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Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
Approach To A Patient With Polyarthritis
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Approach To A Patient With Polyarthritis

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  • 1. Approach to a patient with Polyarthritis Dr. K. K. Pruthi Prof & Head S. N. Medical College, Agra
  • 2. ‘ Patterned’ approach Grouping a constellation of symptoms, signs and investigations to arrive at a diagnosis.
  • 3. POLYARTHRITIS 4 or more joint involvement PAUCI / OLIGOARTHRITIS 2 or 3 joint involvement MONOARTHRITIS 1 joint involvement Definition
  • 4. <ul><li>Site (distribution) </li></ul><ul><li>Type of pain </li></ul><ul><li>Associated features </li></ul><ul><li>Duration and onset </li></ul><ul><li>Risk factors </li></ul><ul><li>Physical signs </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Investigation </li></ul>Assessment of joint pain
  • 5. Site and distribution of pain <ul><li>Is it joint, peri-articular or muscle pain? </li></ul><ul><li>Which joints are involved? </li></ul><ul><li>Is it symmetrical or asymmetrical? </li></ul><ul><li>Where did it start? </li></ul><ul><li>Is the arthritis migratory, additive, episodic? </li></ul><ul><li>Site & </li></ul><ul><li>Distribution </li></ul>
  • 6. Site and distribution of pain <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>RA </li></ul><ul><li>PIP, MCP, wrists, elbows, shoulders, neck, </li></ul><ul><li>knee, ankle, MTP </li></ul><ul><li>DIP not involved </li></ul><ul><li>symmetrical </li></ul><ul><li>Sero-ve </li></ul><ul><li>DIP, dactylitis, enthesitis, spinal </li></ul><ul><li>PIP not involved </li></ul><ul><li>asymmetrical </li></ul><ul><li>OA </li></ul><ul><li>Weight bearing joints </li></ul><ul><li> DIP, PIP, CMC, ACJ </li></ul><ul><li>MP not involved </li></ul>
  • 7. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul>Type of pain <ul><li>Is it inflammatory? </li></ul><ul><li>Is it mechanical / degenerative? </li></ul><ul><li>What makes the pain worse/better? </li></ul>
  • 8. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul>Type of pain <ul><li>Inflammatory Mechanical </li></ul><ul><li>Immobility stiffness Latter day </li></ul><ul><li>EMS>30-60 mins EMS<30-60 mins </li></ul><ul><li>Better with activity Worse with activity </li></ul><ul><li>Joint swelling, erythema, heat Instability </li></ul><ul><li>Systemic symptoms Locking </li></ul><ul><li>Multi-organ involvement Trauma, strain, over usage </li></ul>
  • 9. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul>Associated features <ul><li>Is there morning stiffness? </li></ul><ul><li>Have there been any symptoms of infection? </li></ul><ul><li>Have there been any rashes ? </li></ul><ul><li>Any urinary, genital or gut problems? </li></ul>
  • 10. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul>Duration & onset <ul><li>When did the joint pains begin? </li></ul><ul><li>Are the symptoms getting better or worse? </li></ul>
  • 11. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul>Duration & onset <ul><li>Acute </li></ul><ul><ul><li>Viral </li></ul></ul><ul><ul><ul><li>parvo/rubella </li></ul></ul></ul><ul><ul><li>Bacterial </li></ul></ul><ul><ul><ul><li>strep </li></ul></ul></ul><ul><ul><li>Rheumatoid </li></ul></ul><ul><ul><li>Reactive </li></ul></ul><ul><ul><ul><li>GU/gastro </li></ul></ul></ul><ul><ul><li>Erythema nodosum </li></ul></ul><ul><ul><li>Vasculitis </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>Rheumatoid </li></ul></ul><ul><ul><li>Seronegative </li></ul></ul><ul><ul><ul><li>psoriatic/AS/IBD </li></ul></ul></ul><ul><ul><li>Connective tissue disease </li></ul></ul><ul><ul><ul><li>SLE/SjS/DM </li></ul></ul></ul><ul><ul><li>Polyarticular OA </li></ul></ul>
