIC ERYTHEMATOSUS LUPUS
Immune complex deposition disease, involving
many organs
Female:Male 10:1
ANA and other criterion will make the diagnosis
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CRITERION FOR DIAGNOSIS OF SLE NEED 4 OUT OF 11 TO MAKE THE DIAGNOSIS
MalarRash :Rash spares nasolabialfolds 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 HematologicDisorder: Hemolysis, Leukopenia<4000, Lymphopenia <1500,Thrombocytopenia <100000 ANA Immunologic disorder: Anti-DNA, Anti-Sm, APS
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SLE- NON EROSIVE ARTHRITIS
Intermittent polyarthritis
Soft tissue & muscle involv.
Myositis,tendonitis Hand,wrist,knee
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SERONEGATIVE SPONDOARTHROPATHIES
Psoriatic arthritis Reactive arthritis Enteropathic arthritis Ankylosing sponylosis
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FEATURES OF SPONDOARTHROPATHIES
Absence of RA Factor,subcut nodules Sacroiliatis/spondylitis + Assymetric peripheral joints Extra articular- ocular,oral,skin,enthesitis Familial aggregation HLA-B27 +
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DISTRIBUTION OF SPONDOARTHROPATHIES
r
Assymetric arthritis Axial spine & lower
limb joints Soft tissues
involvmnt Bursitis,achilles
tendonitis,epichondylitis,plantar fascitis
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PSORIATIC ARTHRITIS
Psoriasis precedes in 60-70% Wright & Molls 5 patterns of arthropathy Nail changes in 90% INVOLVEMENT OF DIP joints Dactylitis,enthesitis,tenosynovitis Arthritis mutilans
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PSORIATIC ARTHRITIS
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REACTIVE ARTHRITIS
Acute ,painful,assymetric Knee,ankle ,ST,MT ,IP joints Dactylitis Constitutional symptoms Tendonitis,enthesitis,fascitis Ocular,muco-cutaneous lesions
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ANKYLOSING SPONDYLITIS
Sacroiliatis Syndesmophytes Bamboo spine Inflamm. Backache Age<50 Improves with
exercise not with rest
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ENTEROPATHIC ARTHRITIS
Ankylosing spondylitis Peripheral arthritis-acute oligo & chronic
polyarthritis Joint invl same in UC &CD Erosion and deformity rare
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SOFT TISSUE RHEUMATISM
Most common cause of MSK pain Enthesopathy,bursitis,tedonitis,tenosynovitis Mostly associated with fibromyalgia Improves with local steriod inj.
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SOFT TISSUE RHEUMATISM
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LAB INVESTIGATIONS
Routine blood tests ESR,CRP Rheumatoid factor,CCP ANA Autoimmune antibodies Complement levels
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SYNOVIAL FLUID EXAMINATION
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INTERPRETATION OF SYNOVIAL FLUID EXAMINATIONStrongly consider synovial fluid examination if
MonoarthritisTrauma with joint effusion
Mono arthritis in a pt. with chronic arthritisSuspicion of joint infection,crystal induced arthritis,heamarthrosi
AppearanceViscocity
WBC countCrystal identification
Gram stain,culture if neded
Is the effusion is hemorrhagic?
Inflammatory or non inflammatory
articular condition
Is wbc . 2000/ μl ?
Conside
r noninflamm
. Conditio
nOsteoarthrit
isTraumaOther
Conside
r inflamm. Or septic
arthritis
is the % PMNs.75% ?
Consider noninflamm articular conditionsOsteoarthrutisTraumaother
Are crystals present?
Consider other inflamm. Or septic arthritides.gram stain ,culture
Is WBC .50000/μl ?
Probable inflamm arthritis
Possible septic arthritis
Crystal identification for specific diagnosisGout or pseudogout
ConsiderTrauma or
mechanical derangementCoagulopathyNeuropathic arthropathy
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DIAGNOSTIC IMAGING
Plain X-ray Ultrasonography Scintigraphy-Tc-99,Ga-67 CT Scan MRI
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