Rheumatology teachingRheumatology teaching
Pilot 4 sessionsPilot 4 sessions Consultant Rheumatologist/student Consultant Rheumatologist/student
presentationpresentation Based on Phase II objectivesBased on Phase II objectives Polyarthritis, Monoarthritis, Back pain, Polyarthritis, Monoarthritis, Back pain,
Soft-tissue disordersSoft-tissue disorders Ward 2 RheumatologyWard 2 Rheumatology
Approach to PolyarthralgiaApproach to Polyarthralgia
Dr Jaya RavindranDr Jaya RavindranConsultant RheumatologistConsultant Rheumatologist
UHCWUHCW
Approach to PolyarthralgiaApproach to Polyarthralgia
AimsAims
Differential diagnosis of Differential diagnosis of polyarthralgia/polyarthritispolyarthralgia/polyarthritis
InvestigationsInvestigations
Differential diagnosis of Differential diagnosis of polyarthalgia/polyarthritispolyarthalgia/polyarthritis
‘‘Poly` > 4 jointPoly` > 4 jointo Rheumatoid arthritis Rheumatoid arthritis
o Polyarticular OAPolyarticular OA
o Sero-ve Spondyloarthropathy (eg psoriatic, reactive)Sero-ve Spondyloarthropathy (eg psoriatic, reactive)
o Polyarticular crystal arthropathy Polyarticular crystal arthropathy
o Multi-organ disease – CTD and vasculitisMulti-organ disease – CTD and vasculitis
o Viral arthritis (eg parvovirus, rubella, hepatitis)Viral arthritis (eg parvovirus, rubella, hepatitis)
o (Polymyalgia rheumatica/GCA) (Polymyalgia rheumatica/GCA)
Differential diagnosis of Differential diagnosis of polyarthalgia/polyarthritispolyarthalgia/polyarthritis
‘‘Poly` > 4 jointsPoly` > 4 joints
o Medical conditions Medical conditions o thyroid disease / hyperparathyroidism / osteomalacia thyroid disease / hyperparathyroidism / osteomalacia o diabetic cheiroarthropathydiabetic cheiroarthropathyo paraneoplastic syndromes, multiple myelomaparaneoplastic syndromes, multiple myelomao infective endocarditisinfective endocarditiso sarcoidosissarcoidosis
o FibromyalgiaFibromyalgia
Age and sex IncidenceAge and sex Incidence
AGEAGE FEMALEFEMALE MALEMALE
Young adultsYoung adults RARA Reactive Reactive arthritisarthritis SLESLE (Sero-(Sero-ve)ve)
Psoriatic arthritisPsoriatic arthritis(Sero-ve)(Sero-ve)
Middle ageMiddle age RARA RARAOAOA GoutGout
Old ageOld age OAOAPMRPMRCrystal arthritisCrystal arthritis
CLUESCLUES
Prodromal event eg GI/GU infection Prodromal event eg GI/GU infection Associated conditions eg psoriasis, Associated conditions eg psoriasis,
colitis, iritiscolitis, iritis Inflammatory or mechanical*Inflammatory or mechanical* Pattern of joint and symmetry eg RA Pattern of joint and symmetry eg RA
vs PsA vs OA*vs PsA vs OA* Multi-organ disease*Multi-organ disease* Fibromyalgia symptoms* Fibromyalgia symptoms*
How do you differentiateHow do you differentiate
between mechanical andbetween mechanical and
inflammatory symptoms?inflammatory symptoms?