  • 12. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul>Other risk factors <ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Racial/ethnic background </li></ul><ul><li>Family history </li></ul><ul><li>Treatment history </li></ul><ul><li>Social history </li></ul>
  • 13. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul>Other risk factors AGE FEMALE MALE Young adults RA Reactive arthritis SLE (Sero-ve) Psoriatic arthritis (Sero-ve) Middle age RA RA OA Gout Old age OA PMR Crystal arthritis
  • 14. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul>Physical signs <ul><li>Joint distribution +/- spine </li></ul><ul><li>Skin and appendages </li></ul><ul><li>Rash, nodules, eyes, mouth ulcers, hair </li></ul><ul><li>Temp, LNs, CVS, RS, Abdomen, Neurological </li></ul>
  • 15. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul><ul><li>Differential </li></ul><ul><li>diagnosis </li></ul>Differential diagnosis <ul><li>Osteoarthritis </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Chronic (trophaceous) gout </li></ul><ul><li>Systemic lupus erythematous </li></ul><ul><li>Reiter’s disease </li></ul><ul><li>Ankylosing spondylitis </li></ul><ul><li>Psoriatic arthritis </li></ul>
  • 16. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul><ul><li>Differential </li></ul><ul><li>diagnosis </li></ul><ul><li>Investigati- </li></ul><ul><li>ons </li></ul>Investigations <ul><li>Radiographs of corresponding joints </li></ul><ul><li>Hemogram, ESR </li></ul><ul><li>RA factor, CRP </li></ul><ul><li>S.Uric Acid - Notoriously unreliable !! </li></ul><ul><li>Urine, stool </li></ul><ul><li>Synovial fluid </li></ul><ul><li>Cultures </li></ul><ul><li>CT/MRI </li></ul><ul><li>Arthroscopy/Biopsy( to be considered in chronic, >6 weeks, </li></ul><ul><li>non traumatic arthritis in which diagnosis is not established ) </li></ul><ul><li>Bone scan </li></ul><ul><li>Serologic tests like ANA, RF, ANCA - rarely if ever indicated </li></ul>
  • 17. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul><ul><li>Differential </li></ul><ul><li>diagnosis </li></ul><ul><li>Investigati- </li></ul><ul><li>ons </li></ul>Investigations Synovial fluid examination most important !! <ul><li>Protein </li></ul><ul><li>TLC, DLC, cells </li></ul><ul><li>Gram stain </li></ul><ul><li>C/S </li></ul><ul><li>Atypical organisms </li></ul><ul><li>Crystals with polarising microscopy </li></ul><ul><li>Sugar </li></ul><ul><li>Other tests </li></ul>
  • 18. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul><ul><li>Differential </li></ul><ul><li>diagnosis </li></ul><ul><li>Investigati- </li></ul><ul><li>ons </li></ul>Synovial fluid analysis Apperance Viscosity Cells/mm 3 %PMN Normal Transparent High < 180 < 10% OA Transparent High 200-2000 < 10% RA Translucent Low 2000- Variable 50,000 Psoriatic Translucent Low 2000- Variable Arthritis 50,000 Reactive Translucent Low 2000- Variable Arthritis 50,000 Spondlyo Translucent Low 2000- Variable -arthro. 50,000 Gout Translucent Low 200- > 90% to cloudy 50,000 Pseudo Translucent Low 200- > 90% gout to cloudy 50,000 Bacterial Cloudy Variable > 50,000 > 90% Arthritis
  • 19. Osteoarthritis (OA) <ul><li>Most common joint disorder </li></ul><ul><li>Affects 190 million worldwide </li></ul><ul><li>Nearly 70% of people over 65 years </li></ul><ul><li>Aging population over 65 years </li></ul><ul><li>1997~ 400 million ( 70 million plus in India ) </li></ul><ul><li>2025~ 800 million ( 150 million plus in India ) </li></ul><ul><li>In India has overtaken diabetes, and now ranks </li></ul><ul><li>1 st in chronic debilitating disease. </li></ul>
  • 20. <ul><li>Predisposing factors </li></ul><ul><ul><ul><li>Incongruity </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>Systemic diseases - RA </li></ul></ul></ul>Osteoarthritis
