Rheumatic diseases an introduction and evaluation | Rheumatoid Arthritis

1. Rheumatic Diseases-An
Introduction and Evaluation
Dr. Subhash Thakur
MD (PGIMER, Chandigarh)
MBBS 3rd Year, Lecture, 2nd June 2021 @ CMC, Bharatpur, Nepal
And
Rheumatoid Arthritis

2. Contents
• Evaluating a Patient with
Arthritis and Rheumatic
Disease
• Tests in Rheumatology
• Rheumatoid Arthritis
• Introduction
• Clinical Features & manifestations
• Diagnostic Criteria
• Associated Syndromes
• Laboratory
• Treatment
• Complications

3. Evaluating a Patient With Arthritis and
Rheumatic Disease
Evaluation of Joint Swelling
1. Distribution
2. Acute Vs Chronic
3. Symptoms beyond Arthritis (Systemic)
4. Joint Inflammation

4. 1. Distribution
A. Polyarticular Symmetric
B. Monoarticular
C. Oligoarticular Asymmetric
D.Migratory

5. A. Polyarticular Symmetric
• Rheumatoid Disease
• Systemic Lupus Erythematosus
• Viral Infections: Hepatitis B, EBV, Parvo B-19

6. B. Monoarticular
• Osteoarthritis (OA)
• Septic Arthritis
• Gout or Pseudogout

7. C. Oligoarticular Asymmetric
• Spondyloarthropathies
• Ankylosing Spondylitis
• Psoriatic Arthritis etc

8. D. Migratory
• Lyme Disease
• Gonococcall eg. Disease
• Rheumatic Fever

9. 2. Acute Vs Chronic
• Patient: Monoarthritis
• Symptomatic for months to years: OA
• Few days: Crystal induced arthropathy or Septic Arthritis

10. 3. Evidence of Systemic Symptoms
• SLE
• Skin, Lung, CNS, Blood, Kidney
• Sjogren’s
• Sicca, Parotid enlargement
• Systemic Sclerosis
• Skin, Raynaud’s
• Wegner’s
• Sinusitis, rhinitis, Lung, Kidney
• OA
• Paucity of systemic Symptoms

11. 4. Evidence of Inflammation
• Erythema, warmth
• Joint Stiffness>1 hour
• Elevated ESR and CRP
• Elevated white Cells in the aspirate
• Eg. RA Vs OA

12. Eg. A 62 years old male with right Knee pain
• For 5 years, hx of football playing, crushly sound, no stiffness
• Arthrocentesis need to be done to rule out Septic Arthritis
• For 1 day: Monoarticular Arthritis: D/d Crystal Induced or Septic Arthritis
• D/d: OA, X-ray and treat accordingly

13. 2. 24 years old female, symmetric wrist, MCPs,
PIPs, swelling and pain
• To look for systemic Symptoms
• To look for viral titers
• To look for RF
• Polyarticular Symmetric

14. 3. 32 years male, right knee swelling, few days ago he
had right wrist swelling and pain that has resolved now
• Migratory
• Lyme
• Gonococcal
• Rheumatic Fever

15. 4. 29 years male, right knee and left hip pain for may
years. His other problem is chronic back pain and
stiffness
•Oligo articular Asymmetric
•Ankylosing Spondylitis

16. Tests In Rheumatology

17. Tests In Rheumatology
A. Joint Aspiration
B. Anti-nuclear Antibodies (ANAs)
C. Rheumatoid Factor (RF)
D.ANCA (Anti Nuclear Cytoplasmic Antibody)
E. Antiphospholipid Antibodies

18. A. Joint Aspiration
• When do we do a joint Aspiration
Ans: Always, when concerned about septic arthritis, Acute Monoarthritis
• Contraindications:
• Cellulitis
• Bleeding diathesis
• What Tests Do we Get?
Ans: 3 Cs and gram stain: Cells, Culture, Crystals

19. Stratification
Diseases WBCs Crystals/Polarization
DJD, Traumatic <2000 Negative
Inflammatory
Rheumatoid Arthritis
Gout
CPPD
5000-50000 Negative for RA
Needle shaped or negative
birefringent
Rhombdoid or Positive birefringent
Septic >50000 Negative
Gram Stain and Culture: Usually
Negative

20. B. Anti-nuclear Antibodies (ANAs)
• Antibody against nuclear structures
• Common in SLE, Sjogren’s, Scleroderma
• May be seen in normal patients
• Pattern: Rim, Nucleolar
• Subsets: Ds DNA antibodies, SM ab’s, anti histone ab’s

21. Patterns
Peripheral (Rim) SLE
Diffuse Non – Specific
Speckled Non – Specific
Centromere CREST
Nucleolar Systemic Sclerosis

22. Specific Antibodies
Anti ds DNA (native DNA) SLE only (60%), an indicator of disease activity and
Lupus nephritis
Anti – SM SLE Only (25-30%)
Anti histone Drug induced Lupus (95%)
Anti-Ro (SSA) Neonatal Lupus, Sjogren’s and in the 3% of ANA – lupus
Anti – LA (SSB) Sjogren’s
Anti-Centromere CREST
Anti RNP 100% mixed Connective Tissue Disorder

