Approach patient with Approach patient with ARTHRITISARTHRITIS

DR. MOHAMMED O. AL-RUKBANDR. MOHAMMED O. AL-RUKBANAssistant ProfessorAssistant Professor

Department of Family and Community MedicineDepartment of Family and Community MedicineCollege of MedicineCollege of Medicine

King Saud UniversityKing Saud University

Normal Joint..Normal Joint..

Introduction..Introduction..

Causes include various self-limited Causes include various self-limited illness and disabling and life-illness and disabling and life-threatening.threatening.

Is it Arthritis or Arthralgia?Is it Arthritis or Arthralgia?Musculoskeletal emergencies Musculoskeletal emergencies

(infection, sepsis, compartment (infection, sepsis, compartment syndrome…).syndrome…).

Arthralgia..Arthralgia..

FibromyalgiaFibromyalgiaBursitisBursitisTendinitisTendinitisHypothyroidismHypothyroidismNeuropathic painNeuropathic painMetabolic bone diseaseMetabolic bone diseaseDepressionDepression

Monoarthritis..Monoarthritis.. TraumaTrauma Infection:Infection:

DGI ± Skin lesion.DGI ± Skin lesion. Nongonococcal bacterial infections: large joints.Nongonococcal bacterial infections: large joints. Mycobacterial and fungal infection.Mycobacterial and fungal infection.

Crystal induced arthritisCrystal induced arthritis Monosodium Urate crystals (MPJ)Monosodium Urate crystals (MPJ) Ca pyrophosphate dihydrate crystals (knee)Ca pyrophosphate dihydrate crystals (knee)

Lyme diseaseLyme disease Systemic Rheumatoid diseases:Systemic Rheumatoid diseases:

Seronegative spodyloarthropathy (Reactive arthritis, psoriatic Seronegative spodyloarthropathy (Reactive arthritis, psoriatic arthritis, Inflammatory BD..)arthritis, Inflammatory BD..)

Sarcoid periarthritisSarcoid periarthritis RARA

OsteoarthritisOsteoarthritis

Polyarthritis..Polyarthritis..

Rheumatoid ArthritisRheumatoid ArthritisSystemic lupus ErythrematosusSystemic lupus ErythrematosusViral arthritisViral arthritisReiter’s diseaseReiter’s diseasePsoriatic arthritis Psoriatic arthritis Reactive arthritisReactive arthritis

Migratory Arthritis..Migratory Arthritis..

Differential diagnosis:Differential diagnosis:Rheumatic feverRheumatic feverGonococcemiaGonococcemiaMeningococcemiaMeningococcemiaViral ArthritisViral ArthritisSLESLEAcute LeukemiaAcute Leukemia

Rheumatic Fever..Rheumatic Fever..

Majer Criteria:Majer Criteria:1- 1- Carditis Carditis 2-2- Polyarthritis Polyarthritis 3- 3- ChoreaChorea

4-4- Erythema Marginatum Erythema Marginatum 5- 5- Subcutaneous nodulesSubcutaneous nodules

● Minor criteria:Minor criteria:

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

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

History.. AgeHistory.. Age

<30=<30= SLE, Ankylosis spodylitis, SLE, Ankylosis spodylitis, Reactive Arthritis.Reactive Arthritis.

30-50=30-50= RA, Systemic sclerosis, Gout. RA, Systemic sclerosis, Gout.>50=>50= OA, Pseudogout, PMR OA, Pseudogout, PMRAny Age group=Any Age group= Psoriatic arthritis, Psoriatic arthritis,

Enteropathic arthritisEnteropathic arthritis

History.. SexHistory.. Sex

>Female:>Female:SLE, RA, OA, Systemic sclerosis, SLE, RA, OA, Systemic sclerosis,

Ankylosis spodylitis, PMR.Ankylosis spodylitis, PMR.Male=Female:Male=Female:Psoriatic arthritis, Enteropathic Psoriatic arthritis, Enteropathic

arthritis Pseudogout. arthritis Pseudogout. >Male:>Male: Gout, Reactive Arthritis.Gout, Reactive Arthritis.

