approach to poly-arthritis cbnel2011xlearning.ufs.ac.za/internal_medicine_on/resources/3. academic...
TRANSCRIPT
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APPROACH TO POLY-ARTHRITIS
DR CB NEL
Joints cartilage/synovium
Arthritis
Degenerative
Osteoartritis
Inflammatory
Rheumatoid arthritis
Seronegative
spondiloarthropaties
Gout
Septic
Lower back pain
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Diagnostic approach
• Inflammatory vs. Noninflamatory
• Acute vs. Chronic
• Temporal pattern of joint involvement
• Distribution of joint involvement
• Age of patient
• Sex of patient
• Systemic involvement
Inflammatory vs Mechanical
Morning stiffness>1 hr
FatigueProfound
ActivityImproves symptoms
RestWorsens symptoms
Systemic involvementYes
Swelling, warmth, erythema,
tenderness, loss of function
• Morning stiffness
– <30 min
• Fatigue
– Minimal
• Activity
– Worsens symptoms
• Rest
– Improves symptoms
• Systemic involvement
– No
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Acute vs. Chronic
Acute Polyarthritis
• Infection
– Gonococcal
– Meningococcal
– Acute rheumatic fever
– Bacterial endocarditis
– Viral(esp.. rubella,
hepatitis B, parvovirus,
Epstein-Barr, HIV)
• Other inflammatory
– Rheumatoid arthritis
– Juvenile chronic arthritis
– SLE
– Reactive arthritis
– Psoriatic arthritis
– Polyarticular gout
– Sarcoid arthritis
– Serum sickness
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Chronic Polyarthritis (>6 weeks)
• Inflammatory
– Rheumatoid arthritis
– Polyarticular Juvenile
chronic arthritis
– SLE
– Progressive systemic
sclerosis
– Polymyositis
– Reiter’s syndrome
– Psoriatic arthritis
– Enteropathic arthritis
– Polyarticular gout
– Pseudogout (CPPD)
– Sarcoid arthritis
– Vasculitis
– Polymialgia rheumatica
Chronic Polyarthritis (>6 weeks)
• Noninflammatory
– Osteoarthritis
– Pseudogout (CPPD)
– Polyarticular gout
– Paget’s disease
– Fibromyalgia
– Benign hypermobility syndrome
– Hemochromatosis
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Temporal patterns of joint
involvement
• Migratory
– Rheumatic fever
– Gonococcal arthritis
• Additive
– Nonspecific
• Rheumatoid arthritis
• SLE
• Intermittent
– Rheumatoid arthritis
– Psoriatic arthritis
– Reactive Arthritis
• Palandromic
– Gout
– Rheumatoid arthritis
Distribution of joint involvement
• Rheumatoid arthritis
– Commonly involved
• Wrist, MCP, PIP, elbow, glenohumeral, cervical spine,
hip, knee, ankle, tarsal, MTP
– Commonly spared
• DIP, thoracolumbar spine
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Distribution of joint involvement
• Osteoarthritis
– Commonly involved
• First CMC, DIP, PIP, cervical spine, thoracolumbar spine,
hip, knee, first MTP, toe IP
– Commonly spared
• MCP, wrist, elbow, glenohumeral, ankle, tarsal
Distribution of joint involvement
• Reactive arthrits
– Commonly involved
• Knee, ankle, tarsal, MTP, toe IP, elbow, axial
• Gonococcal arthritis
– Commonly involved
• Knee, wrist, ankle, hand IP
– Commonly spared
• Axial
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RHEUMATOID ARTHRITIS
CLINICAL FEATURES
• Prolonged morning stiffness
• Synovitis of small joints of hands, wrists and feet
• Other synovial structures (tenosynovitis, bursae) also common
• Typical hand features:
o Symmetrical swelling of the MCP and PIP joints
o Tenderness of involved joints
o Swan neck deformities
o Boutonniére deformities
o Z-deformity of the thumb
o Dorsal subluxation of the ulna styloid
o Triggering of the fingers
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EXTRA-ARTICULAR MANIFESTATIONS
• Systemic
Fever, fatigue, weight loss, increased infection risk
• MSK
Muscle-wasting, tenosynovitis, bursitis, osteoporosis
• Haematological
Reactive thrombocytosis, microcytic anaemia, anaemia of
chronic disease(normochromic, normocytic)
• Lymphatic
Splenomegaly, Felty’s syndrome(RA, splenomegaly,
neutropenia)
EXTRA-ARTICULAR MANIFESTATIONS
• Ocular
Episcleritis, scleritis, scleromalacia, keratoconjunctivitis
sicca
