a basic approach to diagnosis in joint diseases. is it arthritis or not? arthritis or arthralgia
TRANSCRIPT
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A BASIC APPROACH TO DIAGNOSIS
IN
JOINT DISEASES
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IS IT ARTHRITIS OR NOT?
ARTHRITIS OR ARTHRALGIA
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AN IDENTIFIABLE
PATHOLOGICAL PROCESS
INVOLVING JOINTS MUST BE
PRESENT
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IS IT AN INFLAMMTORY PROCESS
OR
NOT
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INFLAMMATION
SYSTEMIC EFFECTS
TARGET ORGAN EFFECTS
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• REDNESS
• HEAT
• SWELLING
• PAIN
• LOSS OF FUNCTION
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• Soft tissue swelling
• Early morning joint pain and stiffness
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INFLAMMATORY >5,000 white cells/ mm³
“NON-INFLAMMATORY” <1,000 white cells/mm³
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SYSTEMIC EFFECTS OF INFLAMMATION
1. CLINICALtirednesswt lossfevergrowth retardation
2. LABORATORYacute phase reactants
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• Haemoglobin ↓
• White cell count ↑ or normal
• Platelets ↑ or normal
• ESR ↑
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CRP (C reactive protein) ↑
Gamma globulins (immunoglobulins) ↑
Albumin ↓
Alkaline phosphatase (ALP) ↑
Iron and TIBC ↓
Ferretin ↑
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WHICH INFLAMMATORY JOINT DISEASE?
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COMMON MODES of PRESENTATION of
RHEUMATIC DISEASES
SYSTEMIC
POLYARTICULAR
MONO / OLIGOARTICULAR
AXIAL
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• ACUTE
• CHRONIC
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JOINT FLUID
• White cell count
• Examination for crystals
• Culture and sensitivity
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• Multiple pathologies can coexist in the one joint
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PATTERN OF JOINT INVOLVEMENT
NON-JOINT MANIFESTATIONS
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Pattern of Involvement
• In distribution symmetrical or notsmall or large jointsaxial or peripheralmany, few or single joint
• In time episodicflittingconstantadditive
Associated extra-articular problems
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Joints
Skin
Eyes
Lymph nodes – spleen
Lungs
Kidneys
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Rheumatoid Factor ≠ Rheumatoid arthritis
ANA ≠ Systemic lupus
HLA B27 ≠ Ankylosing spondylitis
High urate ≠ Gout
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HLA B27
• ANKYLOSYNG SPONDYLITIS 90%
• NORMAL POPULATION 9%
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BACK PAIN THAT IMPROVES WITH ACTIVITY
CONSIDER THE POSSIBILITY of INFLAMMATORY
SPONDYLARTHROPATHY
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Rheumatoid arthritis: hands, advanced deformity
(radiograph)
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Klareskog L et al Arthritis Rheumatism 2006
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Rheumatoid Arthritis
• Early intervention matters
• Smoking is a risk factor
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Hypouricaemic therapy
• Can precipitate gout in the introductory phase of treatment & needs to be covered
• Do not stop because of breakthrough flare
• Treat to target serum urate level
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• Multiple pathologies can coexist in the one joint
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• REDNESS
• HEAT
• SWELLING
• PAIN
• LOSS OF FUNCTION
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Tendinitis
Enthesitis
Fibrositis
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DIAGNOSIS
EVALUATION
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SYSTEMIC
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MONO or OLIGOARTICULAR
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Rheumatoid Arthritis
A systemic inflammatory disease of unknown cause, with a particular predilection to involve the synovium
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Osteoarthritis
A localised disease of joints, thought to arise as a consequence of cartilage degeneration
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POLYARTICULAR
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Basics of diagnosis
by G Major