  • 21. <ul><li>Primary </li></ul><ul><li>Secondary </li></ul><ul><ul><li>SCFE </li></ul></ul><ul><ul><li>CDH </li></ul></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><li>Traumatic Dislocation </li></ul></ul><ul><ul><li>Perthes </li></ul></ul><ul><ul><li>Pagets </li></ul></ul><ul><ul><li>Fracture Acetabulum </li></ul></ul><ul><ul><li>Hemophilia </li></ul></ul>Osteoarthritis Types PRIMARY OA SECONDARY OA
  • 22. Risk Factors for OA OA Increased age Genetic disposition Gender & hormonal factors Obesity Mechanical factors Systemic factors (Hypertension, raised serum cholesterol, raised uric acid levels) Prior inflammatory disease Osteoarthritis Degenerative disorder Weight bearing joints usually involved
  • 23. Pathology <ul><li>Synovitis </li></ul><ul><li>Cartilage fibrillation </li></ul><ul><li>Cartilage flaking & delamination </li></ul><ul><li>Exposure of subchondral bone </li></ul><ul><li>Microfractures & osteophytes </li></ul><ul><li>Fibrosis-ankylosis </li></ul>Osteoarthritis
  • 24. Clinical Features <ul><li>Old patient </li></ul><ul><li>Females > males </li></ul><ul><li>Lower limb joints~ knees, hips, 1 st CM jt </li></ul><ul><li>Rest pain </li></ul><ul><li>Pain during movement </li></ul><ul><li>Crepitus </li></ul><ul><li>Characteristic deformities </li></ul>Osteoarthritis <ul><li>Bouchard nodes </li></ul><ul><li>Heberden nodes </li></ul>
  • 25. Radiology <ul><li>Sharpening of edges </li></ul><ul><li>Subchondral sclerosis (eburnation) </li></ul><ul><li>Decreased joint space </li></ul><ul><li>Osteophytes </li></ul><ul><li>Subchondral cysts </li></ul><ul><li>Deformities </li></ul><ul><li>Radioisotope scan-increased uptake </li></ul>Osteoarthritis
  • 26. Joint space narrowing Subchondral bone sclerosis and cysts Marginal osteophyte formation
  • 27.  
  • 28. Kellegren & Lawrence Scale for Osteoarthritis <ul><li>0 – No features of osteoarthritis </li></ul><ul><li>1 – Doubtful, unimute osteophylic of doubtful significance </li></ul><ul><li>2 – Minimal, definite osteophyte but joint space unimpaired </li></ul><ul><li>3 – Moderate, moderate diminution of joint space </li></ul><ul><li>4 – Severe, Joint space severely impaired with scelerosis of </li></ul><ul><li>subchondral bone </li></ul>Osteoarthritis
  • 29. Role of inflammation in OA <ul><li>OA is not characterized by a </li></ul><ul><li>significant systemic inflammatory process </li></ul><ul><li>Inflammation, where present, </li></ul><ul><li>is usually mild </li></ul>Osteoarthritis
  • 30. <ul><li>A common chronic inflammatory joint condition </li></ul><ul><li>‘ Rheumatoid’ first used in 1859 by Garrod </li></ul><ul><li>Little evidence for RA prior to 16th Century </li></ul><ul><li>Possibly earlier in New World </li></ul>Rheumatoid Arthritis
  • 31. Epidemiology <ul><li>Incidence </li></ul><ul><ul><li>1.4/10000 male, 3.6/10000 females </li></ul></ul><ul><li>Prevalence 0.5-2 % </li></ul><ul><li>male:female 1:3 </li></ul><ul><li>Worldwide distribution </li></ul><ul><ul><li>higher in native Americans </li></ul></ul><ul><ul><li>absent in some parts of Africa </li></ul></ul><ul><li>Onset any age but maximum </li></ul><ul><ul><li>40 - 70 years in women </li></ul></ul><ul><ul><li>60 - 70 years in men </li></ul></ul>Rheumatoid Arthritis
  • 32. Etiology Rheumatoid Arthritis Post viral immunomodulation RA HLA DR4 Genetic disposition monozygotic twins – 15% dizygotic twins – 4% Gender & hormonal factors Prior inflammatory disease Multifactorial etiology
  • 33. Excised synovial membrane shows many villous folds with compact nodular clusters of lymphocytes and plasma cells. Pathology Rheumatoid Arthritis
