Approach Patient with Arthritis
Introduction Chronic monoarthritis: common causes Causes include various self-limited A. Non-inflammatory illness and disabling and life- Osteoarthritis threatening. Mechanical derangement. Musculoskeletal emergencies Osteonecrosis. (infection, sepsis, compartment Neuropathic arthropathy. syndrome…). Reflex Sympathetic Dystrophy (RSD). Adjacent Bone lesion (Tumor, A careful history and physical examination Infection) are the most important tools. B. Inflammatory. Laboratorytesting and imaging studies Infectious (TB, Fungal, Lyme disease). provide definitive answers in only a few Crystal arthritis. instances. RA. Juvenile chronic arthritis. Many chronic polyarticular diseases require Spondyloarthropathy. months or years to diagnose (delayed extra- HemophilicArthropathy. articular, lab and radiographic findings) Synovial neoplasms. Pigmented villonodular synovitis History Taking Acute polyarthritis: common causes Is it Arthritis or Arthralgia? A. Infection-related Common causes of arthralgia Bacterial species Fibromyalgia Neisseria species Bursitis Lyme disease. Tendinitis Rheumatic fever. Hypothyroidism AIDS Neuropathic pain Viral arthritis Metabolic bone disease B. Non-infectious causes. Depression RA. Juvenile chronic arthritis. Number of joints and Acuteness of Other Connective Tissuediseases. symptoms Spondyloarthropathy. Acute monoarthritis: common causes Gout and pseudogout. A. Inflammatory. Henoch-Schonleinpurpura. Crystal arthritis. Sickle-cell Arthropathy. Septic Hypertrophic osteoarthropathy. Spondyloarthropathy. Sarcoidosis Palindrome Rheumatism Leukemia. Rheumatoid arthritis (RA). Intermittent arthritis: common causes Juvenile chronic arthritis. Sarcoid arthritis Mechanical B. Non-inflammatory Loose Bodies disease Trauma o Partial tears Sickle-cell Arthropathy. o Ligament laxity Osteonecrosis. Crystals o Gout Any Age group= Psoriatic arthritis, o Pseudogout Enteropathic arthritis o Hydroxyapatite Sex Infection o Lyme disease. >Female:SLE, RA, OA, Systemic o Whipple’s disease sclerosis, PMR. Palindromic Rheumatism Male=Female:Psoriatic arthritis, Intermittent Hydroarthrosis Pseudogout, Enteropathic arthritis. EpisodicRA >Male: Gout, Ankylosisspodylitis, Familial Mediterranean Fever. Reactive Arthritis. Sarcoidosis Distribution of joint involvement Chronic polyarthritis: common causes Symmetrical: RA, psoriatic A. (RA- Osteoarthritis like), 1ry OA, SS Rheumatoid arthritis (RA). Asymmetric: LL>UL: Sero – Juvenile chronic arthritis. vearthropathy, gout Other Connective Tissuediseases. Large joints: OA, Reactive Spondyloarthropathy. PIP or DIP, MCP and PIP: RA, SLE Chronic crystal arthritis. DIP: psoriasis, gout, 1ry OA Hypertrophic osteoarthropathy. 1st MTP= Gout, OA Hypothyroidism. Spine= OA, Ankylosisspodylitis, Metabolic and infiltrative bone and Psoriatic arthritis, Reactive arthritis joint diseases. Shoulder= PMR Temporal pattern of joint involvement in Pain character polyarthritis Aggravated by motion= Mechanical Migratory pattern:Arthritis in certain Relieved by motion= Inflammatory. joints remit to reappear in other Duration joints e.g Rheumatic fever, Gonococcal arthritis, Viral Arthritis, <6 wks= viral arthri s, systemic Acute Leukemia rheumatic diseases Additive pattern: Arthritis persists, >6 wks=systemic rheuma c diseases with subsequent involvement of Associated Symptoms other joints e.g RA, SLE. Morning s ffness: >1hr= RA, PMR, Intermittent pattern: Repetitive Inflammatory, < 30 min= OA attacksof acute polyarthritis with Multi-system involvement= Systemic complete remissionbetween attacks rheumatic diseases. e.g RA, polyarticular gout, sarcoid Fever= infection, reactive arthritis, arthritis, Reiter’s syndrome & RA, SLE, Crystal induced arthritis… psoriatic arthritis. Past Medical history:Trauma, fracture, Age surgical procedures… <30= SLE, Ankylosing spodyli s, Medication list:Drug induced lupus, diuretics Reactive Arthritis. inducing gout. 30-50= RA, Systemic sclerosis, Gout. Physical Examination >50= OA, Pseudogout, PMR Inspect for: o TB arthritis. Skin manifestations: SLE, Psoriasis, o Fungal arthritis. Dermatomyositis, sarcoidosis, Behcet, Systemic Examination Rheumatic fever, Cryoglobulinemia, HSP, Still’s disease. Nervous System: SLE, Behcet, Subcutaneous nodules: RA, RHD, Gout vasculitis (tophi),1ry OA Lung and pleura: RA,SLE, SS, PM, Parotid enlargement: Sjogren’s Lung: Sarcoidosis, Vasculitis. Mucocutaneous: Peri- and myocardium: RA,SLE, SS, o Oral ulcer: Reiter’s, Behcet, SLE PM. o genital ulcer: Reiter’s, Behcet Heart valve: Rheum fever, RA, SLE, Nail changes: Psoriasis Reiter’s S. Eye: RA, AS, Reiter’s, Behcet, Kidney: SLE, vasculitis, Polyarticular Sarcoidosis gout. Nose: Wegner’s granulomatosis, GIT: Reiter’s, IBD, SS. relapsing polychondritis. Liver: HCV, SS, IBD, sarcoidosis. Ear: Relapsing polychondritis. Joints examination Laboratory Studies Soft tissue swelling, warm, Can be misleading. effusion…= Inflammation. Basic: CBC, Urinalysis, RFT, LFT. Acute phase reactant: ESR, CRP. Normal passive motion with limited active motion= bursitis, tendinitis, Uric acid concentration= Gout muscle injury. CK:PM/DM , hypothyroidism Ca+² ,P +³:endocrinal, metabolic Limited passive and active motion = Antibody tests: Synovitis o ANA= SLE Erythematous Joint o Anti-dsDNA= SLE o Gout,chondrocalcinosis o Anti-native DNA, anti-Sm= SLE o RF= RA o Septic arthritis. o Anti-CCP antibody=RA o Rheumatic fever Hepatitis B and C o Leukemia Salmonella, brucella Serology: ReA, Parvovirus serology o RSD Rheumatoid Factor Deformity o Rheumatoid Arthritis o RA o Connective tissue diseases o Psoriasis o Viral infection o SS-Sclerodactyly (flexion contof o Leishmaniasis fingers) o Leprosy o SLE- JaccoudArthropathy. o Tuberculosis o Sickle cell disease o Sarcoidosis Associated Tenosynovitis o Liver diseases o RA, o Subacute bacterial endocarditis o Gout, o Reiter’s syndrome, Imaging Studies o Gonococcal arthritis. X-ray: o OARAChronic Gout o RSD o Ankylosing spondylitis. Synovial Fluid Analysis MRI: Indications o Ankylosing spondylitis.Internal 1. Infec on derangement, 2. Crystal induced arthri s o Avascular necrosis,Osteomyelitis, 3. Hemarthrosis (trauma c, pigmented o Pigmented villonodular synovitis. villnodular synovitis). Bone scan: 4. Differen a nginflammatory from non- inflammatory arthritis (WBCs count) o Stress fracture.