Approach To A Patient With Polyarthritis

36,261 views

Published on

Published in: Health & Medicine
20 Comments
89 Likes
Statistics
Notes
No Downloads
Views
Total views
36,261
On SlideShare
0
From Embeds
0
Number of Embeds
1,244
Actions
Shares
0
Downloads
0
Comments
20
Likes
89
Embeds 0
No embeds

No notes for slide

Approach To A Patient With Polyarthritis

  1. 1. Approach to a patient with Polyarthritis Dr. K. K. Pruthi Prof & Head S. N. Medical College, Agra
  2. 2. ‘ Patterned’ approach Grouping a constellation of symptoms, signs and investigations to arrive at a diagnosis.
  3. 3. POLYARTHRITIS 4 or more joint involvement PAUCI / OLIGOARTHRITIS 2 or 3 joint involvement MONOARTHRITIS 1 joint involvement Definition
  4. 4. <ul><li>Site (distribution) </li></ul><ul><li>Type of pain </li></ul><ul><li>Associated features </li></ul><ul><li>Duration and onset </li></ul><ul><li>Risk factors </li></ul><ul><li>Physical signs </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Investigation </li></ul>Assessment of joint pain
  5. 5. Site and distribution of pain <ul><li>Is it joint, peri-articular or muscle pain? </li></ul><ul><li>Which joints are involved? </li></ul><ul><li>Is it symmetrical or asymmetrical? </li></ul><ul><li>Where did it start? </li></ul><ul><li>Is the arthritis migratory, additive, episodic? </li></ul><ul><li>Site & </li></ul><ul><li>Distribution </li></ul>
  6. 6. Site and distribution of pain <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>RA </li></ul><ul><li>PIP, MCP, wrists, elbows, shoulders, neck, </li></ul><ul><li>knee, ankle, MTP </li></ul><ul><li>DIP not involved </li></ul><ul><li>symmetrical </li></ul><ul><li>Sero-ve </li></ul><ul><li>DIP, dactylitis, enthesitis, spinal </li></ul><ul><li>PIP not involved </li></ul><ul><li>asymmetrical </li></ul><ul><li>OA </li></ul><ul><li>Weight bearing joints </li></ul><ul><li> DIP, PIP, CMC, ACJ </li></ul><ul><li>MP not involved </li></ul>
  7. 7. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul>Type of pain <ul><li>Is it inflammatory? </li></ul><ul><li>Is it mechanical / degenerative? </li></ul><ul><li>What makes the pain worse/better? </li></ul>
  8. 8. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul>Type of pain <ul><li>Inflammatory Mechanical </li></ul><ul><li>Immobility stiffness Latter day </li></ul><ul><li>EMS>30-60 mins EMS<30-60 mins </li></ul><ul><li>Better with activity Worse with activity </li></ul><ul><li>Joint swelling, erythema, heat Instability </li></ul><ul><li>Systemic symptoms Locking </li></ul><ul><li>Multi-organ involvement Trauma, strain, over usage </li></ul>
  9. 9. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul>Associated features <ul><li>Is there morning stiffness? </li></ul><ul><li>Have there been any symptoms of infection? </li></ul><ul><li>Have there been any rashes ? </li></ul><ul><li>Any urinary, genital or gut problems? </li></ul>
  10. 10. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul>Duration & onset <ul><li>When did the joint pains begin? </li></ul><ul><li>Are the symptoms getting better or worse? </li></ul>
  11. 11. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul>Duration & onset <ul><li>Acute </li></ul><ul><ul><li>Viral </li></ul></ul><ul><ul><ul><li>parvo/rubella </li></ul></ul></ul><ul><ul><li>Bacterial </li></ul></ul><ul><ul><ul><li>strep </li></ul></ul></ul><ul><ul><li>Rheumatoid </li></ul></ul><ul><ul><li>Reactive </li></ul></ul><ul><ul><ul><li>GU/gastro </li></ul></ul></ul><ul><ul><li>Erythema nodosum </li></ul></ul><ul><ul><li>Vasculitis </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>Rheumatoid </li></ul></ul><ul><ul><li>Seronegative </li></ul></ul><ul><ul><ul><li>psoriatic/AS/IBD </li></ul></ul></ul><ul><ul><li>Connective tissue disease </li></ul></ul><ul><ul><ul><li>SLE/SjS/DM </li></ul></ul></ul><ul><ul><li>Polyarticular OA </li></ul></ul>