• Vasculitis
Nailfold infarcts, skin ulcers, pyoderma gangrenosum,
mononeuritis multiplex, visceral arteritis
• Cardiac
Pericarditis, myocarditis
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EXTRA-ARTICULAR MANIFESTATIONS
• Neurological
Atlantoaxial subluxation, carpal tunnel syndrome, peripheral
neuropathies, mononeuritis multiplex
• Pulmonary
Nodules, pleural effusions, pulmonary fibrosis, bronchiolitis, Caplan’s
syndrome(RA plus pneumoconiosis), bronchiectasis
• Nodules
Subcutaneous, lungs, pericardium
• Amyloidosis
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RA feet
SPECIAL INVESTIGATIONS
• CRP and ESR usually elevated
• Rheumatoid factor positive in 70%
• Anti-CCP positive in a sub-population
• X-rays: periarticular osteopenia and marginal erosion
(x-ray changes takes months to develop)
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CLASSIFICATION CRITERIA OF RA
NEW CRITERIA HAS BEEN PUBLISHED IN 2010
TREATMENT• A multidisciplinary team approach is followed
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PATIENT EDUCATION• The nature of the disease as well as its chronic
course
• Disease is characterised by fluctuations
• It takes a considerable time before the therapy
starts to show results
• Ignorance and especially the fear of becoming
an invalid must be adressed
PHYSIOTHERAPY
• Exercise programme– Maintain muscle strength– Maintain joint mobility as well as prevent
contractures
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OCCUPATIONAL THERAPY
• Patient guidance with regard to work activities
and joint-saving techniques, as well as the
positions of joints during sleep
• Rest and night splints are also important
• Other aids for daily activies are also provided
PHARMACOLOGICAL THERAPY
• Analgesics
• DMARD (changes the course of the disease)
• Corticosteroids
• Immunotherapy
• Other
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ANALGESICS
• Oral analgesics (Paracetamol, tramadol)• NSAID’s
– gastro-intestinal and renal side-effects– high-risk cases
• Misoprostol (Cytotec)• Proton pump inhibiters• H2 antagonists
• Coxibs
CORTICOSTEROIDS
• Low dose oral (chronic as a “DMARD”)
• Intra-articular steroids
• Pulse high dose treatment
– Flares
– Treatment of complications
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DMARD’S
• Chloroquine• Sulphasalazine• Methotrexate• Other immunosuppressants• Combination therapy
Biologic agents when patients fail DMARD therapy
- TNF alpha inhibiters
- B cell inhibiters
- Interleukin 6 inhibiters
OTHER
• Orthopaedic aids
• Orthopaedic surgical treatment
• Rx extra-articular complications
• Supportive therapy
– education
– anxiety
– depression
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OSTEOARTHRITIS
OSTEOARTHRITIS
• Most common arthritis
• Strongly associated with aging
• Characterised by focal loss of articular cartilage with new bone
proliferation and remodelling of the joint contour
• Inflammation is NOT a prominent feature
• Risk factors
– Family history
– Caucasians
– Women
– Trauma
– Adverse loading(obesity,sport,profession)
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PATHOLOGICAL CHANGES IN OA
SYMPTOMS
• Artralgia and functional restriction
• Insidious onset of symptoms
• Pain worsened by movement and relieved by rest
• Brief (<15min.) morning stiffness and brief “gelling” after rest
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PHYSICAL SIGNS
• Bony swelling and deformity around joint margins
• Joint-line tenderness
• Decreased range of movement
• Palpable coarse crepitations
• Muscle wasting
• Antalgic gait common with involvement of lower limbs
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OA HANDS
SPECIAL INVESTIGATIONS
• NO impact on inflammatory markers(CRP, ESR)
• X-ray changes
– Joint space narrowing
– Subchondral sclerosis
– Osteophytes
– Bone cysts
• Correlation between x-ray changes and the level of pain and
disability is variable
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TREATMENT OF OA
