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ARTHRITIS & RHEUMATOLOGY by DR K. DELE
- 1. ARTHRITIS BY: DR KD DELE DEPT OF FAMILY MEDICINE DORA NGINZA HOSPITAL
- 3. INTRODUCTION • Joint pain can originate from the joint itself or from the surrounding tissues. • More than 100 rheumatic conditions • Overlap in clinical presentations • Initial presentation may not lead to a precise diagnosis in up to 50% of cases • Over time most patients will have characteristic features of a disease
- 4. INTRODUCTION, CONT. • Patients will typically complain of: • “Dr I have Arthritis” • Pain specific to certain joints or groups of joints • “My Body Is Sore!” • Careful History and Physical examination is required to discern between pathologies and to make a diagnosis. • DIAGNOSIS CAN BE MADE BASED ON HISTORY AND PHYSICAL EXAM FINDINGS 80-90% OF THE TIME
- 5. THE RHEUMATOLOGIC HISTORY • Pain is the cardinal symptom of musculoskeletal disorders DIAGNOSTIC APPROACH : • Establish the demographics of the patient: Age Gender Ethnicity Family History • Characterize joint pain and ask about associated features • Characterize the pain: Inflammatory vs. Non inflammatory • Constitutional symptoms
- 6. 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
- 7. HISTORY CONT. History of 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.
- 8. HISTORY CONT. Where is the Pain? •Which joints are involved •Mono / Polyarticular For how long have you had pain? •Acute •Chronic (>6weeks) •Intermittent? History of Trauma?
- 9. HISTORY CONT. •Early morning? •Constant during the day? •Night waking? When do you get the pain? •Work •Repetitive Stress of joint •Food / Drink Aggravating Factors
- 10. HISTORY CONT. • Relieving Factors: • Rest • Analgesia – simple; NSAIDS; Opiates • Effect on Activities of Everyday Living. • Age and Gender of Patient.
- 11. CHRONOLOGY OF COMPLAINTS ONSET- Acute: < 6 weeks e.g. • infectious arthritis • crystal arthropathy • reactive arthritis. Chronic: >6 weeks e.g. • Non-inflammatory arthritis (OA) • Inflammatory arthritis(RA) • Fibromyalgia.
- 12. CHRONOLOGY OF COMPLAINTS CONT. •Monoarticular (one joint involved) •Oligo- or pauci- articular (2-4 joints are involved) •Polyarticular (> 4 joints are involved) Extent of articular involvement •Symmetrical: upper and lower limb; e.g. RA, SLE •Asymmetrical: e.g. psoriatic arthritis, spondylo-arthropathy, gout •Involvement of axial skeletal: e.g. AS, OA, RA (only cervical spine) Distribution of joint involvement
- 13. HISTORY CONT. ORGAN SPECIFIC SYMPTOMS Eye: Pain, redness, dryness, vision changes Heart: Chest pain, palpitations, orthopnea, PND Lungs: Dyspnea, cough Kidneys: Hematuria, edema GI: GERD, dysphagia, GIB, bowel habit changes Skin: Ulcer, photosensitivity, rashes, alopecia, nail abnlity Neuro: CNS changes, neuropathy, CN abnormalities ID: recent infections
- 14. PHYSICAL EXAMINATION Head to toe evaluation: Rashes, telangiectasias, nail changes, pigmentation changes Peripheral pulses, bruits Back exam Joint exam
- 15. RHEUMATIC DISEASE SIGNS Swelling Posture of joint Deformity Warmth Redness Tenderness Limitation of joint movement Crepitus Stability Function
- 16. DIFFERENTIAL DIAGNOSIS Monoarthritis 1 Joint Oligoarthritis 2-4 joints or joint groups Polyarthritis 5 or more joints • Septic Arthritis • Crystal Synovitis • Gout • Pseudogout • Hemarthrosis • Foreign Body / Trauma • Neoplasm • Avascular necrosis • Monoarticular presentation of oligo- or polyarticular disease • Osteoarthritis • Seronegative spondylo-arthropathy • Erythema Nodosum • Infection • Neisseria • Mycobacteria • Bacterial Endocarditis • Generalised osteoarthritis • Rheumatoid Arthritis • Seronegative spondylo-arthopathy • Lupus • Chronic Gout • Scleroderma • JRA
- 17. ARTICULAR AND NON-ARTICULAR PAIN ARTICULAR • Deep or diffuse pain. • Painful or limited range of movement - both active and passive • Swelling of joint • Crepitation. • Joint instability. • Locking of joint. • Deformity. NON-ARTICULAR • 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.