  12. 12. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul>Other risk factors <ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Racial/ethnic background </li></ul><ul><li>Family history </li></ul><ul><li>Treatment history </li></ul><ul><li>Social history </li></ul>
  13. 13. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul>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
  14. 14. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul>Physical signs <ul><li>Joint distribution +/- spine </li></ul><ul><li>Skin and appendages </li></ul><ul><li>Rash, nodules, eyes, mouth ulcers, hair </li></ul><ul><li>Temp, LNs, CVS, RS, Abdomen, Neurological </li></ul>
  15. 15. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul><ul><li>Differential </li></ul><ul><li>diagnosis </li></ul>Differential diagnosis <ul><li>Osteoarthritis </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Chronic (trophaceous) gout </li></ul><ul><li>Systemic lupus erythematous </li></ul><ul><li>Reiter’s disease </li></ul><ul><li>Ankylosing spondylitis </li></ul><ul><li>Psoriatic arthritis </li></ul>
  16. 16. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul><ul><li>Differential </li></ul><ul><li>diagnosis </li></ul><ul><li>Investigati- </li></ul><ul><li>ons </li></ul>Investigations <ul><li>Radiographs of corresponding joints </li></ul><ul><li>Hemogram, ESR </li></ul><ul><li>RA factor, CRP </li></ul><ul><li>S.Uric Acid - Notoriously unreliable !! </li></ul><ul><li>Urine, stool </li></ul><ul><li>Synovial fluid </li></ul><ul><li>Cultures </li></ul><ul><li>CT/MRI </li></ul><ul><li>Arthroscopy/Biopsy( to be considered in chronic, >6 weeks, </li></ul><ul><li>non traumatic arthritis in which diagnosis is not established ) </li></ul><ul><li>Bone scan </li></ul><ul><li>Serologic tests like ANA, RF, ANCA - rarely if ever indicated </li></ul>
  17. 17. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul><ul><li>Differential </li></ul><ul><li>diagnosis </li></ul><ul><li>Investigati- </li></ul><ul><li>ons </li></ul>Investigations Synovial fluid examination most important !! <ul><li>Protein </li></ul><ul><li>TLC, DLC, cells </li></ul><ul><li>Gram stain </li></ul><ul><li>C/S </li></ul><ul><li>Atypical organisms </li></ul><ul><li>Crystals with polarising microscopy </li></ul><ul><li>Sugar </li></ul><ul><li>Other tests </li></ul>
  18. 18. <ul><li>Site & </li></ul><ul><li>Distribution </li></ul><ul><li>Type </li></ul><ul><li>Associated </li></ul><ul><li>features </li></ul><ul><li>Duration & </li></ul><ul><li>onset </li></ul><ul><li>Risk </li></ul><ul><li>factors </li></ul><ul><li>Physical </li></ul><ul><li>signs </li></ul><ul><li>Differential </li></ul><ul><li>diagnosis </li></ul><ul><li>Investigati- </li></ul><ul><li>ons </li></ul>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
  19. 19. Osteoarthritis (OA) <ul><li>Most common joint disorder </li></ul><ul><li>Affects 190 million worldwide </li></ul><ul><li>Nearly 70% of people over 65 years </li></ul><ul><li>Aging population over 65 years </li></ul><ul><li>1997~ 400 million ( 70 million plus in India ) </li></ul><ul><li>2025~ 800 million ( 150 million plus in India ) </li></ul><ul><li>In India has overtaken diabetes, and now ranks </li></ul><ul><li>1 st in chronic debilitating disease. </li></ul>
  20. 20. <ul><li>Predisposing factors </li></ul><ul><ul><ul><li>Incongruity </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>Systemic diseases - RA </li></ul></ul></ul>Osteoarthritis