• Exercise
• Lose weight
• Heat or cold
• Analgesia
– Paracetamol
– Topical NSAID
– Oral NSAID
– Opioids
• Intra-articular steroids can give temporary relief
• Surgery
– For uncontrolled pain
– Progressive functional impairment
Seronegative
spondilo-arthropathies
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CLINICAL FEATURES OF THE SERONEGATIVE
SPONDARTHRITIS
• Asymmetrical inflammatory oligoarthritis (lower>upper limb)
• Sacroiliitis and inflammatory spondylitis
• Inflammatory enthesitis
• Tendency for familial aggregation
• NO association with positve Rheumatoid factor
• Absence of nodules and other extra-articular features of RA
• Strong association with HLA-B27
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ENTHESITIS: Inflammation of the attachment of tendons or ligaments to bone
(hallmark feature of the seronegative spondarthritis)
LOWER BACKPAIN
InflammatoryInflammatory MechanicalMechanical
AgeAge < 40 years< 40 years Any ageAny age
ProgressionProgression Slowly/ChronicSlowly/Chronic AcuteAcute
Duration of symptomsDuration of symptoms > 3 months> 3 months < 4 weeks< 4 weeks
Morning stiffnessMorning stiffness > 60 min.> 60 min. < 3o min.< 3o min.
Night pain(vertebral)Night pain(vertebral) CommonCommon AbsentAbsent
ExerciseExercise ImproveImprove WorsensWorsens
SISI--joint tendernessjoint tenderness CommonCommon AbsentAbsent
Vertebral mobilityVertebral mobility ↓ all directions↓ all directions ↓ flection↓ flection
Chest expansionChest expansion Decreased Decreased NormalNormal
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ANKYLOSING SPONDYLITIS
• Predilection for the sacroiliac joints and spine
• Male : female ratio of 3:1
• Progressive stiffening and fusion of axial skeleton
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SPINAL FEATURES
• Insidious onset over months to years
• Restriction of lumbar movements
• Possible involvement of the entire spine as disease progress
• Progressive spinal fusion
o Loss of lumbar lordosis
o Marked thoracic kyphosis
o Reduced chest expansion
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EXTRASPINAL FEATURES
• Plantar fasciitis and Achilles tendinitis
• Asymmetrical peripheral arthritis: shoulders, hips, knees and
ankles
• Anterior uveitis
• Aortic incompetence
• Cardiac conduction defects
• UPPER lobe pulmonary fibrosis
• Osteoporosis
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TREATMENT
• Physiotherapy
• Regular NSAID’s
• Sulfasalazine for peripheral arthritis
• Tumour necrosis factor(TNF)-Alpha inhibiters
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REACTIVE ARTHRITIS
• Classically young men
• Acute onset inflammatory oligoarthritis 1-3 weeks afer an infection
affecting the small and large joints of the lower limbs
• Infective “trigger”
– Bacterial dysentery (due to Salmonella, Campylobacter, Shigella,
Yersinia)
– Non-spes. urethritis (due to Clamydia)
• First attack usually self-limiting with spontaneous remission within 4-6
months
• Treatment:
– Mostly symptomatic with NSAID’S
– DMARD’s in worse cases
PSORIATIC ARTHROPATHY
• Five major articular presentations:
– Asymmetrical inflammatory oligoarthritis
– Symmetrical polyarthritis (Strongly resemble RA)
– Predominantly distal interphalangeal joint arthritis
– Psoriatic spondylitis (strongly resemle Ankylosing spondylitis)
– Arthritis mutilans
• Skin lesions
• Nail changes: pitting, onycholysis, subungual hyperkeratosis
• Treatment similar to Ankylosing spondulitis
(methotrexate will also help for peripheral arthritis)
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Symmetric psoriatic polyarthritis resembling RA
Distal interphalangeal joint involvement
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Psoriatic Arthritis
Nail pitting
Skin
Enthesophathy
Dactilitis
ARTHRITIS ASSOCIATED WITH INFLAMMATORY
BOWEL DISEASE
• Two patterns of articular involvement:
– Acute oligoarthritis with a predilection for the lower limb
joints.
– Sacroiliitis and ankylosing spondylitis