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Approach To A Patient With Polyarthritis

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Pramod Mahender
Pramod Mahender
Health & Medicine
1 of 62
Approach to a patient with Polyarthritis Dr. K. K. Pruthi Prof & Head S. N. Medical College, Agra
‘ Patterned’ approach Grouping a constellation of symptoms, signs and investigations to arrive at a diagnosis.
POLYARTHRITIS 4 or more joint involvement PAUCI / OLIGOARTHRITIS 2 or 3 joint involvement MONOARTHRITIS 1 joint involvement Definition
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Assessment of joint pain
Site and distribution of pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Site and distribution of pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],Type of pain ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],Type of pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],Associated features ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Duration & onset ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Duration & onset ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Other risk factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Physical signs ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Differential diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Investigations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Investigations Synovial fluid examination most important !! ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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
Osteoarthritis (OA) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis Types PRIMARY OA SECONDARY OA
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
Pathology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis
Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis ,[object Object],[object Object]
Radiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis
Joint space narrowing Subchondral bone sclerosis and cysts Marginal osteophyte formation
 
Kellegren & Lawrence Scale for Osteoarthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis
Role of inflammation in OA ,[object Object],[object Object],[object Object],[object Object],Osteoarthritis
[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis
Epidemiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis
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
Excised synovial membrane shows many villous folds with compact nodular clusters of lymphocytes and plasma cells. Pathology Rheumatoid Arthritis
Onset ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis
One can confidently make a diagnosis of RA on clinical grounds even if RF is absent. Clinical features ,[object Object],[object Object],[object Object],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
Clinical features ,[object Object],[object Object],[object Object],Rheumatoid Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis Clinical features Swan neck deformity Boutonniere deformity Ulnar deviation & nodule Hammer toe deformity Hallux valgus
Radiology ,[object Object],[object Object],[object Object],[object Object],[object Object]
Extra articular findings ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis Rheumatoid nodule Episcleritis Digital infarcts
Be Cautious to diagnose RA if : ,[object Object],[object Object],[object Object],[object Object],[object Object],Mere presence of rheumatoid factor in blood is not enough to make a diagnosis of RA. Rheumatoid Arthritis
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Not all seropositive arthritides are RA Rheumatoid Arthritis
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],American Rheumatism Association,1997 revised criteria for diagnosing RA Rheumatoid Arthritis
Predictive factors for persistent RA Rheumatoid Arthritis ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Seronegative Inflammatory polyarthritides
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Seronegative Spondyloarthropathies (SpA)
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Seronegative SpA Features
Ankylosing spondylitis ,[object Object],[object Object],[object Object],[object Object]
Etiology ,[object Object],[object Object],[object Object],[object Object],[object Object],Ankylosing spondylitis
Pathology ,[object Object],[object Object],[object Object],[object Object],[object Object],Ankylosing spondylitis
Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ankylosing spondylitis
Radiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ankylosing spondylitis
Crystal Arthropathies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Crystal Arthropathies Types & Causes
Gout ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Crystal Arthropathies
Monosodium Urate Crystal Crystal Arthropathies Positive bifringence & needle shaped
Pseudogout Crystal Arthropathies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Psoriatic Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Radiology ,[object Object],[object Object],[object Object],[object Object],Psoriatic Arthritis
Reiter’syndrome ,[object Object],[object Object],[object Object],[object Object],Asymmetrical arthritis Urethritis/cervicitis or Diarrhoea Conjunctivitis
Systemic Lupus Erythematous ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Features Photosensitivity Butterfly facial rash Discoid rashes
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Arthritis in SLE SLE
THANK YOU

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Approach To A Patient With Polyarthritis

  • 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
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  • 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
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  • 26. Joint space narrowing Subchondral bone sclerosis and cysts Marginal osteophyte formation
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  • 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
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  • 55. Monosodium Urate Crystal Crystal Arthropathies Positive bifringence & needle shaped
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