  21. 21. <ul><li>Primary </li></ul><ul><li>Secondary </li></ul><ul><ul><li>SCFE </li></ul></ul><ul><ul><li>CDH </li></ul></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><li>Traumatic Dislocation </li></ul></ul><ul><ul><li>Perthes </li></ul></ul><ul><ul><li>Pagets </li></ul></ul><ul><ul><li>Fracture Acetabulum </li></ul></ul><ul><ul><li>Hemophilia </li></ul></ul>Osteoarthritis Types PRIMARY OA SECONDARY OA
  22. 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
  23. 23. Pathology <ul><li>Synovitis </li></ul><ul><li>Cartilage fibrillation </li></ul><ul><li>Cartilage flaking & delamination </li></ul><ul><li>Exposure of subchondral bone </li></ul><ul><li>Microfractures & osteophytes </li></ul><ul><li>Fibrosis-ankylosis </li></ul>Osteoarthritis
  24. 24. Clinical Features <ul><li>Old patient </li></ul><ul><li>Females > males </li></ul><ul><li>Lower limb joints~ knees, hips, 1 st CM jt </li></ul><ul><li>Rest pain </li></ul><ul><li>Pain during movement </li></ul><ul><li>Crepitus </li></ul><ul><li>Characteristic deformities </li></ul>Osteoarthritis <ul><li>Bouchard nodes </li></ul><ul><li>Heberden nodes </li></ul>
  25. 25. Radiology <ul><li>Sharpening of edges </li></ul><ul><li>Subchondral sclerosis (eburnation) </li></ul><ul><li>Decreased joint space </li></ul><ul><li>Osteophytes </li></ul><ul><li>Subchondral cysts </li></ul><ul><li>Deformities </li></ul><ul><li>Radioisotope scan-increased uptake </li></ul>Osteoarthritis
  26. 26. Joint space narrowing Subchondral bone sclerosis and cysts Marginal osteophyte formation
  27. 28. Kellegren & Lawrence Scale for Osteoarthritis <ul><li>0 – No features of osteoarthritis </li></ul><ul><li>1 – Doubtful, unimute osteophylic of doubtful significance </li></ul><ul><li>2 – Minimal, definite osteophyte but joint space unimpaired </li></ul><ul><li>3 – Moderate, moderate diminution of joint space </li></ul><ul><li>4 – Severe, Joint space severely impaired with scelerosis of </li></ul><ul><li>subchondral bone </li></ul>Osteoarthritis
  28. 29. Role of inflammation in OA <ul><li>OA is not characterized by a </li></ul><ul><li>significant systemic inflammatory process </li></ul><ul><li>Inflammation, where present, </li></ul><ul><li>is usually mild </li></ul>Osteoarthritis
  29. 30. <ul><li>A common chronic inflammatory joint condition </li></ul><ul><li>‘ Rheumatoid’ first used in 1859 by Garrod </li></ul><ul><li>Little evidence for RA prior to 16th Century </li></ul><ul><li>Possibly earlier in New World </li></ul>Rheumatoid Arthritis
  30. 31. Epidemiology <ul><li>Incidence </li></ul><ul><ul><li>1.4/10000 male, 3.6/10000 females </li></ul></ul><ul><li>Prevalence 0.5-2 % </li></ul><ul><li>male:female 1:3 </li></ul><ul><li>Worldwide distribution </li></ul><ul><ul><li>higher in native Americans </li></ul></ul><ul><ul><li>absent in some parts of Africa </li></ul></ul><ul><li>Onset any age but maximum </li></ul><ul><ul><li>40 - 70 years in women </li></ul></ul><ul><ul><li>60 - 70 years in men </li></ul></ul>Rheumatoid Arthritis
  31. 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
  32. 33. Excised synovial membrane shows many villous folds with compact nodular clusters of lymphocytes and plasma cells. Pathology Rheumatoid Arthritis
  33. 34. Onset <ul><li>Typical </li></ul><ul><li>Insidious onset polyarthritis </li></ul><ul><li>Affecting small joints of hand & feet </li></ul><ul><li>Atypical </li></ul><ul><li>Polymyalgic </li></ul><ul><li>Palindromic </li></ul><ul><li>Systemic </li></ul><ul><li>Persistent monoarthritis </li></ul>Rheumatoid Arthritis