23. C. Rheumatoid Factor (RF)
• Usually positive in RA
• RF negative RA (20-30%)
• Very high RF: poor prognosis
• RF positive in other diseases: Osteomyelitis, Tuberculosis, Subacute
Endocarditis

24. D. ANCA
• Wegner’s: C-ANCA +
• PAN, IBD: P-ANCA +

25. E. Antiphospholipid Antibodies
• Lupus Anticoagulant
• Anticardiolipin Antibodies
• Elevated PTT (Lab phenomenon), False+ VDRL
• Hypercoaguable State : Venous + Arterial
• Spontaneous abortion in otherwise healthy women
• Treatment: Anticoagulate if Symptomatic

26. Rheumatoid
Arthritis

27. Rheumatoid Arthritis
• Rheumatoid Arthritis
• Introduction
• Clinical Features & manifestations
• Diagnostic Criteria
• Associated Syndromes
• Laboratory
• Treatment
• Complications

28. Clinical Scenario
• A 26 years old female, presents with a 3 week history of joint swelling and
stiffness, PIPs, MCPs and wrists are involved symmetrically, which you
confirm on exam. Stiffness in the morning is > 2 hrs. She also has fatigue
and low grade fever. She has no back pain or DIP involvement.
Ans: Polyarticular Symmetric: RA Vs SLE Vs Viral Infections

29. Rheumatoid Arthritis
• Chronic Inflammatory, multisystem disease
• Main focus: Synovium
• Hall mark: Inflammatory synovitis in a symmetric distribution
• Bone erosions, deformities
• Predominant Cells: T-Lymphocytes
• Pro-Inflammatory Cytokines that mediate inflammation: TNF-α, IL-1, IL-6

30. Q. What Rheumatic Disease is uncommon in
HIV ?
• RA
• Decreased Helper T-Cells
Q. A patient has RA and all of sudden his
RA gets better?
• HIV

31. Diagnostic Criteria
• Morning Stiffness (>1 hr) for 6 weeks
• Swelling of wrists, MCPs, PIP For 6 weeks
• Swelling of 3 joints for 6 weeks
• Symmetric joint swelling for 6 weeks
• Joint erosions on X-rays
• RF+
• Rheumatoid Nodules

32. Manifestations
• Articular
• Extraarticular

33. Articular
• Radial deviation of the wrist and ulnar deviation of the digits
• Boutonniere Deformity
• PIP: Flexed
• DIP: Extended
 Its not that DIP joint is involved its actually tendon arthropathy.

34. • Swan Neck Deformity
• PIP: Extended
• DIP: Flexed
 Its not that DIP joint is involved its actually tendon arthropathy.

35. Extra Articular
• Are not as common as in Lupus
• Rheumatoid Nodules
• Focal Vasculitis
• 20-30% RA
• Occur in area of mechanical stress:
• Olecranon, Occiput, Achilles tendon
• Methotrexate may cause a flair

36. Associated Syndromes
• Felty’s Syndromes
• Triad of : RA +
Splenomegaly +
Neutropenia (Infections)

37. • Caplan Syndrome
• Pneumoconiosis + RA
• Rheumatoid nodules
in Lung

38. Laboratory
• RF
• Anaemia: ACD, 1st rule out IDA with Iron Profile (S. iron, ferritin and TIBC)
• ESR: Elevated
• X-rays: erosions or periosteal depletion
• Synovial Fluid Analysis: Cells (5000-50000)
• Gm Stain -
• Culture -
• Crystal -

39. Treatment
• NSAIDs
• COX-2 Inhibitors
• Corticosteroids
• Methotrexate
• TNF Inhibitors

40. NSAIDs
• One is not better than other. All are same

41. COX-2 Inhibitors
• a/w stroke, CVA
• Supposed to be more protective for peptic ulcer

42. Methotrexate
• On Methotrexate: Check CBC:
to rule out myelosuppression
and Liver Enzymes
• Every 2-3 weeks
• Unless very mild, start on MTX
directly
• Especially in people with poor
prognosis
• Requires few weeks to month,
till then NSAIDs, Steroids

43. Dosing
• Initial: 7.5 mg PO/IV/IM as a single weekly dose, OR
• 2.5 mg PO q12hr for 3 sequential doses per week
folic acid or folinic acid to reduce the risk of methotrexate adverse reactions

44. HydroxyChloroquine
• Antimalarial

45. TNF Inhibitors
• In resistant RA
• Infliximab
• Adalimumab
• Etanercept
Caution: Tb Reactivation: check with PPD

46. Complications
• Atlantoaxial Subluxation:
• Atlas (C1) and Axis (C2) involvement
• Incidence: 25-80%, if spine gets involved: paraplegia, quadriplegia
• Subtle Symptoms:
• Neck pain, Occipital (C2 radicular pain)
• Paraesthesia of hands and foot
• Diagnosis:
• X-ray of cervical Spine (open mouth view)
 Screen for C1 and C2 subluxation before intubation or anaesthesia

47. Thank You