This document provides guidance on evaluating a patient presenting with arthritis. It describes how arthritis is defined and classified based on the number and duration of involved joints. Key components of the history include symptoms, physical exam findings, classification, differential diagnoses, and initial investigations for monoarthritis and polyarthritis. Initial workup may include blood tests, imaging, and synovial fluid analysis to help identify conditions like gout, pseudogout, septic arthritis, trauma, and rheumatic diseases.

1. APPROACH TO THE
PATIENT WITH
ARTHRITIS
Presenter-Dr Ashutosh

2. Introduction
• A patient is said to have arthritis if one has joint pain and
swelling, and the origin of “joint pain” (True arthritis) is from
the Joint (articular ) structures, in contrast to pain arising
from periarticular structures.
• Articular structures include Synovium, synovial fluid, cartilage,
intraarticular ligaments, the joint capsule and the adjacent
bone
• Periarticular structures include ligaments, tendons, bursae,
muscle, fascia , bone and nerve.

3. SYMPTOMS
• Pain-Pain is a subjective hurting sensation or experience
described in various terms, often of actual or perceived
physical damage.
• Swelling-Patients with inflammatory arthritis may describe
swelling of joints in a distribution typical of a specific
disease—symmetric swelling of the metacarpophalangeal
joints and wrists in rheumatoid arthritis, or swelling of several
toes and a knee in psoriatic arthritis
• Stiffness-Discomfort and limitation on attempted movement
of joints after a period of inactivity.
• Limitation of Motion-Duration of restriction and determining
the rapidity.

4. • Loss of Function-The extent of disability may vary from loss of
the ability to use one finger joint due to arthritis to complete
physical incapacitation due to severe inflammatory
polyarthritis.
• Fatigue-Patients with rheumatic diseases experience fatigue
even without activity.
• Weakness-The temporal course of weakness is important to
the differential diagnosis.

5. SIGNS
• Tenderness-In the musculoskeletal examination, tenderness
indicates unusual discomfort on palpating and putting
pressure on articular and periarticular tissues.
• Crepitation-Crepitation is a palpable or audible grating or
crunching sensation produced by motion. This sensation may
or may not be accompanied by discomfort.
• Deformity-Deformity of the joints may manifest as a bony
enlargement, articular subluxation, contracture, or ankylosis in
non anatomic positions.
• Instability -Joint instability is present when the joint has
greater than normal movement in any plane.

6. Classification of Arthritis
Based on Number of joints involved:
• Monoarthritis-Single joint involvement
• Oligoarthritis- 2-3 joint involvement
• Polyarthritis- Pain and swelling involving 4 or more joints
Based on duration of Arthritis;
• Acute arthritis-Duration less than 6 weeks
• Chronic arthritis-Duration more than 6 weeks

8. APPROACH TO
MONOARTHRITIS

9. HISTORY
Age-Gout usually occurs in age group of 30-60 years,
Degenervative disorders associated with old age
Occupation- Increased prevalence of OA of the elbows, knees,
and spine in miners, farmers, firefighters, mill workers,
unskilled manual laborers
 Drug history- Gout precipitated by Loop and Thiazide
diuretics, Ethambutol, Pyrizinamide.
Sexual history- Gonococcal arthritis, Reactive arthritis

10. • Pain and joint stiffness, its diurnal variation, and aggravating
and relieving factors should be sought, and a history of
swelling should be established.
• Specific features of relevance include trauma, joint locking.
• Presence of systemic symptoms (fevers ,sweats, rigors, and
weight loss)-suggestive of septic arthritis
• Inquiring about ocular, oral, respiratory, gastrointestinal, or
skin symptoms can facilitate the diagnosis.

12. EXAMINATION
• The Regional Examination of the Musculoskeletal System(REMS) can
be used to identify monoarticular abnormalities.
• Look, feel, and move joints to assess function—comparing the
affected joint and normal side
• In any acutely swollen joint, examination should include looking for
local signs of inflammation (pain, erythema, swelling, heat, and loss
of function).
• Any patient with preceding arthritis should be assessed for chronic
changes to joint structure and disability. Local synovial swelling
and/or effusion, joint instability, limited movement, and deformity
of any single joint necessitate detailed investigation.
• Local monoarticular tenderness without swelling could indicate
enthesitis, tendinitis, bursitis, or bone disease.
• A complete examination should look specifically for ocular signs,
skin rashes,ulcers, and nodules

13. INVESTIGATIONS
1)BLOOD
• Inflammatory, septic, and crystal arthritides cause
elevated (ESR), C-reactive protein (CRP), and white cell
count (WCC), often associated with anemia.
• Systemic disease involvement is assessed by renal, liver,
muscle, or bone biochemical screening and protein
electrophoresis.
• Raised uric acid levels suggest a diagnosis of gout.