  • 34. Onset <ul><li>Typical </li></ul><ul><li>Insidious onset polyarthritis </li></ul><ul><li>Affecting small joints of hand & feet </li></ul><ul><li>Atypical </li></ul><ul><li>Polymyalgic </li></ul><ul><li>Palindromic </li></ul><ul><li>Systemic </li></ul><ul><li>Persistent monoarthritis </li></ul>Rheumatoid Arthritis
  • 35. One can confidently make a diagnosis of RA on clinical grounds even if RF is absent. Clinical features <ul><li>RA is entirely a clinical diagnosis . </li></ul><ul><li>only 80-85% of the individuals are seropositive. </li></ul><ul><li>15-20% are seronegative. </li></ul>A negative RF may be repeated 4-6 monthly for the first 2 years of disease, since some patients with RA may take 18-24 months to become seropositive. Rheumatoid Arthritis
  • 36. Clinical features <ul><li>Symmetrical deforming polyarthritis </li></ul><ul><ul><li>Affects synovial lining of joints, bursae and tendons </li></ul></ul><ul><ul><li>More then just joint disease </li></ul></ul>Rheumatoid Arthritis <ul><li>Progression of joint involvement </li></ul><ul><li>Spread occurs within months to years to other joints </li></ul><ul><ul><li>Almost any joint may be involved </li></ul></ul><ul><ul><li>Spontaneous remission can occur </li></ul></ul><ul><ul><li>Poor prognosis – RA factor exists </li></ul></ul><ul><li>Symptoms </li></ul><ul><ul><li>Of inflammation </li></ul></ul><ul><ul><ul><li>Stiffness, pain, swelling, warmth, redness </li></ul></ul></ul>
  • 37. <ul><li>Pattern of joint involvement </li></ul><ul><li>symmetrical </li></ul><ul><li>small joints of hands - DIP spared </li></ul><ul><li>characteristic features </li></ul><ul><ul><li>Boutonniere </li></ul></ul><ul><ul><li>Swan neck </li></ul></ul><ul><ul><li>Z thumb </li></ul></ul><ul><ul><li>Volar subluxation </li></ul></ul><ul><ul><li>Ulnar deviation </li></ul></ul>Rheumatoid Arthritis Clinical features Swan neck deformity Boutonniere deformity Ulnar deviation & nodule Hammer toe deformity Hallux valgus
  • 38. Radiology <ul><li>Soft tissue swelling </li></ul><ul><li>Juxta-articular osteoporosis </li></ul><ul><li>Juxta-articular and subchondral erosions </li></ul><ul><li>Joint space narrowing & subluxation </li></ul><ul><li>Secondary OA & bony ankylosis </li></ul>
  • 39. Extra articular findings <ul><li>Nodules </li></ul><ul><li>Eye </li></ul><ul><li>Lung </li></ul><ul><li>Cardiac </li></ul><ul><li>Vasculitis </li></ul><ul><li>Nerves </li></ul><ul><li>Felty’s </li></ul><ul><li>(Neutropenia + RA) </li></ul>Rheumatoid Arthritis Rheumatoid nodule Episcleritis Digital infarcts
  • 40. Be Cautious to diagnose RA if : <ul><li>Monoarticular </li></ul><ul><li>Hands not involved </li></ul><ul><li>Asymmetrical or unilateral involvement </li></ul><ul><li>Only DIP are involved </li></ul><ul><li>Lumbar spine involved </li></ul>Mere presence of rheumatoid factor in blood is not enough to make a diagnosis of RA. Rheumatoid Arthritis
  • 41. <ul><li>Diseases associated with a positive RF </li></ul><ul><li>Condition Prevalence (%) </li></ul><ul><li>RA 80-85 </li></ul><ul><li>Elderly people 5 </li></ul><ul><li>Other chronic inflammatory rheumatic diseases </li></ul><ul><li>– Primary Sjogren’s syndrome 75-90 </li></ul><ul><li>– Mixed cryoglobulinaemia 90-100 </li></ul><ul><li>– SLE 20-30 </li></ul><ul><li>– Systemic sclerosis 20-30 </li></ul><ul><li>– Mixed connective tissue disease 50-60 </li></ul><ul><li>Chronic bacterial infections </li></ul><ul><li>– Subacute bacterial endocarditis 25-50 </li></ul><ul><li>Miscellaneous conditions </li></ul><ul><li>– Sarcoidosis 5-33 </li></ul><ul><li>– Interstitial pulmonary fibrosis 10-50 </li></ul><ul><li>– Chronic active hepatitis 25-40 </li></ul>Not all seropositive arthritides are RA Rheumatoid Arthritis