Mechanical vs InflammatoryMechanical vs Inflammatory
Inflammatory Inflammatory MechanicalMechanical Immobility stiffness Immobility stiffness latter daylatter day EMS>30-60 minsEMS>30-60 mins EMS<30-60 minsEMS<30-60 mins Better with activity and NSAIDsBetter with activity and NSAIDs worse with worse with
activityactivity Joint swelling,erythema,heat Joint swelling,erythema,heat instabilityinstability Systemic symptoms Systemic symptoms lockinglocking Multi-organ involvement Multi-organ involvement trauma, straintrauma, strain
overusage overusage
Pattern and symmetryPattern and symmetry
RA - PIP, MCP, wrists, elbows, shoulders, RA - PIP, MCP, wrists, elbows, shoulders, neck, knee, ankle, MTP, symmetricalneck, knee, ankle, MTP, symmetrical
Sero-ve – DIP, asymmetrical, dactylitis, Sero-ve – DIP, asymmetrical, dactylitis, enthesitis, spinal enthesitis, spinal
OA – DIP, PIP, CMC, ACJOA – DIP, PIP, CMC, ACJWeight bearing jointsWeight bearing joints
Sero-ve Spondyloarthritis – Sero-ve Spondyloarthritis – psoriatic arthritispsoriatic arthritis
DIP, poly, DIP, poly, dactylitis, dactylitis,
enthesitis, spinal enthesitis, spinal
OsteoarthritisOsteoarthritis
Mechanical Mechanical symptomssymptoms
Bony swelling, Bony swelling, crepituscrepitus
DIP (Heberden), PIP DIP (Heberden), PIP (Bouchard), 1(Bouchard), 1stst CMCJ, neck, lower CMCJ, neck, lower back, hips, knees, back, hips, knees, 11stst MTP MTP
Polyarticular crystal eg goutPolyarticular crystal eg gout
ChronicChronic TophiTophi ErosionsErosions
Fibromyalgia Fibromyalgia
““All over pain”All over pain” FatigueFatigue Sleep disturbanceSleep disturbance DepressionDepression AnxietyAnxiety Irritable bowelIrritable bowel Tender spotsTender spots Diagnosis of exclusionDiagnosis of exclusion
Connective tissue diseaseConnective tissue disease
Eg SLE, scleroderma, polymyositis, Eg SLE, scleroderma, polymyositis, Sjogren’sSjogren’s
Auto-immuneAuto-immune Multi-organMulti-organ Anti-nuclear antibodiesAnti-nuclear antibodies
Connective tissue disease Connective tissue disease symptomssymptoms
o Photosensitive Photosensitive rashesrashes
o Skin tightnessSkin tightnesso Raynauds – late Raynauds – late
onset, trophic onset, trophic changeschanges
o Mouth ulcersMouth ulcers
Connective tissue disease Connective tissue disease symptomssymptoms
o Dry eyes and mouth Dry eyes and mouth
o Arthralgias, arthritis – non deformingArthralgias, arthritis – non deforming
o Proximal myopathy – pain and weakness Proximal myopathy – pain and weakness (PMR pain and stiffness – think also (PMR pain and stiffness – think also GCA)GCA)
Connective tissue disease Connective tissue disease symptomssymptoms
o SwallowingSwallowing
o Serositis/ILD – pleurisy, Serositis/ILD – pleurisy, dyspnoea, coughdyspnoea, cough
o RENAL DISEASE – silent, RENAL DISEASE – silent, URINE DIP + BPURINE DIP + BP
o Systemic - fatigue, Systemic - fatigue, fever, weight loss fever, weight loss
Connective tissue disease Connective tissue disease symptomssymptoms
o Vasculitis – Vasculitis – petechial, purpura, petechial, purpura, ulcer ulcer
What are the vasculitides What are the vasculitides and what type of and what type of symptoms and signs?symptoms and signs?