- 18. ARTICULAR AND NON-ARTICULAR PAIN • Articular structures include the synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule, and juxta-articular bone. • Non articular (or periarticular) structures include: supportive extra articular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin,
- 22. INFLAMMATORY Acute arthritis Chronic arthritis Monoarthritis e.g. • Crystal induced arthritis (gout and pseudogout) • Septic arthritis • Gonococcal arthritis • Acute onset of inflammatory polyarthritis (like RA, SLE) Monoarthritis e.g. • Tubercular arthritis • Fungal arthritis • Other infections (e.g Brucellosis) • Immunoinflammatory arthritis • Crystal induced arthritis Polyarthritis e.g. • acute onset of polyarthritis, • reactive arthritis Polyarthritis e.g. • RA, • psoriatic arthritis, • spondyloarthritis
- 23. NON-INFLAMMATORY Acute arthritis Chronic arthritis Monoarthritis Hemarthrosis Trauma Monoarthritis Single joint osteoarthritis Neuropathic arthropathy Osteonecrosis Pigmented villo nodular synovitis Polyarthritis Polyarthritis (e.g., osteoarthritis)
- 24. LABORATORIES: • Results must be interpreted in light of the clinical findings • Three areas of interest: • Blood, • Urine, • Synovial fluid
- 25. LABORATORIES: BLOOD • • CBC: Anaemia, leukopaenia, thrombocytopenia • • Chemistries: renal insufficiency, elevated LFT’s, uric acid • • ESR/CRP: non specific • • Autoantibodies: RF, ANA, ENA, dsDNA, ANCA • • HLA B-27, HLA B-51 • • ASO • • Ferritin • • Lyme titre
- 26. LABORATORIES: URINE • Proteinuria • Haematuria • Active sediment
- 27. LABORATORIES: SYNOVIAL FLUID • Cell count • Gram stain and culture • Crystal analysis
- 29. DIAGNOSTIC IMAGING • Plain X-ray • Ultrasonography • Scintigraphy-Tc-99,Ga-67 • CT Scan • MRI
- 31. SEPTIC ARTHRITIS
- 32. INTRO • Medical Emergency! • Rapid onset monoarticular joint inflammation • Rapid destructive joint disease • Morbidity and mortality of 10% • Patients with septic arthritis already have a bacteraemia!
- 33. RISK FACTORS • Extremes of Age • Pre-existing joint disease • Immunosuppression • Prosthetic hip / knee joint / Joint surgery • Skin Infection • Rheumatoid Arthritis. • Diabetes Mellitus. • Elderly patients over age 80 years old. • Intravenous drug use (unusual joints affected).
- 34. AETIOLOGY • Young sexually active adults • Neisseria gonorrhoeae (most common, and more common in women • Staphylococcus aureus • Streptococcus • Older adults • Staphylococcus aureus (50%) • Streptococcus species • Gram Negative Bacilli • Most common organism Staph. Aureus, however important to rule out disseminated gonococcal infection in young sexually active patient.
- 35. CLINICAL FEATURE OF SEPTIC ARTHRITIS • Acute onset • Typical joints include knee and hip • Swollen joint. • Erythema • Warm joint. • Held in position of least resistance
- 36. CLINICAL FEATURE OF SEPTIC ARTHRITIS 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
- 37. INVESTIGATION: • Joint Aspiration and MCS • Sterile procedure • Fluid may appear purulent / turbid, bloodstained or normal • Infective Markers • Blood Culture
- 38. MANAGEMENT: • Hospitalization • Analgesia • IV Antibiotics: e.g. Cloxacillin 200mg / kg / day • Surgical Drainage • Rehabilitation • Oral Antibiotics: e.g. Flucloxacillin 100mg / kg / day for 3 weeks
- 39. GOUT
- 40. GOUT: URIC ACID CRYSTALS • Pathological reaction of the joint and periarticular tissue to presence of sodium monourate crystals.
