An apt yet detailed description of Polyarthritis for undergraduate level with basic definitions, classification, concept, clinical features along with descriptive images, diagnosis & assessment with distinguishing features along with differential diagnosis.
6. RHEUMATOID ARTHRITIS
Chronic inflammatory joint disease with multisystem
involvement.
*Epidemiology -
• Incidence 1.4/10000 male, 3.6/10000 females
• Prevalence 0.5-2 %
• male:female 1:3
• Worldwide distribution - higher in native Americans
absent in some parts of Africa
• Onset any age but maximum - 40 - 70 years in
women , 60 - 70 years in men
7.
8. * Onset
Typical
-Insidious onset polyarthritis
-Affecting small joints of hand & feet
- Fatigue, anorexia, weakness & vague musculoskeletal
symptoms
Atypical
-Polymyalgic
-Palindromic
-Systemic
-Persistent monoarthritis
9. • Symmetrical deforming polyarthritis
-Affects synovial lining of joints, bursae and tendons
-More than just joint disease
• Progression of joint involvement
-Spread occurs within months to years to other joints
-Almost any joint may be involved
-Spontaneous remission can occur
-Poor prognosis – RA factor exists
• Symptoms Of inflammation
-Stiffness, pain, swelling, warmth, redness
* Clinical Features
10. Pattern of joint involvement
• symmetrical
• small joints of hands - DIP spared
• characteristic features
-Boutonniere
-Swan neck
-Z thumb
-Volar subluxation
-Ulnar deviation
14. • Morning stiffness > 1 hours
• Arthritis in 3 or more joints
• Bilateral compression pain in MP joints
• IgM RA factor > 5 I.U.
* Predictive factors for persistent RA
15. • Most common joint disorder
• Affects 190 million worldwide
• Nearly 70% of people over 65 years
• Aging population over 65 years
-1997~ 400 million ( 70 million plus in India )
-2025~ 800 million ( 150 million plus in India )
• In India has overtaken diabetes, and now ranks 1st in
chronic debilitating disease.
OSTEOARTHRITIS
18. • Old patient
• Females > males
• Lower limb joints~ knees, hips, 1st CM joint
• Rest pain
• Pain during movement
• Crepitus
• Characteristic deformities
* Clinical Features
19.
20. 0 – No features of osteoarthritis
1 – Doubtful, osteophyte of doubtful significance
2 – Minimal, definite osteophyte but joint space
unimpaired
3 – Moderate, moderate diminution of joint space
4 – Severe, Joint space severely impaired with sclerosis
of sub-chondral bone
* Kellegren & Lawrence Scale for Osteoarthritis
22. • Seronegative, that is, rheumatoid factor is absent
• Affect the axial skeleton; inflammatory low back pain
is common.
• Cardinal feature is involvement of sacroiliac joints
• Peripheral joint involvement is usually asymmetrical
Oligoarticular, below waist
• Usually associated with HLA-B27.
• Enthesopathy is characteristic
• Usual age < 40 years
• Male preponderance
* Features
23. I. Ankylosing Spondylitis
• Spondyloarthropathy
• Late adolescence & early adulthood
• Spine & large joints
• Leads to fibrous/bony ankylosis
24. • Male predisposition 4:1
• Autosomal inheritance
• 70% penetrance
• 90% association with HLA B27
• Rare in negroes
* Etiology
25. • Similar to RA
• Articular & bone destruction
• Fibrous & bony bridging
• Para- articular calcification & ossification
• Bamboo spine
* Pathology
28. Primary Gout
-Heritable Error of metabolism
-Causing
overproduction or retraction of uric acid
Secondary Gout
-Myeloproliferatic disease
-Chronic glomerulo-nephritis and pyelonephritis
-Hypothyroidism
* Types
29. • Hyperuricaemia
• Monoarticular in early stage
• MCP joint - great toe
• Uric acid crystal deposition
• Tophus
• Punched out para-articular lytic lesion
• Tophi & synovial fluid shows presence of MSU
crystals- confirmatory of diagnosis
* Gout
30. • Younger age group compared to gout
• Larger joints involved compared to gout
• Knee most commonly involved
• Severity of clinical features less compared to gout
• Calcification of cartilages hallmark sign
* Pseudogout
35. • Arthritis most common manifestation
• Symmetric non erosive arthritis
• Small joints of hand, wrist, knee most commonly involved
• Nodules similar to RA present
• Jaccoud’s arthropathy ( ulnar deviation + swan neck
deformity)
• Systemic features help in reaching diagnosis.
* Arthritis in SLE
36. Feature Ankylosing
Spondylitis
Reactive Arthritis Psoriatic
Arthritis
IBD associated
spondyloarthropathy
Age at onset Late teens to
early adulthood
Late teens to early
adulthood
35-35 years Any age
Male to female
ratio
4:1 5:1 1:1 1:1
HLA-B27
positive
90% 80% 40% 30%
Frequency of
sacroilitis
100% 40-60% 40% 20%
Distribution of
sacroilitis
Symmetrical Asymmetrical Asymmetrical Symmetrical
Syndesmophytes Marginal Non-marginal Non-marginal Marginal
Enthesitis Common Very common Very common Occasional
Dactylitis Uncommon Common Common Uncommon
Skin changes None Circinate
blanitis,keratoderma,
blenorrhagica
Psoriatic
lesions
Erythema nodosum,
pyoderma
gangrenosum
38. Assessment of Joint Pain
Site (distribution)
Type of pain
Associated features
Duration & onset
Risk factors
Physical Signs
Differential Diagnosis
Investigations
39. Site & distribution of pain
• Is it joint, peri-articular or muscle pain?
• Which joints are involved?
• Is it symmetrical or asymmetrical?
• Where did it start?
• Is the arthritis migratory, additive, episodic?
40. RA
PIP, MCP, wrists, elbows, shoulders, neck,knee, ankle,
MTP, symmetrical
DIP not involved
Sero-ve
DIP, dactylitis, enthesitis, spinal
PIP not involved
asymmetrical
OA
Weight bearing joints DIP, PIP, CMC, ACJ
MP not involved
41. Type of Pain
• Is it inflammatory?
• Is it mechanical / degenerative?
• What makes the pain worse/better?
Inflammatory Mechanical
Immobility stiffness Latter day EMS>30-
60 mins EMS<30-60 mins Better with
activity Worse with activity Joint
swelling, erythema, heat Instability Systemic
symptoms Locking Multi-organ
involvement Trauma, strain
42. • Is there morning stiffness?
• Have there been any symptoms of infection?
• Have there been any rashes ?
• Any urinary, genital or gut problems?
Associated features
43. • When did the joint pains begin?
• Are the symptoms getting better or worse?
Duration & Onset
Acute Chronic
* Viral - parvo/rubella
* Bacterial - strep
* Rheumatoid
* Reactive - GU/Gastro
* Erythema nodosum
* Vasculitis
* Rheumatoid
* Sero - negative - Psoriatic/ IBD
* Connective tissue disease - SLE/SjS
* Polyarticular OA
44. • Age
• Sex
• Racial/ethnic background
• Family history
• Treatment history
• Social history
Other risk factors