14. • In acute hemarthrosis, a platelet count, INR, and
clotting studies are warranted.
• Blood cultures are mandatory in patients with
suspected septic arthritis and should precede
antibiotic prescription
• Viral screening (IgG and IgM antibodies),
antistreptolysin-O test (ASOT), and Lyme serology
can be diagnostic in relevant situations.

15. 2)URINE
• The urinary tract can be a source of gram-negative bacteria in
septic arthritis in the elderly.
• Significant proteinuria and or hematuria and red cell casts
indicate renal damage in SLE, vasculitis, or subacute bacterial
endocarditis

16. IMAGING STUDIES
• A range of imaging studies assist in diagnosis of acute
monoarthritis.
1. Plain radiographs identify soft tissue swelling, calcium in
periarticular tissues, fractures, local bone disease, and loose
bodies, as well as destructive changes in long-standing arthritis
2. Computed tomography (CT): CT scanning better identifies
fractures, bone diseases, and intra-abdominal and chest
pathology. It is useful when magnetic resonance imaging (MRI)
is contraindicated. In acute arthritis, CT scan can show
osteomyelitis over and above acute inflammation.
3. Musculoskeletal ultrasound (US): In acute monoarthritis US
can show loculated synovial fluid to better target aspiration and
injection and power Doppler views can demonstrate increased
blood flow in active synovitis.

17. 4. MRI: Best technique for soft tissueimaging, MRI can
diagnose internal ligament damage and tendon enthesitis and is
most effective in identifying avascular necrosis of bone. MRI is
also useful when identifying the extent of inflammation in acute
monoarthritis and subclinical joint involvement.
5. Arthrography: Imaging internal joint structure after injection
of radiopaque solutions in association with CT scanning is useful
for hip cartilage tears and in situations when MRI is not feasible.
6. Radionuclide scans.
• Bone scintigraphy is helpful when excluding bone and joint
disorders in patients with chronic pain syndromes.
• Bone scans show differences in the pattern of joint
involvement between inflammatory conditions and
osteoarthritis.
• Labeled white cell scans can identify areas of infection,
especially when the source of infection is uncertain in patients
with septic arthritis

18. SYNOVIAL FLUID ANALYSIS
The most useful test in acute monoarthritis is examination of
synovial fluid, which should be analyzed for:
• Color and cloudiness
• Predominant cell type
• Gram stain to detect bacteria
• Polarized light analysis to identify uric acid or calcium
pyrophosphate dehydrate (CPPD) crystals.
• Synovial fluid culture can provide results even when a Gram
stain is negative.

20. SYNOVIAL OR BONE BIOPSY
Arthroscopic synovial biopsy is necessary in
• Tuberculosis
• Sarcoidosis,
• Amyloidosis
• Pigmented villonodular synovitis
• Foreign body synovitis

21. Amyloidosis with deposits on synovial
surface with congo red stain
Synovial pathology of gonococcal arthritis with marked
infiltrate with polymorphonuclear leukocytes and
vascular congestion is present

22. SEPTIC ARTHRITIS
• Large limb joints are most frequently involved.
• Usually associated with underlying osteoarthritis or
inflammatory arthropathies, especially RA.
• Patients are particularly at risk following joint surgery,
arthroplasty, or intra-articular injection, as are patients with a
distant infection, intravenous drug users and those with
underlying disease or drugs that impair the immune response.
• History often elicits an acute, painful, swollen monoarthritis,
but it is noteworthy that more than 10% of patients with native
joint infections present with polyarticular infection.
• Fever occurs in less than 50% and sweats/rigors occur in
approximately 30%.
• Blood cultures may identify bacteria in patients where synovial
fluid culture is negative.