  34. 35. One can confidently make a diagnosis of RA on clinical grounds even if RF is absent. Clinical features <ul><li>RA is entirely a clinical diagnosis . </li></ul><ul><li>only 80-85% of the individuals are seropositive. </li></ul><ul><li>15-20% are seronegative. </li></ul>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
  35. 36. Clinical features <ul><li>Symmetrical deforming polyarthritis </li></ul><ul><ul><li>Affects synovial lining of joints, bursae and tendons </li></ul></ul><ul><ul><li>More then just joint disease </li></ul></ul>Rheumatoid Arthritis <ul><li>Progression of joint involvement </li></ul><ul><li>Spread occurs within months to years to other joints </li></ul><ul><ul><li>Almost any joint may be involved </li></ul></ul><ul><ul><li>Spontaneous remission can occur </li></ul></ul><ul><ul><li>Poor prognosis – RA factor exists </li></ul></ul><ul><li>Symptoms </li></ul><ul><ul><li>Of inflammation </li></ul></ul><ul><ul><ul><li>Stiffness, pain, swelling, warmth, redness </li></ul></ul></ul>
  36. 37. <ul><li>Pattern of joint involvement </li></ul><ul><li>symmetrical </li></ul><ul><li>small joints of hands - DIP spared </li></ul><ul><li>characteristic features </li></ul><ul><ul><li>Boutonniere </li></ul></ul><ul><ul><li>Swan neck </li></ul></ul><ul><ul><li>Z thumb </li></ul></ul><ul><ul><li>Volar subluxation </li></ul></ul><ul><ul><li>Ulnar deviation </li></ul></ul>Rheumatoid Arthritis Clinical features Swan neck deformity Boutonniere deformity Ulnar deviation & nodule Hammer toe deformity Hallux valgus
  37. 38. Radiology <ul><li>Soft tissue swelling </li></ul><ul><li>Juxta-articular osteoporosis </li></ul><ul><li>Juxta-articular and subchondral erosions </li></ul><ul><li>Joint space narrowing & subluxation </li></ul><ul><li>Secondary OA & bony ankylosis </li></ul>
  38. 39. Extra articular findings <ul><li>Nodules </li></ul><ul><li>Eye </li></ul><ul><li>Lung </li></ul><ul><li>Cardiac </li></ul><ul><li>Vasculitis </li></ul><ul><li>Nerves </li></ul><ul><li>Felty’s </li></ul><ul><li>(Neutropenia + RA) </li></ul>Rheumatoid Arthritis Rheumatoid nodule Episcleritis Digital infarcts
  39. 40. Be Cautious to diagnose RA if : <ul><li>Monoarticular </li></ul><ul><li>Hands not involved </li></ul><ul><li>Asymmetrical or unilateral involvement </li></ul><ul><li>Only DIP are involved </li></ul><ul><li>Lumbar spine involved </li></ul>Mere presence of rheumatoid factor in blood is not enough to make a diagnosis of RA. Rheumatoid Arthritis
  40. 41. <ul><li>Diseases associated with a positive RF </li></ul><ul><li>Condition Prevalence (%) </li></ul><ul><li>RA 80-85 </li></ul><ul><li>Elderly people 5 </li></ul><ul><li>Other chronic inflammatory rheumatic diseases </li></ul><ul><li>– Primary Sjogren’s syndrome 75-90 </li></ul><ul><li>– Mixed cryoglobulinaemia 90-100 </li></ul><ul><li>– SLE 20-30 </li></ul><ul><li>– Systemic sclerosis 20-30 </li></ul><ul><li>– Mixed connective tissue disease 50-60 </li></ul><ul><li>Chronic bacterial infections </li></ul><ul><li>– Subacute bacterial endocarditis 25-50 </li></ul><ul><li>Miscellaneous conditions </li></ul><ul><li>– Sarcoidosis 5-33 </li></ul><ul><li>– Interstitial pulmonary fibrosis 10-50 </li></ul><ul><li>– Chronic active hepatitis 25-40 </li></ul>Not all seropositive arthritides are RA Rheumatoid Arthritis