- 41. GOUT: URIC ACID CRYSTALS
- 42. PATHOPHYSIOLOGY HYPERURICAEMIA Over Production •Unidentified abnormality •Specific Enzyme Defect •Chronic Myeloproliferative or lymphoproliferative disorders Under Excretion •Inherited Renal Tubular Defect •Renal Failure •Drugs – Aspirin; Thiazides; Cyclosporin •Lactic Acidosis.
- 43. RISK FACTOR • -Obesity • -Diabetes Mellitus • -Hyperlipidemia • -Hypertension • -Atherosclerosis • -Alcohol use • -Thiazide Diuretics • -Renal insufficiency • -Myeloproliferativedisease
- 44. CLINICAL FEATURE GOUT: • Joint Inflammation - Asymmetric joint involvement. May only involve one side with the first attack • Acute , intermittent and recurrent • Chronic Tophaceous Gout • Severe pain (Worst ever) • Extreme tenderness • Swelling, erythema and hot joint. • Fever and chills
- 45. MOST COMMON JOINTS • 1st Metatarsophalangeal joint (MTP) – 50% • Ankle • Midfoot • Knee • Small joints of hand • Wrist • Elbow
- 48. INVESTIGATION: • It is a clinical diagnosis • investigations is to rule out other pathology: • Aspiration of Synovial Fluid: Sodium urate crystals / Neutrophils • Serum Urate / Uric Acid: No bearing on diagnosis and management as often is normal during attacks • UEC • FBC / ESR - Rule out myeloproliferative disorders • X-rays
- 49. MANAGEMENT: ACUTE ATTACK • NSAIDS (not aspirin) • Colchicine • Joint aspiration and intraarticular steroids • Rule out Septic Arthritis
- 50. MANAGEMENT: CHRONIC MANAGEMENT • Patient education • Correction of Lifestyle (Gout Diet) • Allopurinol • Recurrent attacks • Tophaceous gout • Bone / joint damage • Associated renal disease • Greatly elevated sUrate • Surgery • Removal of chronic deposits • Repair damaged soft tissue • Joint repair
- 51. OSTEOARTHRITIS
- 52. OSTEOARTHRITIS • Most common form of arthritis. • Results from disparity between stress applied to a joint and the ability of the joint to withstand the stress • Degenerative disorder characterised by progressive loss of articular cartilage, capsular fibrosis and new bone formation
- 53. OSTEOARTHRITIS • Prevalence directly increases with age: • Almost universal after 65 years but only 50% of patients are symptomatic • Associated functional impairment • Primary - No demonstrated cause • Secondary - Due to abnormal stress on joint • Marginal osteophytes
- 54. CLINICAL FEATURES OF OSTEOARTHRITIS • Pain: Aggravated by stress on joint / motion; and relieved by rest. • Stiffness: Progressive loss of range of motion (initially after use of joint). Typically Morning stiffness of short duration (<30 minutes) • Crepitus • Deformity • Swelling - Persistent or intermittent
- 55. DISTRIBUTION OF OSTEOARTHRITIS • Typical joints involved: • Small joints in hands • DIP (Heberden’s Nodes) • PIP (Bouchard's Nodes) • First CMC joint (thumb) • Hip / Knee / Feet and Shoulder joint. • Cervical and lumbar spine
- 58. INVESTIGATION: • It is a clinical diagnosis. • X ray is non essential but may help in differentiating OA from other arthritis • XR Features of OA: • Joint space narrowing • Subchondral sclerosis • Osteophyte formation • Bone Cysts formation. • No osteopenia • Evidence of previous disorders e.g. trauma or congenital problem.