23. • Organisms detected most commonly include staphylococci
(Staphylococcus aureus and Staphylococcus epidermidis),
streptococci, and gram-negative bacteria with an increasing
prevalence of methicillin-resistant S. aureus.
• Infection with Neisseria gonorrhoeae should be suspected in
sexually active patients presenting with migratory arthralgias,
tenosynovitis, skin rashes ,and vesicles.

25. GOUT
• The three stages of gout are asymptomatic hyperuricemia, acute and
intercritical gout, and chronic gouty arthritis.
• Podagra is the classic monoarthritis of the first metatarsophalangeal
joint, but other lower limb joints can be affected.
• Patients tend to be obese males, aged 40 to 50 with hypertension,
and consumers of excess alcohol.
• Increasingly, postmenopausal females with low estrogens . Many
drugs raise serum urate levels and predispose to gout attacks,
especially diuretics ,ethambutol ,pyrizinamide
• Tophi are indicative of the diagnosis.
• Blood Investigations reveal increase in White cell count, ESR,and CRP
are raised
• Serum uric acid may be raised, but levels are low in 33% during
acute attacks.
• Renal and liver function should be assessed.

26. • Needle-shaped uric acid crystals (that are negatively
birefringent under polarized light) are present in synovial fluid
or tophi aspirate and confirm the diagnosis.
• Routine radiographs frequently show no bony abnormalities
but may identify erosions after repeated or prolonged attacks.
• Diagnostic ultrasound and MRI can identify synovial fluid for
aspiration, tophi, and erosive disease

32. PSEUDOGOUT
• Patients with pseudogout or pyrophosphate (CPPD)
arthropathy present with similar symptoms, usually in the knee
or wrist in older females often concurrent with osteoarthritis.
• Acute attacks often occur following a trigger such as infection,
trauma, or surgery.
• Calcinosis can be seen cartilage, and periarticular tissues can be
seen on a radiograph.
• Ultrasound may assist in the diagnosis of pyrophosphate
arthritis because crystal deposits can be seen.
• Synovial fluid microscopy demonstrates rhomboid-shaped
crystals .
• Culture should exclude coexistent septic arthritis.
• Hemarthrosis necessitates review for an occult fracture.
• Repeat imaging (e.g., using MRI) may be necessary to formally
exclude bone injury if clinical suspicion exists.

34. Acute Calcific Periarthritis
• Calcium deposition in periarticular tissues is common adjacent
to upper and lower limb large joints.
• Many patients are asymptomatic, but an acute shoulder
monoarthropathy with loss of function is well recognized.
• Calcium crystals can be associated with subacromial bursitis,
identified on routine radiographs, ultrasound, or MRI.
• Hypercalcemia necessitates that hyperparathyroidism should
be excluded.
Calcium Phosphate Crystal Arthritis
• Intra-articular deposits of basic calcium phosphate (BCP) are
rare but present in older female patients with osteoarthritis,
with a destructive shoulder arthropathy usually on the
dominant side (Milwaukee shoulder) as an acute on chronic
monoarthritis.
• Synovial fluid can be viscous and blood-stained and may
contain calcium aggregates and cartilage fragments.
• Plain radiographs show upward shoulder dislocation, and MRI
• exhibits characteristic features.

35. REACTIVE ARTHRITIS
• Reactive arthritis characteristically presents as a Large joint
monoarthritis, a Flitting polyarthritis, or Enthesitis with a
history of preceding throat, urogenital, or g.i tract infection.
• Classic triad of ReA is Noninfectious urethritis, Arthritis and
Conjunctivitis
• Patients can present with coexistent circinate balanitis, sterile
urethritis, and keratoderma blennorrhagica.
• Uveitis may precede arthritis and requires urgent review.
• Urethral cultures should be performed.
• The findings of an inflammatory synovial fluid with no
bacteria after culture and lack of crystals should exclude other
acute arthritides.
.

36. • The acute phase response is usually high.
• Conventional radiologic investigations and ultrasound can
identify synovial swelling and effusions
• MRI is particularly useful for identifying enthesitis and extra-
articular soft tissue disease.
• Antibodies against chlamydia, salmonella and campylobacter
can be present

38. TRAUMAAND INTERNAL
DERANGEMENT
• Trauma, either acute or after repeated injury, is the
commonest cause of acute monoarticular pain, especially in
the knee and the ankle.
• In the knee, torn menisci or loose bodies in the synovial fluid
“wedge” between articulating surfaces leading to sudden and
painful locking and weakness when walking described as
“giving way.”
• History is diagnostic and examination can elicit locking using
McMurray’s test. Examination for other ligament damage is
mandatory, using tests for cruciate or collateral knee ligament
stability.
• Plain radiographs may demonstrate abnormal architecture,
dislocation, or loose bodies, but MRI will usually establish the
cause of a trauma-related diagnosis.