VasculitisVasculitis
Small, medium, large vesselSmall, medium, large vessel Eg MPA, Churg Strauss, PAN, Eg MPA, Churg Strauss, PAN,
Wegeners, GCA Wegeners, GCA ANCAANCA
VasculitisVasculitis
Systemic, vasculitic ulcers/rashes, Systemic, vasculitic ulcers/rashes, arthralgias/arthritis – non deformingarthralgias/arthritis – non deforming
ENT - sinusitisENT - sinusitis Pulmonary – haemoptysis, late onset Pulmonary – haemoptysis, late onset
asthmaasthma Cardiac failureCardiac failure RENAL – URINE DIP + BPRENAL – URINE DIP + BP Neuropathy eg footdropNeuropathy eg footdrop
Polymyalgia rheumatica and Polymyalgia rheumatica and GCAGCA
Over 50’sOver 50’s Proximal inflammatory Proximal inflammatory
pain and stiffnesspain and stiffness GCA – large vessel GCA – large vessel
arteritisarteritis Temporal headache, Temporal headache,
jaw claudication visual jaw claudication visual disturbance, systemic disturbance, systemic upset upset
Raised ESR and CRP – Raised ESR and CRP – urgent steroidsurgent steroids
TA biopsyTA biopsy
InvestigationsInvestigations
Inflammatory arthritis – RAInflammatory arthritis – RA FBC, ESR, CRP, U+E, LFT, RF, XR Hands FBC, ESR, CRP, U+E, LFT, RF, XR Hands
and feetand feet ? CTD/vasculitis - ANA, ENA, RF, DNA ? CTD/vasculitis - ANA, ENA, RF, DNA
binding, ANCA, complementbinding, ANCA, complement Urine dip and BPUrine dip and BP Organ based investigations Organ based investigations Diffuse symptoms – CK, Ca, ALP, TFTDiffuse symptoms – CK, Ca, ALP, TFT Viral – Parvovirus, LFT+Hepatitis Viral – Parvovirus, LFT+Hepatitis
Rheumatoid factorRheumatoid factor
Infection: Acute infection eg infectious mononucleosis; ChronicInfection: Acute infection eg infectious mononucleosis; Chronicinfection eg SBE, TB; Parasitic eg malaria; vaccinationinfection eg SBE, TB; Parasitic eg malaria; vaccination
Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic activeactive
hepatitis, cryoglobulinaemiahepatitis, cryoglobulinaemia
Malignancy: Lymphoma, leukaemia, myeloma, solid tumours Malignancy: Lymphoma, leukaemia, myeloma, solid tumours
5% healthy population 5% healthy population
RF <15 not significant unless associated with appropriate RF <15 not significant unless associated with appropriate clinical scenarioclinical scenario
ANA and ENAANA and ENA
ANA 1/40 not significant unless associated ANA 1/40 not significant unless associated with appropriate clinical scenariowith appropriate clinical scenario
Also in RA, cirrhosis, ai liver disease, Also in RA, cirrhosis, ai liver disease, neoplasia, healthy populationneoplasia, healthy population
ENA – extractable nuclear antigensENA – extractable nuclear antigens Anti-Ro and anti-La - SjogrensAnti-Ro and anti-La - Sjogrens Scl 70 and anti-centromere – SclerodermaScl 70 and anti-centromere – Scleroderma Anti-RNP – mixed CTDAnti-RNP – mixed CTD Anti-Jo1 - myositis Anti-Jo1 - myositis
ANCAANCA
Antibodies vs specific antigens in Antibodies vs specific antigens in cytoplasm of neutrophilscytoplasm of neutrophils
ANCA reactive to myeloperoxidase ANCA reactive to myeloperoxidase (MPO) – perinuclear pattern of (MPO) – perinuclear pattern of staining P-ANCA eg microscopic staining P-ANCA eg microscopic polyarteritispolyarteritis
ANCA reactive to proteinase 3 (PR3) ANCA reactive to proteinase 3 (PR3) – cytoplasmic pattern of staining C-– cytoplasmic pattern of staining C-ANCA eg Wegener’s granulomatosisANCA eg Wegener’s granulomatosis
What are the radiologicalWhat are the radiological
feature of OA, RA (and feature of OA, RA (and PsA) ?PsA) ?
Radiology - OA Radiology - OA
Four cardinal Four cardinal features:features: Joint space Joint space
narrowingnarrowing SclerosisSclerosis Subchondral cystsSubchondral cysts OsteophytesOsteophytes
Radiology - RARadiology - RA
soft tissue swellingsoft tissue swelling
juxta-articular osteoporosisjuxta-articular osteoporosis
juxta-articular and juxta-articular and subchondral erosionssubchondral erosions
joint space narrowing & joint space narrowing & subluxationsubluxation
secondary OA & bony secondary OA & bony ankylosis ankylosis
Radiology - PsARadiology - PsA
ErosionErosion OsteolysisOsteolysis Bone Bone
proliferationproliferation AnkylosisAnkylosis