- 61. MANAGEMENT: EARLY • Reduce Load: Reduce weight / Avoid abnormal loading / Use walking stick • Increase Movement: Physiotherapy • Pain Relief: • Simple analgesia • NSAIDS if inflammatory component noted. • Hyaluronic Acid (still no compelling evidence)
- 62. MANAGEMENT: LATE • This is when there's failure of conservative management • Joint debridement • Osteotomy • Arthroplasty • Arthrodesis • Decompression
- 63. MANAGEMENT: LATE When to Operate • Patient’s symptoms are interfering with ADL • Benefits of surgery outweigh risks • Preventative surgery
- 66. RHEUMATOID ARTHRITIS • Symmetrical, deforming small and large joint polyarthritis, often associated with systemic disturbance and extra articular features • 3% of population • Affects all ethnic groups • Peak incidence 4-6th decades • Lowest in Black Males / Highest in White Females • Pathology is based on synovial proliferation with inflammatory destruction of the joint
- 67. CLINICAL FEATURE RHEUMATOID ARTHRITIS: • 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 Right &Left 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 (supports diagnosis – 20% are seronegative). • 7. Radiographic changes – erosion or bony decalcification in or adjacent to involved joints. • NEED TO HAVE 4 OF 7
- 68. SCORING CRITERIA- AMERICAN COLLEGE OF RHEUMATOLOGY 2010 • A. Joint involvement • 1 large joint: 0 • 2-10 large joints: 1 • 1-3 small joints (+/- large joints): 2 • 4-10small joints (+/- large joints): 3 • >10 joints (at least 1 small joints): 5
- 69. SCORING CRITERIA- AMERICAN COLLEGE OF RHEUMATOLOGY 2010 • B. Serology. At least 1 test result is needed for scoring: • Neg RF+ & ACPA* (</= ULN**): 0 • Low positive RF or ACPA (</=3 X ULN): 2 • High positive RF or ACPA(>3 X ULN): 3 • *ACPA – Anti-citrullinated protein antibody • **ULN – upper limit of normal • +RF – Rheumatoid Factor
- 70. SCORING CRITERIA- AMERICAN COLLEGE OF RHEUMATOLOGY 2010 • C. Acute phase reactants (at least 1 test result needed for classification) • Normal CRP or ESR: 0 • Abnormal CRP or ESR: 1
- 71. SCORING CRITERIA- AMERICAN COLLEGE OF RHEUMATOLOGY 2010 • D. Duration of symptoms • <6 weeks: 0 • >/= 6 weeks: 1
- 72. NB • Score >/= 6/10 is RA • Large joints: shoulders, elbows, hips, knees, ankles • Small joints: PIP, MCP, MTP, wrists (Spares DIP) • Diff diagnosis: SLE, Psoriatic arthritis, etc. • Duration of symptoms is as self reported by patient
- 74. DEFORMITIES • Z deformity • Swan neck deformity • Boutonniere deformity
- 76. Z - DEFORMITY
- 78. EXTRAARTICULAR FEATURES: • Systemic • Musculoskeletal • Haematological • Lymphatic • Ocular • Vasculitis • Cardiac • Pulmonary • Neurological
- 79. INVESTIGATION: • Confirmed according to clinical criteria • Rheumatoid Factor : Not positive in all patients, and Not all positive pts. have RA • X-ray Features: • Periarticular Soft Tissue Swelling • Joint Space Narrowing • Bony erosions • Subchondral cysts • Periarticular Osteopenia
- 80. X-RAY FEATURES:
- 81. X-RAY FEATURES:
- 82. MANAGEMENT: • Team Approach • Goals • Stop Synovitis • Prevent Deformity • Reconstruct • Rehabilitate
- 83. 1. STOP SYNOVITIS: • NSAIDS: Gives Symptomatic relief, non curative • DMARDS: • Corticosteroids: • Ineffective Response to DMARDs • Acutely ill • Significant systemic disease • Social Problems
- 84. 1. STOP SYNOVITIS: DMARDS: • Chloroquine: • Safe, little need for laboratory follow up / Inexpensive / Ocular Toxicity • METHOTREXATE (MTX): • Low dose is the Gold Standard for DMARDS • Rapid Disease Suppressing effect • Baseline UEC / LFT and Hep Screen • LFT’s 4-8 weeks • DOSAGE IS WEEKLY • NEVER GIVE WITH COTRIMOXAZOLE (Haemotoxic) • Others : Gold / Sulphasalazine / D-Penicillamine / Azathroprine