History.. SxHistory.. Sx

Site:Site: Symmetrical= RA, SLE, Systemic sclerosisSymmetrical= RA, SLE, Systemic sclerosis Asymmetrical=OAAsymmetrical=OA Large joints=OALarge joints=OA DIP= OA, Psoriatic arthritisDIP= OA, Psoriatic arthritis MCP, PIP= RA, SLEMCP, PIP= RA, SLE 11stst MTP= Gout, OA MTP= Gout, OA Spine= OA, Ankylosis spodylitis, Psoriatic arthritis, Spine= OA, Ankylosis spodylitis, Psoriatic arthritis,

Reactive arthritisReactive arthritis Shoulder= PMR Shoulder= PMR

History.. SxHistory.. Sx

Pain character:Pain character: Aggravated by motion= MechanicalAggravated by motion= Mechanical Relieved by motion= Inflammatory.Relieved by motion= Inflammatory.

Duration:Duration: <6 wks= viral arthritis, systemic rheumatic <6 wks= viral arthritis, systemic rheumatic

diseasesdiseases >6 wks=systemic rheumatic diseases>6 wks=systemic rheumatic diseases

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

History.. SxHistory.. Sx

Associated Sx:Associated Sx: Multi-system involvement= Systemic Multi-system involvement= Systemic

rheumatic diseases. rheumatic diseases. Past Medical history:Past Medical history:

Trauma, fracture, surgical procedures…Trauma, fracture, surgical procedures…Medication list:Medication list:

Drug induced lupus.Drug induced lupus. Diuretics.Diuretics.

Phy. Examination..Phy. Examination..

Joint:Joint: Soft tissue swelling, warm, effusion…= Soft tissue swelling, warm, effusion…=

Inflammation.Inflammation. Inflammation signs extended= Inflammation signs extended= septic septic

arthritis, crystal induced arthritis, fracture.arthritis, crystal induced arthritis, fracture. Passive motion (N), active(↓↓)= Passive motion (N), active(↓↓)= bursitis, bursitis,

tendinitis, muscle injury.tendinitis, muscle injury. Passive motion (↓↓), active(↓↓)= Passive motion (↓↓), active(↓↓)= SynovitisSynovitis

Phy. Examination..Phy. Examination..

General Examination:General Examination: LAP, parotid enlargement, oral ulceration, heart LAP, parotid enlargement, oral ulceration, heart

murmurs, pericardial or pleural friction rubs, murmurs, pericardial or pleural friction rubs, crackle…= crackle…= systemic disease.systemic disease.

Fever= Fever= infection, reactive arthritis, RA, SLE, infection, reactive arthritis, RA, SLE, Crystal induced arthritis…Crystal induced arthritis…

Subcutaneous nodules= Subcutaneous nodules= RA, RHD, Gout (tophi)RA, RHD, Gout (tophi) Skin manifestations= Skin manifestations= psoriasis, RA, SLE…psoriasis, RA, SLE… Eye disease (keratoconjunctivitis sicca, uveitis. Eye disease (keratoconjunctivitis sicca, uveitis.

Conjunctivitis, episcleritis…)Conjunctivitis, episcleritis…)

Laboratory Studies..Laboratory Studies..

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

ANA= ANA= SLESLE Anti-dsDNA= Anti-dsDNA= SLESLE Anti-native DNA, anti-Sm= Anti-native DNA, anti-Sm= SLESLE RF= RF= RARA Anti-CCP antibody=Anti-CCP antibody=RARA

Rheumatoid Factor..Rheumatoid Factor..

Rheumatoid ArthritisRheumatoid Arthritis Connective tissue diseasesConnective tissue diseases Viral infectionViral infection LeishmaniasisLeishmaniasis LeprosyLeprosy TuberculosisTuberculosis SarcoidosisSarcoidosis Liver diseasesLiver diseases Subacute bacterial endocarditisSubacute bacterial endocarditis

Laboratory Studies..Laboratory Studies..

Uric acid concentration= Uric acid concentration= GoutGoutSynovial fluid analysis= Synovial fluid analysis= infection, infection,

crystal induced arthritis,crystal induced arthritis, inflammatory..inflammatory..Hepatitis B and CHepatitis B and CParvovirus serologyParvovirus serology

Imaging Studies..Imaging Studies..

X-ray: X-ray: RARA Chronic GoutChronic Gout OAOA Ankylosing spondylosis.Ankylosing spondylosis.

MRI:MRI: Ankylosing spondylosis. Ankylosing spondylosis.