39. POLYARTHRITISPRESENTINGAS
ACUTEMONOARTHRITIS
• Patients with a personal or family history of Psoriasis may develop
monoarthritis, digital dactylitis, or enthesitis.
• Up to 25% of Inflammatory bowel disease patients can present with
a seronegative lower limb large-joint acute monoarthritis.
• In Whipple’s disease, 60% of patients present with large migratory
joint monoarthritis or oligoarthritis. The diagnosis is based on
detection of periodic acid–Schiff-positive material (probably from
Tropheryma whippelii) in jejunal macrophages and in foamy cellson
synovial biopsy.
• Up to 20% of patients presenting with acute knee monoarthritis
progress to develop RA.
• In adolescent boys, a monoarthritis may represent the harbinger of
Spondyloarthropathy. Features of inflammatory back pain, duration
of pain for more than 3 months, and presence of HLA-B27 should
raise this suspicion.

40. MONOARTICULARARTHRITISIN
SYSTEMICDISEASES
• Sarcoidosis is being linked with ankle arthritis, erythema
nodosum, and bilateral hilar lymphadenopathy. Synovial fluid
contains lymphocytes, and synovial biopsy shows noncaseating
granulomas.
• Amyloid protein deposition (AL or AA) produces an
arthropathy with non inflammatory synovial fluid, which is
diagnosed on synovial biopsy.

42. APPROACH TO POLYARTHRITIS
1)HISTORY:
• Demographics. Age, sex, and family background may
provide clues to the type of arthritis. Gout is more
common in men ; osteoarthritis affects older patients
more often than younger counterparts, and in
spondyloarthritides familial association
• Symptom Onset. If patients present with abrupt onset of
symptoms, consider infection, gout, pseudogout, or
trauma, whereas if symptoms were present for
months/years, rheumatoid arthritis (RA), psoriatic
arthritis (PsA), chronic infection (e.g., syphilis, hepatitis,
human immunodeficiency virus [HIV]) and OA are
differentials.

43. • Pattern of Joint Involvement.
Patients who present with involvement of distal interphalangeal
joints (DIPs)may indicate osteoarthritis or psoriatic arthritis
 Symptoms in proximal interphalangeal joints (PIPs) and
metacarpophalangeal joints(MCPs) favour rheumatoid arthritis
Involvement of large joints such as hips and shoulders may
suggest polymyalgia rheumatica or a spondyloarthritis.
• Disease Course.
Patients who have chronic symptoms may describe varying
patterns of presentation ranging from an
 Intermittent pattern, where attacks are punctuated by periods of
complete remission
 Additive pattern, where symptoms begin with a few joints and
progress to involve more joints with time
Migratory pattern,where certain joints are affected for a time,
then the disease remits, only to reappear elsewhere in other
joints

44. • Presence of Inflammation.
History that may provide diagnostic clues to inflammation,
such as morning stiffness and response to activity.
 Cardinal signs of inflammation (redness, warmth, swelling,
pain in the morning) may have an inflammatory arthropathy.
• Drug history
Drugs like hydralazine, isoniazid, pyrizinamide can produce a
lupus like syndrome with the clinical presentation of myalgia,
arthalgia and ANA positivity.

45. PHYSICAL EXAMINATION
Arthralgia vs. Arthritis.
• Characteristics that distinguish synovitis include warmth, erythema,
tenderness to palpation, and synovial effusion. Any or all of these
findings may accompany arthralgia.
• Range of motion, muscle strength, and function may be limited around
the inflamed joint.
• In an effort to reduce joint volume and pain, the patient often will
involuntarily hold the joint in a position of partial flexion. Hence, joint
contractures may indicate an underlying inflammatory process (present
or past)
• . In RA, any diarthrodial joint can be affected, but the pattern of
involvement typically involves the MCPs, PIPs, wrist,
metatarsophalangeal joints (MTPs), and ankle joints.6 This pattern of
involvement should be distinguished from osteoarthritis (DIPs, PIPs,
carpometacarpal , knee, hip ,spine), psoriatic arthritis (DIPs, PIPs, wrist,
toes), and pseudogout (knee, wrist, MTPs).