  41. 42. <ul><li>Criterion Definition </li></ul><ul><li>1. Morning stiffness Stiffness in joints lasting at least 1 hour </li></ul><ul><li>2. Arthritis in 3 or more joints Pain and swelling in at least 3 joints </li></ul><ul><li>3. Arthritis in hand joints Swelling in at least 1 of the following </li></ul><ul><li>areas: wrist, MCP or PIP joint </li></ul><ul><li>4. Symmetric arthritis Involvement of the same joint area on </li></ul><ul><li>both sides of the body </li></ul><ul><li>5. Rheumatoid nodules Subcutaneous nodules over bony prominences </li></ul><ul><li>or extensor surfaces or around joints </li></ul><ul><li>6. Serum rheumatoid factor Positive rheumatoid factor </li></ul><ul><li>7. Radiologic changes Periarticular osteopenia or erosions in </li></ul><ul><li>joints visible on radiographs of hands or feet </li></ul><ul><li>Criteria 1 through 4 must be present for at least 6 weeks. </li></ul><ul><li>Confirmation of 4 or more of these 7 criteria is considered diagnostic of rheumatoid </li></ul><ul><li>arthritis. </li></ul>American Rheumatism Association,1997 revised criteria for diagnosing RA Rheumatoid Arthritis
  42. 43. Predictive factors for persistent RA Rheumatoid Arthritis <ul><li>Morning stiffness > 1 hours </li></ul><ul><li>Arthritis in 3 or more joints </li></ul><ul><li>Bilateral compression pain in MP joints </li></ul><ul><li>IgM RA factor > 5 I.U. </li></ul>
  43. 44. <ul><li>Seronegative RA </li></ul><ul><li>Psoriatic arthropathy </li></ul><ul><li>SLE </li></ul><ul><li>Scleroderma </li></ul><ul><li>Juvenile idiopathic arthritis </li></ul><ul><li>Adult onset Still’s disease </li></ul><ul><li>Inflammatory bowel disease </li></ul>Seronegative Inflammatory polyarthritides
  44. 45. <ul><li>Ankylosing spondylitis </li></ul><ul><li>Reactive arthritis (including Reiter’s syndrome) </li></ul><ul><li>Psoriatic spondyloarthropathy </li></ul><ul><li>Inflammatory bowel disease </li></ul><ul><li>(Enteropathic spondyloarthropathy) </li></ul><ul><li>Juvenile spondyloarthropathy </li></ul><ul><li>Unclassifiable or undifferentiated spondyloarthropathy </li></ul>Seronegative Spondyloarthropathies (SpA)
  45. 46. <ul><li>Seronegative, that is, rheumatoid factor is absent </li></ul><ul><li>Affect the axial skeleton; inflammatory low back pain </li></ul><ul><li>is common. </li></ul><ul><li>Cardinal feature is involvement of sacroiliac joints </li></ul><ul><li>Peripheral joint involvement is usually asymmetrical </li></ul><ul><li>Oligoarticular, below waist </li></ul><ul><li>Usually associated with HLA-B27. </li></ul><ul><li>Enthesopathy is characteristic </li></ul><ul><li>Usual age < 40 years </li></ul><ul><li>Male preponderance </li></ul>Seronegative SpA Features
  46. 47. Ankylosing spondylitis <ul><li>Spondyloarthropathy </li></ul><ul><li>Late adolescence & early adulthood </li></ul><ul><li>Spine & large joints </li></ul><ul><li>Leads to fibrous/bony ankylosis </li></ul>
  47. 48. Etiology <ul><li>Male predisposition 7:1 </li></ul><ul><li>Autosomal inheritance </li></ul><ul><li>70% penetrance </li></ul><ul><li>90% association with HLA B27 </li></ul><ul><li>Rare in negroes </li></ul>Ankylosing spondylitis
  48. 49. Pathology <ul><li>Similar to RA </li></ul><ul><li>Articular & bone destruction </li></ul><ul><li>Fibrous & bony bridging </li></ul><ul><li>Para- articular calcification & ossification </li></ul><ul><li>Bamboo spine </li></ul>Ankylosing spondylitis
  49. 50. Clinical Features <ul><li>Morning pain & stiffness </li></ul><ul><li>Sacroiliac pain </li></ul><ul><li>Muscle spasm- flexed posture </li></ul><ul><li>Wt loss, anaemia </li></ul><ul><li>Decreased chest expansion </li></ul><ul><li>Ankylosis </li></ul>Ankylosing spondylitis
  50. 51. Radiology <ul><li>Patchy osteoporosis </li></ul><ul><li>Fusion of SI joints </li></ul><ul><li>Squaring of vertebral bodies </li></ul><ul><li>Syndesmophytes – bone bridge </li></ul><ul><li>Diminished joint space </li></ul><ul><li>Bony ankylosis of major joints </li></ul>Ankylosing spondylitis
