Xryas and Arthritis Phenotypes

8/15/2019 Xryas and Arthritis Phenotypes

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Leanne Alblas2nd year rheumatology trainee

Western Health 2015


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QuestionsReview of Arthritis approachImaging in arthritis


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Inflammatoryor Mechanical

Large vs.small joints

Deforming vs. Non

deforming

Mono-,Oligo-

orPolyarthritis

Acute,subacute,

or ChronicSymmetrical vs.

Asymmetrical


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65 yo female with an acute non-deforming symmetrical small jointinflammatory polyarthritis

85 yo man with a chronic large jointasymmetrical mechanical oligoarthritis

32 yo woman with a subacuteinflammatory deforming monoarthritis ofher right knee


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Inflammatory Mechanical

Early Morning Stiffness >30min


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Monoarthritis Oligoarthritis

Polyarthritis

Number 1 2-4 ≥5

Commoncauses OAGoutCPPD

Septic arthritis

PsARA (initially)OA

RASLE

Acute Subacute ChronicWeeks 6


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Asymmetrical

OAPsA

Symmetrical

RA


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Single jointDDx• Septic arthritis• Traumatic (haemarthrosis, #)• Crystals (gout, pseudogout)• Initial presentation of RA, PsA, Ank Spond


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Eye – scleritis/iritis (A.S, RA, reactive)Rash (SLE, Psoriasis)Obesity (psoriasis/gout)ILD• Basal - RA, SLE, Scleroderma,• Apical - Ank spond

Nail changes• Ridging/pitting – Psoriasis• Nailfold (capillaries) – SLE, scleroderma


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OsteoarthritisRheumatoid ArthritisPsoriatic Arthritis

Ankylosing spondylitisGoutPseudogout (CPPD)

SLEHaemachromatosis


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AsymmetricalOlder populationInvolvesFeatures:• Crepitus• Mechanical (worse post activity)

• Bony joint enlargement• Limited joint mobility


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Usually SPARES wrists, elbows, shoulders,ankles, MCP, 2 nd -5 th MTP• If present, consider 2° causes

Group Example

Congenital Congenital Hip Dislocation

Dysplasia Epiphyseal

Mechanical Joint hypermobility, valgus/varus deformity

Trauma ACL tear, meniscectomy/prev. arthroscopyMetabolic HH, Haemaglobinopathy, Crystal deposition

Endocrine Acromegaly, Thyroid

Neuropathy DM, Syphilis

Other End result of inflammatory/infective arthritis


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Joint Space NarrowingOsteophytes ‘spurs’ Subchondral cysts ‘geodes’ Sclerosis


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• Hard bony enlargements

• Bouchard’s nodes

atthe PIP joints

• Heberden’s nodes atthe DIP joints

• Often have “squared” firstCMC joint due toosteophytes at that joint


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Change

pic tonon-erosive


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Heberden’s nodes - DIP


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Bouchard’s nodes - PIP


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• JSN (usually medial >lateral)

• Osteophytes• Subchondral sclerosis


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• JSN (usually medial >lateral)

• Osteophytes• Subchondral sclerosis

•

Subchondralcysts


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Component ofinflammation

Affect:• 5-10% of OA patients• Typically women in 40s

Joints involved:• DIP, PIP, 1 st CMC

• BilateralInvestigations• Normal ESR/CRP• Neg RF, ANA

‘Gull wing’ sign


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Component ofinflammation

Affect:• 5-10% of OA patients• Typically women in 40s

Joints involved:• DIP, PIP, 1 st CMC

• BilateralInvestigations• Normal ESR/CRP• Neg RF, ANA

‘Gull wing’ sign


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Do weight bearing views for large jointsSynovial fluid analysis• WCC


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Symmetrical inflammatory small jointpolyarthritis

Affects F>MInvolves• PIP, wrist, elbow, shoulder, Cervical spine, knees,

ankles, MTPs

SPARES• DIPs, hips, thoraco-lumbar spine


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Uniform JSN (Joint Space Narrowing)Generalised osteoporosisMarginal erosions (of ‘bare areas’) Peri-articular soft tissue swellingSubluxation


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Boutonniere deformingSoft tissue swelling/bogginessUlnar deviation at level of MCPs

Delete

this


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Subluxation and ulnardeviation of proximalphalanx with respect toMCPs

Generalisedosteoporosis

Erosions


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Asymmetrical inflammatory arthritisinvolving• Hands (esp. DIP)• Feet• Sacro-iliac joint (SIJ)• Spine

Peripheral

Axial


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Asymmetrical inflammatory arthritisinvolving• Hands (esp. DIP)