  • 42. <ul><li>Criterion Definition </li></ul><ul><li>1. Morning stiffness Stiffness in joints lasting at least 1 hour </li></ul><ul><li>2. Arthritis in 3 or more joints Pain and swelling in at least 3 joints </li></ul><ul><li>3. Arthritis in hand joints Swelling in at least 1 of the following </li></ul><ul><li>areas: wrist, MCP or PIP joint </li></ul><ul><li>4. Symmetric arthritis Involvement of the same joint area on </li></ul><ul><li>both sides of the body </li></ul><ul><li>5. Rheumatoid nodules Subcutaneous nodules over bony prominences </li></ul><ul><li>or extensor surfaces or around joints </li></ul><ul><li>6. Serum rheumatoid factor Positive rheumatoid factor </li></ul><ul><li>7. Radiologic changes Periarticular osteopenia or erosions in </li></ul><ul><li>joints visible on radiographs of hands or feet </li></ul><ul><li>Criteria 1 through 4 must be present for at least 6 weeks. </li></ul><ul><li>Confirmation of 4 or more of these 7 criteria is considered diagnostic of rheumatoid </li></ul><ul><li>arthritis. </li></ul>American Rheumatism Association,1997 revised criteria for diagnosing RA Rheumatoid Arthritis
  • 43. Predictive factors for persistent RA Rheumatoid Arthritis <ul><li>Morning stiffness > 1 hours </li></ul><ul><li>Arthritis in 3 or more joints </li></ul><ul><li>Bilateral compression pain in MP joints </li></ul><ul><li>IgM RA factor > 5 I.U. </li></ul>
  • 44. <ul><li>Seronegative RA </li></ul><ul><li>Psoriatic arthropathy </li></ul><ul><li>SLE </li></ul><ul><li>Scleroderma </li></ul><ul><li>Juvenile idiopathic arthritis </li></ul><ul><li>Adult onset Still’s disease </li></ul><ul><li>Inflammatory bowel disease </li></ul>Seronegative Inflammatory polyarthritides
  • 45. <ul><li>Ankylosing spondylitis </li></ul><ul><li>Reactive arthritis (including Reiter’s syndrome) </li></ul><ul><li>Psoriatic spondyloarthropathy </li></ul><ul><li>Inflammatory bowel disease </li></ul><ul><li>(Enteropathic spondyloarthropathy) </li></ul><ul><li>Juvenile spondyloarthropathy </li></ul><ul><li>Unclassifiable or undifferentiated spondyloarthropathy </li></ul>Seronegative Spondyloarthropathies (SpA)
  • 46. <ul><li>Seronegative, that is, rheumatoid factor is absent </li></ul><ul><li>Affect the axial skeleton; inflammatory low back pain </li></ul><ul><li>is common. </li></ul><ul><li>Cardinal feature is involvement of sacroiliac joints </li></ul><ul><li>Peripheral joint involvement is usually asymmetrical </li></ul><ul><li>Oligoarticular, below waist </li></ul><ul><li>Usually associated with HLA-B27. </li></ul><ul><li>Enthesopathy is characteristic </li></ul><ul><li>Usual age < 40 years </li></ul><ul><li>Male preponderance </li></ul>Seronegative SpA Features
  • 47. Ankylosing spondylitis <ul><li>Spondyloarthropathy </li></ul><ul><li>Late adolescence & early adulthood </li></ul><ul><li>Spine & large joints </li></ul><ul><li>Leads to fibrous/bony ankylosis </li></ul>
  • 48. Etiology <ul><li>Male predisposition 7:1 </li></ul><ul><li>Autosomal inheritance </li></ul><ul><li>70% penetrance </li></ul><ul><li>90% association with HLA B27 </li></ul><ul><li>Rare in negroes </li></ul>Ankylosing spondylitis
  • 49. Pathology <ul><li>Similar to RA </li></ul><ul><li>Articular & bone destruction </li></ul><ul><li>Fibrous & bony bridging </li></ul><ul><li>Para- articular calcification & ossification </li></ul><ul><li>Bamboo spine </li></ul>Ankylosing spondylitis
  • 50. Clinical Features <ul><li>Morning pain & stiffness </li></ul><ul><li>Sacroiliac pain </li></ul><ul><li>Muscle spasm- flexed posture </li></ul><ul><li>Wt loss, anaemia </li></ul><ul><li>Decreased chest expansion </li></ul><ul><li>Ankylosis </li></ul>Ankylosing spondylitis
  • 51. Radiology <ul><li>Patchy osteoporosis </li></ul><ul><li>Fusion of SI joints </li></ul><ul><li>Squaring of vertebral bodies </li></ul><ul><li>Syndesmophytes – bone bridge </li></ul><ul><li>Diminished joint space </li></ul><ul><li>Bony ankylosis of major joints </li></ul>Ankylosing spondylitis