46. Articular vs. Periarticular.
• In patients with articular pain, the joint capsule is diffusely
involved; thus, pain is often deep and is associated with a
global decreased range of active and passive motion in all
planes.
• Those who have periarticular abnormalities may have point
tenderness in the surrounding soft tissue, and pain occurs only
with active range of motion in a few planes.
• The differential diagnoses in patients with periarticular pain
may include FM, fracture, bursitis, tendinitis, enthesitis, carpal
tunnel syndrome, sickle cell crisis, polymyalgia rheumatica,
neuropathy, and Raynaud’s phenomenon.

47. Extra-articular Manifestations.
• Extra-articular manifestations of RA (e.g.nodules,
keratoconjunctivitis sicca) are seldom present early in the
disease.
• Extra-articular manifestations are prominent early and may
precede the onset of synovitis in SLE (malar rash, serositis)
reactive arthritis (urethritis, conjunctivitis), psoriatic arthritis
(psoriasis, nail pitting), and sarcoidosis (lung, fever, uveitis,
parotitis).
• Nodules in the seronegative patient are more likely to be tophi
from gout than nodules from RA, because the latter are seen
only in those with high-titer rheumatic factor (RF) or cyclic
citrullinated protein (CCP)antibodies.

48. Extra-articularmanifestationsof
rheumatoidarthritis

49. LABORATORYTESTSAND
RADIOLOGICSTUDIES
• Laboratory investigation of polyarthritis is indicated with chronicity
(symptoms longer than 6 weeks), failure to respond to initial
therapy, and the presence of systemic (e.g., fever, rash) or
neurologic symptoms.
Acute Phase Reactants
• Elevations in acute phase reactants such as erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP) provide a
surrogate measure of inflammation; both ESR and CRP have been
correlated with poor prognosis and worse radiologic outcomes.
• Some may have elevations in other acute phase reactants such as
ferritin, haptoglobin, ceruloplasmin, and complement levels.
• Anemia of chronic disease and elevated platelets and white cell
count

50. • When clinical suspicion for Vasculitis is high, i.e patient has
arthritis, proteinuria, and active sediments in urine, suspicious
nodules on chest radiograph, Anti-neutrophil cytoplasmic
antibody (ANCA) test should be involved.
• Baseline Liver function tests, Renal function tests, Examination
of urine for proteinuria and active sediments, Plain chest
radiograph ,ECG and Echocardiogram should be done in all
chronic inflammatory polyarthritis

51. Serologies
• Serum rheumatoid factor (RF),autoantibody (typically immunoglobulin
[Ig]M) that binds to the Fc component of IgG and may play a role in
acute inflammatory arthritis.
• Approximately 20% of patients meeting American College of
Rheumatology(ACR) classification criteria for RA are seronegative.
• The presence of the RF has been found to be predictive of persistent
disease and progression with radiologic damage in patients with
inflammatory arthritis.
• Other serologic markers that have been evaluated for use in early
diagnosis of RA include the Anticitrullinated protein antibodies (ACPAs
or CCP Ab), which are nearly as sensitive as RF but are far more
specific for RA.
• If the CCP Ab test is combined with the RF, one can expect a
sensitivity of 58% with a specificity of 100%; positive and negative
predictive values are 100% and 88%, respectively.

52. • The clinical utility of antinuclear antibodies (ANAs) has also
been evaluated in patients with polyarthritis. The ANA is not
uniquely linked to lupus .
• The specificity of this test is poor because ANAs may be found
in patients with Systemic lupus erythematosus, Systemic
sclerosis, Chronic liver disease, Chronic interstitial lung disease,
Drug-induced lupus, or Hashimoto’s thyroiditis.
• The presence of ANAs in patients with early inflammatory
arthritis ranges from 40% to 69%.
.