Rheumatoid Arthritis..Rheumatoid Arthritis..

EpidemiologyEpidemiology : : The world wide incidence of RA is The world wide incidence of RA is

approximately 3 cases per 10,000 approximately 3 cases per 10,000 population and the prevalence rate is population and the prevalence rate is approximately 1%approximately 1%

Rheumatoid ArthritisRheumatoid Arthritis....

HistoryHistory....

MalaiseMalaisefeverfeverfatigue fatigue weight loss weight loss myalgias myalgias difficulty performing activities of daily difficulty performing activities of daily

livingliving

ExaminationExamination....

Joint affected Joint affected swellingswelling tenderness tenderness warmth warmth decreased range of motion decreased range of motion

Atrophy of the interosseous Atrophy of the interosseous muscles muscles

deformities deformities

DiagnosisDiagnosis....

Morning stiffness Morning stiffness Arthritis of 3 or more joint areasArthritis of 3 or more joint areas Arthritis of hand joints of at least one area Arthritis of hand joints of at least one area

swollen in a wrist, MCP, or PIP joint swollen in a wrist, MCP, or PIP joint Symmetric arthritisSymmetric arthritis Rheumatoid nodules Rheumatoid nodules Serum RF Serum RF Radiographic changes typical of RA Radiographic changes typical of RA

DeformitiesDeformities....

Extra-articular manifestationsExtra-articular manifestations....

Rheumatoid noduleRheumatoid nodule Cardiovascular Cardiovascular Pulmonary Pulmonary GI & RenalGI & Renal HematologicalHematological SkinSkin VasculitisVasculitis Neurological Neurological Ocular Ocular

Progression of RA..Progression of RA..

Stage 1:Stage 1: - no destructive changes.- no destructive changes.

- Osteoporosis.- Osteoporosis. Stage 2:Stage 2:

- periarticular osteoporosis w/wo slight - periarticular osteoporosis w/wo slight subchondral bone destruction.subchondral bone destruction.

- joint mobility limit but no destruction.- joint mobility limit but no destruction.

- adjacent muscle atrophy.- adjacent muscle atrophy.

- extra-articular soft tissue lesions.- extra-articular soft tissue lesions.

Progression of RA..Progression of RA..

Stage 3Stage 3 - cartilage and bone destruction in addition to- cartilage and bone destruction in addition to

periarticular osteoporosis. periarticular osteoporosis. - joint deformity w/wo fibrous or bony ankylosis.- joint deformity w/wo fibrous or bony ankylosis. - extensive muscle atrophy.- extensive muscle atrophy. - extra-articular soft tissue lesions.- extra-articular soft tissue lesions.

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

LaboratoryLaboratory.. ..

Hematologic parametersHematologic parameters AnaemiaAnaemia ThrombocytosisThrombocytosis ↓ ↓ Serum iron & IBCSerum iron & IBC ↑ ↑ Serum globulineSerum globuline ↑ ↑ ALPALP ↑ ↑ Acute phase reactantAcute phase reactant

Immunological parameters Immunological parameters Synovial fluid analysis Synovial fluid analysis

Prognosis..Prognosis..

40 % of patient become disabled after 40 % of patient become disabled after 10 years.10 years.

Persistent active cases more than 1 Persistent active cases more than 1 year likely to lead to joint deformities.year likely to lead to joint deformities.

Periods of activity cases have better Periods of activity cases have better prognosis.prognosis.

Mortality rate 2.5 times than generalMortality rate 2.5 times than generalpopulationpopulation

Systemic Lupus ErythrematosisSystemic Lupus Erythrematosis

Malar rashMalar rash Discoid rashDiscoid rash PhotosensitivityPhotosensitivity Oral ulcersOral ulcers ArthritisArthritis SerositisSerositis Renal disease (proteinuria, cellular cast)Renal disease (proteinuria, cellular cast) Neurologic disease (seizure, psychosis)Neurologic disease (seizure, psychosis) Hematologic diseaseHematologic disease Immunologic abnormalitiesImmunologic abnormalities ANAANA

Summary..Summary..

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

synovitis diagnosed as:synovitis diagnosed as: Rheumatoid Arthritis.Rheumatoid Arthritis. Spondyloarthropathy.Spondyloarthropathy.

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