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Similar to Polyarthritis (clinical approach)
Polyarthritis (clinical approach)
- 1. POLYARTHRITIS Presented by :Ankita Priydarshini MBBS - Phase III/II Jawaharlal Nehru Medical College, KLE University Belagavi, Karnataka
- 2. Topics covered • Definition •Classification • Rheumatoid Arthritis • Osteoarthritis • Sero-negative Spondyloarthropathies • Distinguishing features • Assessment of joint pain
- 3. Definition • Arthritis -Inflammation of joint marked by pain, swelling, redness & increased temperature in the affected region. • Arthralgia?
- 4. • MONOARTHRITIS -1 joint involvement • PAUCI / OLIGOARTHRITIS - 2 or 3 joint involvement • POLYARTHRITIS - 4 or more joint involvement
- 5. Classification Classification with causes Inflammatory *Infections *Immunologic * Crystal induced * Reactive Acute bacterial, mycotic, syphilitic, viral, tuberculous arthritis, septicaemia, Lyme disease RA, SLE, Sero-negative spondyloarthritides Gout, pseudo-gout Reiter’s syndrome, Behcet’s syndrome Mechanical Degenerative joint disease - osteoarthrosis Metabolic Hypothyroidism, Acromegaly, Cushing’s disease, Amyloidosis, Wilson’s disease Neoplastic Paraneoplastic arthropathies, Hypertrophic osteoarthropathy Drug induced Thiazides causing gout, drug induced lupus Miscellaneous Intestinal bypass arthritis, Whipple’s disease
- 6. RHEUMATOID ARTHRITIS Chronic inflammatoryjoint 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
- 8. * Onset Typical -Insidious onsetpolyarthritis -Affecting small joints of hand & feet - Fatigue, anorexia, weakness & vague musculoskeletal symptoms Atypical -Polymyalgic -Palindromic -Systemic -Persistent monoarthritis
- 9. • Symmetrical deformingpolyarthritis -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 jointinvolvement • symmetrical • small joints of hands - DIP spared • characteristic features -Boutonniere -Swan neck -Z thumb -Volar subluxation -Ulnar deviation
- 11. • Nodules -firm,round masses felt in subcutaneous tissues • Eye - scleritis, episcleritis, sicca complex, glaucoma * Extra articular findings
- 12. • Lung -pleural effusion,interstitial fibrosis, Caplan’s syndrome • Cardiac - pericarditis,premature atherosclerosis,conduction defects, valvular involvement • Vasculitis - cutaneous ulcerations,digital gangrene; visceral infarction-stroke, Acute MI, mesentric arteritis • Neurological - nerve entrapment, spinal compression • Felty’s syndrome - (Neutropenia + RA) with splenomegaly
- 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 commonjoint 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
- 16. • Trauma • Diabetes •Obesity • Age • Systemic diseases - RA * Predisposing factors
- 18. • Old patient •Females > males • Lower limb joints~ knees, hips, 1st CM joint • Rest pain • Pain during movement • Crepitus • Characteristic deformities * Clinical Features
- 20. 0 – Nofeatures 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
- 21. • Ankylosing spondylitis •Reactive arthritis (including Reiter’s syndrome) • Psoriatic spondyloarthropathy • Inflammatory bowel disease(Enteropathic spondyloarthropathy) • Juvenile spondyloarthropathy • Unclassifiable or undifferentiated spondyloarthropathy SERO-NEGATIVE SPONDYLOARTHROPATHIES
- 22. • Seronegative, thatis, 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 predisposition4:1 • Autosomal inheritance • 70% penetrance • 90% association with HLA B27 • Rare in negroes * Etiology
- 25. • Similar toRA • Articular & bone destruction • Fibrous & bony bridging • Para- articular calcification & ossification • Bamboo spine * Pathology
- 26. • Morning pain& stiffness • Sacroiliac pain • Muscle spasm- flexed posture • Wt loss, anaemia • Decreased chest expansion • Ankylosis * Clinical features
- 27. *Monosodium urate crystals -GoutyArthritis *Calcium Pyrophosphate crystals -Chondroclacinosis *Calcium hydroxyapatite crystals -Calcific Periarthritis destructive arthropathy II. Crystal Arthropathies
- 28. Primary Gout -Heritable Errorof metabolism -Causing overproduction or retraction of uric acid Secondary Gout -Myeloproliferatic disease -Chronic glomerulo-nephritis and pyelonephritis -Hypothyroidism * Types
- 29. • Hyperuricaemia • Monoarticularin 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 agegroup 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
- 31. • Negative bifringentand rhomboid shaped crystals Gout crystals Pseudogout crytals
- 32. • Symmetric polyarthritis •Higher frequency of DIP involvement • Enthesitis • Dactylitis (sausage shape digits) • Recognition of psoriatic plaques is important III.Psoriatic Arthritis
- 33.
- 34. *Photosensitivity *Malar ordiscoid rash *Mucosal ulcers (hair loss) *Raynaud’s, vasculitis *Arthritis (non-erosive) *Renal disease (urinalysis) *Serositis: pleurisy/pericarditis *Neurological: fits/psychosis *Haematological: -low platelets -leucopenia -haemolytic anaemia *Anti-ds DNA antibodies *ANAFeatures *Photosensitivity *Butterfly facial rash *Discoid rashes V. Systemic Lupus Erthematosus
- 35. • Arthritis mostcommon 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 ArthritisPsoriatic 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
- 37. Feature Ankylosing Spondylitis Reactive Arthritis Psoriatic Arthritis IBD associated spondyloarthropathy Nailchanges None onycholysis Pitting, onycholysis Clubbing Uveitis Acute Acute Chronic Chronic Pulmonary involvement Upper lobe fibrosis None None None GI invovlvement None Diarrhoea None Features of associated Crohn’s disease or ulcerative colitis Genitourinary involvement None Urethritis, Cervicitis None None Cardiac involvement AR, Conduction defects AR, Conduction defects AR, Conduction defects AR
- 38. Assessment of JointPain Site (distribution) Type of pain Associated features Duration & onset Risk factors Physical Signs Differential Diagnosis Investigations
- 39. Site & distributionof 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 theremorning stiffness? • Have there been any symptoms of infection? • Have there been any rashes ? • Any urinary, genital or gut problems? Associated features
- 43. • When didthe 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
- 45. • Joint distribution+/- spine • Skin and appendages • Rash, nodules, eyes, mouth ulcers, hair • Temp, LNs, CVS, RS, Abdomen, Neurological Physical Signs
- 46. • Osteoarthritis • Rheumatoidarthritis • Gout • Systemic lupus erythematous • Reiter’s disease • Ankylosing spondylitis • Psoriatic arthritis Differential Diagnosis
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