53. Genetic Markers
• Associations have been observed between regions of the
Major histocompatibility complex (MHC) on chromosome 6
and rheumatic diseases.
• There is a strong association between HLA-B27 and the
Seronegative spondyloarthritides.
• HFE gene found in patients with hereditary hemochromatosis
(HHC). HHC is an autosomal recessive disorder of iron
metabolism; joint pain is the most common complaint

54. Synovial Fluid Analysis
• In patients with oligoarthritis or in those who present
with joint effusions, arthrocentesis may be useful in
diagnosing patients and relieving symptoms.
• Synovial fluid from an inflamed joint is typically yellow
and turbulent from inflammatory cells. White cell counts
are typically greater than 10,000 cells/mm (range, 5000
to 50,000 cells/mm), with a predominance in
neutrophils.
• Prompt evaluation under polarized microscopy will
maximize the yield for identifying crystals.

55. Imaging:
Indications for radiography include
(1) History of trauma or injury (to exclude
fracture)
(2) Persistence of joint pain and swelling
longer than 6 weeks
(3) Suspicion of septic or gouty arthritis
(4) As a baseline evaluation for a newly
diagnosed polyarticular condition

56. X-RAY
Characteristic findings on radiographs of Inflammatory arthritis
may include:
• Soft tissue swelling,
• Chondrocalcinosis
• Joint effusion
• Juxta-articular osteopenia
• Symmetric loss of articular cartilage with joint space
narrowing
• Bony erosions- important markers of progressive damage

58. USG AND MRI
Helps in detection of synovitis when clinical examination and
conventional radiographs have failed. Advantages of these
devices include
Ability to detect subtle synovitis and soft tissue abnormalities
as tendon rupture or tenosynovitis
To permit more accurate placement of the needle in
diagnostic arthrocentesis and therapeutic
Injections.

61. UNIQUE SITUATIONS
1) Infection and Polyarthritis
• Bacteria, viruses, and atypical microorganisms may cause
polyarthritis directly as a pathogen or indirectly through an
immune-mediated response.
• Bacteria that have been associated with polyarthritis include
Staphylococci, Streptococci, Enterococci, Neisseria
gonorrhoeae, Borrelia burgdorferi, and gram-negative bacilli.
• Certain viruses can also cause polyarthritis; these include
parvovirus B19, mumps, rubella, hepatitis B and C viruses,
CMV, Epstein-Barr virus, HIV, and certain enteroviruses
• In addition, arboviruses (e.g., insect transmitted viruses) have
been associated with polyarthritis.
• Severe cases of debilitating polyarthritis have been
associatedwith the Chikungunya virus.

62. 2) Polyarthritis, Rash, and Fever
• The triad of fever, arthritis, and rash may pose a challenget o
the clinician. Differential diagnoses to consider:
Autoimmune (e.g., SLE, dermatomyositis, vasculitis)
 Infectious(e.g., disseminated gonococcal infection)
Reactive, or inflammatory processes (e.g., serum sickness
reaction, rheumatic fever, adult-onset Still’s disease)

63. Drug-Induced Syndromes
• Drug-induced lupus including Hydralazine,
Procainamide ,Isoniazid, Propylthiouracil
Sulfonamides, Quinidine, Tumor necrosis factor
inhibitors,and Minocycline.
• Myalgias, arthralgias, arthritis, or systemic
complaints of fever, skin rash, pleuropulmonary
disease, or cytopenias
• Positive ANA test is required for diagnosis
• Renal and neurologic features and Double-
stranded DNA (dsDNA) antibodies are usually
absent.

64. Malignancy-RelatedPolyarthritis
• Symptoms typically are not related to direct tumor invasion or
metastatic disease, but instead result from a paraneoplastic
process.
• Patients may present withHypertrophic osteoarthropathy,
Carcinomatous polyarthritis, Dermatomyositis/Polymyositis,
polymyalgia, or Vasculitis.
• Rheumatic manifestations suggestive of an occult malignancy
may include rapid onset of an unusual inflammatory arthritis,
clubbing, diffuse bone pain typically in patients older than 50
years of age, chronic unexplained vasculitis, Refractory
fasciitis, Raynaud’s syndrome unresponsive to vasodilator
therapy, Rapidly progressive digital gangrene, or Lambert-
Eaton myasthenic syndrome.