• Feet• Sacro-iliac joint (SIJ)• Spine

May precede or follow psoriasis

Peripheral

Axial


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Dactylitis

DIP involvement

Nail changes• Onycholysis

• Pitting• Ridging


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Fusiform soft tissue swellingBony proliferation “ periostitis ”

Joint space loss‘pencil in cup’ Normal bone mineralisation


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Sausage likeswelling of whole digits

“dactylitis ”


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“dactylitis ”

severe erosive ∆ of 2 nd & 3 rd DIPs


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“dactylitis ”

severe erosive ∆ of 2 nd & 3 rd DIPs

solid periosteal new bone


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Pencil in cup


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Pencil in cup

Ankylosis


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Pencil in cup

Ankylosis

Periostitis


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Cf. to Ankylosing spondylitis• Unilateral or asymmetrical bulky bony

outgrowths of paraverterbral spine


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Enthesitis is a distinguishing feature

Axial• Insidious onset inflammatory back pain

Peripheral

• Mono/ oligo-arthritis, usually lower limb

HLAB27


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Definite sacroiliitis (on xray)• ≥grade II bilaterally or • Grade III/IV unilaterally

SI changes are usually bilateral &symmetric

Initially involve the synovial lined lower2/3 rd of SI joint


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Grade I Grade II

Suspicious changeIrregular joint space w/o sclerosis or

well defined erosions


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Grade I Grade II

Suspicious changeIrregular joint space w/o sclerosis or

well defined erosions

Min Abnormalitiessmall localised erosions/sclerosis butNormal joint width


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Grade III Grade IV

Unequivocal Abnormal – mod-advanced sacroiliitis & ≥1 of: erosions, sclerosis, widening,narrowing or partial ankylosis


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Grade III Grade IV

Unequivocal Abnormal – mod-advanced sacroiliitis & ≥1 of: erosions, sclerosis, widening,narrowing or partial ankylosis

Completely ankylosed (fused)


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Syndesmophytes


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Diffuse Idiopathic Skeletal HyperostosisNot an arthropathy but a bone formingcondition• Normal cartilage, bony margins & synovium

Affects older patientsEsp. thoracic spine

Assoc. with stiffness/ ROM


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Flowing ossification ofparaspinal phytes – anterior to vertebral

bodies

NOTE• Normal disc spaces• Need ≥4 contiguous

vertrebral bodies withossification

Get AP

view ofDISH


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Ossification oflongitudinal ligament

(ant. To vertebralbodies)

Can cause dysphagia!


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Rapid onset painful erythematous jointpain, swelling and erythema• Initially monoarticular (eg Podagra)

• Later polyarticular

Asymmetrical

Monosodium urate crystals – negativelybifringent


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Commonly affectsFeet>Ankles>Knees> Hands >Elbows

Increasingly recognised in axialspineOften involves periarticularstructures

With chronicity may developtophi


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TophiPunched out lesions with scleroticbordersOverhanging edge of cortexNormal joint space & mineralisation


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Tophi in 1 st – 3 rd MTP& 1st IP with assoc.

erosion

Normalmineralisation


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3 rd most common inflammatory arthritis• 3.4% adults

Characterised by calcium pyrophosphatedeposition in cartilageRisk factors• Age• OA

Presentation very variable:• Acute or chronic• Mono- oligo-, polyarthritis• Inflammatory or non-inflammatory


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Most common joints involved• Wrist• Knee

If presents


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Chondrocalcinosis

Note:• Underlying OA• Should find bilateral

changes on xray• Also xray wrists


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Calcification oftrianglular

fibrocartilage


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Typically inflammatory small jointpolyarthritis – similar to RA• However it is rarely erosive/destructive

Can also have “ Rhupus ” • Arthritis strongly resembling RA with erosions &

positive RF• Fixed derformities


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Jaccoud arthritis – non-erosivearthropathy

Occurs in 10-35%

Swan neck (lax joint capsule, tendons, ligaments)MCP subluxationUlnar deviation


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Jaccoud arthritis – non-erosivearthropathy

Occurs in 10-35%

Swan neck (lax joint capsule, tendons, ligaments)MCP subluxationUlnar deviation


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Hook like osteophytes atMCPs esp. 2 nd & 3rd


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Can involve any joint!Commonly• 2nd & 3 rd MCPs with associated pain and stiffness

• PIPs, radiocarpal, knees, hips, ankles, shouldersCan have CPPD causing flares• Chondrocalcinosis found in 30-60%

Synovial fluid is non-inflammatory

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Xryas and Arthritis Phenotypes