  51. 52. Crystal Arthropathies <ul><li>Monosodium urate crystals </li></ul><ul><ul><ul><li>Gouty Arthritis </li></ul></ul></ul><ul><li>Calcium Pyrophosphate crystals </li></ul><ul><ul><ul><li>Chondroclacinosis </li></ul></ul></ul><ul><li>Calcium hydroxyapatite crystals </li></ul><ul><ul><ul><li>Calcific Periarthritis destructive arthropathy </li></ul></ul></ul>
  52. 53. <ul><li>Primary Gout </li></ul><ul><ul><li>Heritable Error of metabolism </li></ul></ul><ul><ul><li>Causing overproduction or retraction of uric acid </li></ul></ul><ul><li>Secondary Gout </li></ul><ul><ul><li>Myeloproliferatic disease </li></ul></ul><ul><ul><li>Chronic haemolytic slab </li></ul></ul><ul><ul><li>Drug – Dicureties pyrzinemide </li></ul></ul><ul><ul><li>Starvation </li></ul></ul><ul><ul><li>Chronic glomerulo-nephritis and pyelonephritis </li></ul></ul><ul><ul><li>Hypothyroidis </li></ul></ul>Crystal Arthropathies Types & Causes
  53. 54. Gout <ul><li>Hyperuricaemia </li></ul><ul><li>Monoarticular in early stage </li></ul><ul><li>MCP joint - great toe </li></ul><ul><li>Uric acid crystal deposition </li></ul><ul><li>Tophus </li></ul><ul><li>Punched out </li></ul><ul><li>para-articular lytic lesion </li></ul><ul><li>Tophi & synovial fluid shows </li></ul><ul><li>presence of MSU crystals </li></ul><ul><li>- confirmatory of diagnosis </li></ul>Crystal Arthropathies
  54. 55. Monosodium Urate Crystal Crystal Arthropathies Positive bifringence & needle shaped
  55. 56. Pseudogout Crystal Arthropathies <ul><li>Younger age group compared to gout </li></ul><ul><li>Larger joints involved compared to gout </li></ul><ul><li>Knee most commonly involved </li></ul><ul><li>Severity of clinical features less compared to gout </li></ul><ul><li>Calcification of cartilages hallmark sign </li></ul><ul><li>Negative bifringent and rhomboid shaped crystals </li></ul>
  56. 57. Psoriatic Arthritis <ul><li>Symmetric polyarthritis </li></ul><ul><li>Higher frequency of DIP involvement </li></ul><ul><li>Enthesitis </li></ul><ul><li>Dactylitis (sausage shape digits) </li></ul><ul><li>Recognition of psoriatic plaques is </li></ul><ul><li>important </li></ul>
  57. 58. Radiology <ul><li>Erosion </li></ul><ul><li>Osteolysis </li></ul><ul><li>Bone proliferation </li></ul><ul><li>Ankylosis </li></ul>Psoriatic Arthritis
  58. 59. Reiter’syndrome <ul><li>Triad of : </li></ul><ul><li>May be associated with : </li></ul><ul><li>Mucocutaneous disease </li></ul><ul><li>(balanitis, ulcers, keratoderma ) </li></ul>Asymmetrical arthritis Urethritis/cervicitis or Diarrhoea Conjunctivitis
  59. 60. Systemic Lupus Erythematous <ul><li>Photosensitivity </li></ul><ul><li>Malar or discoid rash </li></ul><ul><li>Mucosal ulcers (hair loss) </li></ul><ul><li>Raynaud’s, vasculitis </li></ul><ul><li>Arthritis (non-erosive) </li></ul><ul><li>Serositis: pleurisy/pericarditis </li></ul><ul><li>Neurological: fits/psychosis </li></ul><ul><li>Renal disease (urinalysis) </li></ul><ul><li>Haematological: </li></ul><ul><li>low platelets, </li></ul><ul><li>leucopenia, </li></ul><ul><li>haemolytic anaemia </li></ul><ul><li>Anti-ds DNA antibodies </li></ul><ul><li>ANA </li></ul>Features Photosensitivity Butterfly facial rash Discoid rashes
  60. 61. <ul><li>Arthritis most common manifestation </li></ul><ul><li>Symmetric non erosive arthritis </li></ul><ul><li>Small joints of hand, wrist, knee most commonly involved </li></ul><ul><li>Nodules similar to RA present </li></ul><ul><li>Jaccoud’s arthropathy </li></ul><ul><li>( ulnar deviation + swan neck deformity ) </li></ul><ul><li>Systemic features help in reaching diagnosis. </li></ul>Arthritis in SLE SLE
  61. 62. THANK YOU

×