65. Polyarthritis in the Elderly
• Gerontorheumatologic diseases that should not
be overlooked include late-onset rheumatoid
arthritis, polymyalgia rheumatica, remitting
seronegative symmetric synovitis with pitting
edema (RS3PE) syndrome,
• giant cell arteritis, and paraneoplastic rheumatic
syndrome.
• Often, patients present with polyarticular
chondrocalcinosis of uncertain significance.
• Pseudogout, gout,and drug-induced disorders
are common in the elderly.
• Laboratory testing, including synovial fluid
analysis, may be helpful in diagnosis

66. RHEUMATOID ARTHRITIS
• Rheumatoid arthritis (RA) is a complex disease involving
numerous cell types, including macrophages, T cells, B cells,
fibroblasts, chondrocytes, neutrophils, mast cells, and dendritic
cells
• The ratio of female-to-male patients is 2 : 1 to 3 : 1

70. OSTEOARTHRITIS
• Osteoarthritis is a degenerative joint disease, occurring
primarily in older individuals, characterized by erosion of the
articular cartilage, hypertrophy of bone at the margins
(i.e.,osteophytes), subchondral sclerosis, and a range of
biochemical and morphologic alterations of the synovial
membrane and joint capsule.
• Osteoarthritis is the most common form of arthritis, typically
affecting the hands, hips, knees, spine, and feet.
• These joints may be symptomatic or may be affected only on
radiographs.
• Individuals with OA generally describe pain in the joint(s) that
is worse with activity, with limited morning stiffness (<30
minutes), and pain and stiffness with rest. This stiffness after
inactivity, or “gelling” phenomenon, is often a main complaint,
although morning stiffness is generally less severe and of
shorter duration than that seen in rheumatoid arthritis

74. SPONDYLOARTHROPATHIES
• The Spondyloarthropathies (SpAs) encompass a group of
clinical syndromes that are linked in terms of disease
manifestations and genetic susceptibility.

77. ANKYLOSING SPONDYLITIS
• AS is the most common inflammatory disorder of the axial
skeleton.
• The following is a useful rule of thumb: AS occurs in 0.2% of
the general population, in 2% of the B27-positive population,
and in 20% of B27-positive individuals with an affected family
member.
• There is a male preponderance in the disease, with the male-
to-female ratio ranging from 2.5 : 1 to 5 : 1.
• AS typically begins in young adulthood with an increasing
prevalence of radiographic sacroiliitis. At the other end of the
age spectrum, a small number of patients with late-onset AS
may have sacroiliitis and oligoarthritis.
• The classic manifestation of AS is the onset of low back pain
that persists for more than 3 months, is accompanied by early-
morning stiffness, and is typically improved by exercise.

79. PSORIATIC ARTHRITIS
• PsA develops in 5 to 7% of patients with psoriasis.Most cases arise in
patients with established cutaneous disease, The age at onset can
range from 30 to 55 years, with an equal predilection for PsA in
women and men. Psoriatic spondylitis has a slight male
preponderance.
• The most common form, is an Asymmetrical oligoarthritis that may
involve both large and small joints Dactylitis, arising as sausage digits
• In the second subset there is selective targeting of the Distal
interphalangeal joints, seen in of patients. These changes are
strongly associated with nail dystrophy, of which the features are
onycholysis, subungual keratosis, pitting, and oil drop–like staining.
• The third subset has a Symmetrical polyarthritis that mimics RA in
many ways, except for the absence of rheumatoid nodules and
rheumatoid factor.
• The fourth clinical variant is Psoriatic spondylitis, 50% of such
patients are B27 positive.
• Finally, Arthritis Mutilans (5% of patients) is a destructive, erosive
arthritis that affects large and small joints and can be associated
with marked deformities and significant disability.

80. Radiographic changes in PsA to the appearance of asymmetrical
sacroiliitis with syndesmophytes that are bulky, asymmetrical,
and nonmarginal. The classic “pencil-in-cup” deformity may be
seen in patients with distal interphalangeal joint disease or
arthritis mutilans.

81. ENTEROPATHIC ARTHRITIS
• EA refers to the arthritis associated with Crohn’s disease (CD)
or ulcerative colitis (UC).
• It
• is typically an inflammatory, nonerosive polyarthritis,
predominantly of large
• joints. In general, the clinical activity of the peripheral arthritis
parallels the

82. REFERENCES
• Kelley’s textbook of rheumatology 10th edition
• Goldman-Cecil Medicine 25th edition
• API Medicine update 2017
• Harrison’s Principles of internal medicine 19th edition

83. THANK YOU