  • 52. Crystal Arthropathies <ul><li>Monosodium urate crystals </li></ul><ul><ul><ul><li>Gouty Arthritis </li></ul></ul></ul><ul><li>Calcium Pyrophosphate crystals </li></ul><ul><ul><ul><li>Chondroclacinosis </li></ul></ul></ul><ul><li>Calcium hydroxyapatite crystals </li></ul><ul><ul><ul><li>Calcific Periarthritis destructive arthropathy </li></ul></ul></ul>
  • 53. <ul><li>Primary Gout </li></ul><ul><ul><li>Heritable Error of metabolism </li></ul></ul><ul><ul><li>Causing overproduction or retraction of uric acid </li></ul></ul><ul><li>Secondary Gout </li></ul><ul><ul><li>Myeloproliferatic disease </li></ul></ul><ul><ul><li>Chronic haemolytic slab </li></ul></ul><ul><ul><li>Drug – Dicureties pyrzinemide </li></ul></ul><ul><ul><li>Starvation </li></ul></ul><ul><ul><li>Chronic glomerulo-nephritis and pyelonephritis </li></ul></ul><ul><ul><li>Hypothyroidis </li></ul></ul>Crystal Arthropathies Types & Causes
  • 54. Gout <ul><li>Hyperuricaemia </li></ul><ul><li>Monoarticular in early stage </li></ul><ul><li>MCP joint - great toe </li></ul><ul><li>Uric acid crystal deposition </li></ul><ul><li>Tophus </li></ul><ul><li>Punched out </li></ul><ul><li>para-articular lytic lesion </li></ul><ul><li>Tophi & synovial fluid shows </li></ul><ul><li>presence of MSU crystals </li></ul><ul><li>- confirmatory of diagnosis </li></ul>Crystal Arthropathies
  • 55. Monosodium Urate Crystal Crystal Arthropathies Positive bifringence & needle shaped
  • 56. Pseudogout Crystal Arthropathies <ul><li>Younger age group compared to gout </li></ul><ul><li>Larger joints involved compared to gout </li></ul><ul><li>Knee most commonly involved </li></ul><ul><li>Severity of clinical features less compared to gout </li></ul><ul><li>Calcification of cartilages hallmark sign </li></ul><ul><li>Negative bifringent and rhomboid shaped crystals </li></ul>
  • 57. Psoriatic Arthritis <ul><li>Symmetric polyarthritis </li></ul><ul><li>Higher frequency of DIP involvement </li></ul><ul><li>Enthesitis </li></ul><ul><li>Dactylitis (sausage shape digits) </li></ul><ul><li>Recognition of psoriatic plaques is </li></ul><ul><li>important </li></ul>
  • 58. Radiology <ul><li>Erosion </li></ul><ul><li>Osteolysis </li></ul><ul><li>Bone proliferation </li></ul><ul><li>Ankylosis </li></ul>Psoriatic Arthritis
  • 59. Reiter’syndrome <ul><li>Triad of : </li></ul><ul><li>May be associated with : </li></ul><ul><li>Mucocutaneous disease </li></ul><ul><li>(balanitis, ulcers, keratoderma ) </li></ul>Asymmetrical arthritis Urethritis/cervicitis or Diarrhoea Conjunctivitis
  • 60. Systemic Lupus Erythematous <ul><li>Photosensitivity </li></ul><ul><li>Malar or discoid rash </li></ul><ul><li>Mucosal ulcers (hair loss) </li></ul><ul><li>Raynaud’s, vasculitis </li></ul><ul><li>Arthritis (non-erosive) </li></ul><ul><li>Serositis: pleurisy/pericarditis </li></ul><ul><li>Neurological: fits/psychosis </li></ul><ul><li>Renal disease (urinalysis) </li></ul><ul><li>Haematological: </li></ul><ul><li>low platelets, </li></ul><ul><li>leucopenia, </li></ul><ul><li>haemolytic anaemia </li></ul><ul><li>Anti-ds DNA antibodies </li></ul><ul><li>ANA </li></ul>Features Photosensitivity Butterfly facial rash Discoid rashes
  • 61. <ul><li>Arthritis most common manifestation </li></ul><ul><li>Symmetric non erosive arthritis </li></ul><ul><li>Small joints of hand, wrist, knee most commonly involved </li></ul><ul><li>Nodules similar to RA present </li></ul><ul><li>Jaccoud’s arthropathy </li></ul><ul><li>( ulnar deviation + swan neck deformity ) </li></ul><ul><li>Systemic features help in reaching diagnosis. </li></ul>Arthritis in SLE SLE
  • 62. THANK YOU

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