- 85. MANAGEMENT CONT.: 2. Prevent Deformity • Physiotherapy • Occupational Therapy • Surgery – Tendon Repair or replacement 3. Reconstruct • Arthrodesis • Arthroplasty 4. Rehabilitate • Accompanies all stages of treatment • OT and work training
- 86. SERONEGATIVE SPONDOARTHROPATHIES • Psoriatic arthritis • Reactive arthritis • Enteropathic arthritis • Ankylosing sponylosis
- 87. FEATURES OF SPONDOARTHROPATHIES • Absence of RA Factor, subcut nodules • Sacroiliatis /spondylitis + • Asymmetric peripheral joints • Extra articular - ocular, oral, skin, enthesitis • Familial aggregation • HLA-B27 +
- 88. DISTRIBUTION OF SPONDOARTHROPATHIES • Asymmetric arthritis • Axial spine & lower limb joints • Soft tissues involvement • Bursitis, Achilles tendonitis, epicondylitis, plantar fasciitis
- 90. ANKYLOSING SPONDYLITIS • Inflammatory arthropathy with emphasis on involvement of spine and sacroiliac joints. • Characterised by progressive stiffening and fusion of the axial skeleton. • Sacroiliatis / Syndesmophytes / Bamboo spine / Inflammatory Backache
- 91. CLINICAL FEATURES: • Young males (20’s-30’s / 3:1 Male: Female Ratio) • Chronic insidious onset • Recurrent episodes of low back pain and stiffness • Radiation to buttocks and thighs (symmetrical) • Marked after rest and improve with movement
- 92. ON EXAMINATION • Pain on SI joint compression • Restriction of movement of lumbar spine • Limited Chest expansion • Schober’s Test is positive
- 93. SCHOBER’S TEST
- 94. INVESTIGATION: • ESR • HLA B27 Antigen: Positive 95% cases • X-rays: • Fuzziness or Frank Erosion of SI joint, progressing to sclerosis • Syndesmophytes – Ossification across intervertebral discs • Bamboo spine
- 95. X-RAYS:
- 97. MANAGEMENT: • Relieve Pain and Stiffness • Maintain maximal mobility • Avoid deformity • NSAIDS particularly long acting, given at night may provide symptomatic relief • Surgery: Osteotomy of spine to correct deformity Arthroplasty of destroyed joints
- 98. FIBROMYALGIA
- 99. FIBROMYALGIA • Common cause of multiple regional musculoskeletal pain and disability • No underlying identifiable pathology • Assoc. physiological abnormalities of sleep patterns and pain processing • Reduced amount of Delta sleep during night • Reduced threshold to pain perception and tolerance at characteristic sites throughout the body. • Associated with other medically unexplained symptoms in other systems of the body
- 100. CLINICAL FEATURES: • Multiple body pains – Eventually affecting all body quadrants • Both arms, legs, neck , back • Reported disability is marked – Able to dress, eat, groom • Unable to work etc • Fatigability is often marked – (especially in morning) • On Examination • No overt musculoskeletal pathology (may have signs of other arthropathy not consistent with symptoms) • Hyperalgesia at recognised trigger points producing a wince / withdrawal
- 102. CLINICAL FEATURES CONT’D: • Criteria for Fibromyalgia: • Appropriate symptoms including pain in all body quadrants • Positive Hyperalgesic tender sites in each arm and leg and axially • Negative control tender sites. • (Pressure on Forehead, squeezing distal radius/ulna, pressure over proximal fibular head does not elicit any pain)
- 103. INVESTIGATION: • Fibromyalgia is not associated with test abnormalities • Tests are based on ruling out organic pathology • FBC - Anemia, lymphopenia of lupus • ESR, CRP - Inflammatory disease • TFT’s - Hypothyroidism • CMP - Hyperparathyroidism • ANA - Lupus
- 104. MANAGEMENT: • Education for patient and family • Sleep hygiene • Graded aeorobic exercise programme • Low dose amitriptyline • Fluoxetine
- 106. MUSCULOSKELETAL MANIFESTATIONS OF SYSTEMIC DISEASE • Many systemic diseases result in musculoskeletal symptoms and signs. • A thorough history and PE is essential to avoid treating patient’s musculoskeletal symptoms rather than their systemic disease • “ALL THAT ACHES IS NOT ONLY BONE”