approach to the patİents wİth chronic arthritis
DESCRIPTION
APPROACH TO THE PATİENTS WİTH CHRONIC ARTHRITIS. Dr. MÜGE B IÇAKÇIGİL KALAYCI. CHRONIC MONOARTHRITIS. ESSENTIAL FEATURES Chronic inflammatory monoarthritis infection, crystal-induced arthritis, sarcoidosis, or monoarticular presentation of oligoarthritis or polyarthritis - PowerPoint PPT PresentationTRANSCRIPT
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APPROACH TO THE PATİENTS WİTH CHRONIC ARTHRITIS
Dr. MÜGE BIÇAKÇIGİL KALAYCI
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CHRONIC MONOARTHRITIS
• ESSENTIAL FEATURES• Chronic inflammatory monoarthritis
– infection, crystal-induced arthritis, sarcoidosis, or monoarticular presentation of oligoarthritis or polyarthritis
• Chronic noninflammatory monoarthritis – osteoarthritis, mechanical , Chondromalacia
patellae, and osteonecrosis.
• Arthrocentesis and imaging studies are important dignostic tests
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CHRONIC MONOARTHRITIS• INITIAL CLINICAL EVALUATION• Infections, particularly indolent infections, are
a concern with inflammatory monoarthritis that lasts from weeks to months.
• The particular joint involved influences the differential diagnosis.
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CHRONIC MONOARTHRITIS
• LABORATORY EVALUATION• A critical step is to determine whether the
monoarthritis is inflammatory, preferably by analyzing synovial fluid.
• Synovial fluid should be sent for culture (bacterial, mycobacterial, and fungal), WBC count, and gram stain and examined for crystals by polarized light microscopy.
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CHRONIC MONOARTHRITIS
• Routine laboratory studies (eg, complate blood cell count, creatinine, and urine analysis) and determination of the ESR or CRP and uric acid level can provide helpful information.
• Patients with inflammatory monoarthritis and negative bacterial cultures shoud be tested for reactivity to purified protein derivative (PPD)
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CHRONIC MONOARTHRITIS
• IMAGING STUDIES• Unlike in acute monoarthritis , radiographs
can be helpful in evaluating chronic monoarthritis and can point to correct diagnosis in cases of infection, osteoarthritis, and osteonecrosis.
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Differential diagnosis of chronic
inflammatory monoarthritisInfection Nongonococcal septic arthritis Gonococcal Mycobacterial Fungal ViralCrystal-induced aarthritisGout Pseudogut
Monoarticular presentation of oligoarthritis or polyarthritis
SpondyloarthropathiesRheumatoid arthritisLupus and other systemic autoimmune diseases.
Sarcoidosis
Uncommon or rareFMFAmyloidosisPigmented villonodular synovitis
Non-inflammatory
OsteoarthritisInternal derangements (eg,torn,meniscus)Chondromalacia patellaOsteonecrosisNeıropathic (charcot) arthropathy
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CHRONIC MONOARTHRITIS
• Tuberculous infection of a joint can present after days, weeks or months of symptoms.
• Smears for acid fast bacilli are positive only 20% of cases,
• Cultures for mycobacteria are positive in 80 %, but test results take weeks.
• Synovial biopsy can expedite the diagnosis of tuberculous arthritis , and is also indicated in suspected cases of fungal arthritis.
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CHRONIC OLIGOARTHRITIS
• ESSENTIAL FEATURES• Careful description of arthritis and detection
of extraarticular disease facilitate accurate diagnosis.
• Radiographs are often of diagnostic value.
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CHRONIC OLIGOARTHRITISCommon inflammatory causesSpondyloartropatiesReactive arthritisAnkylosing spondylitisPsoriatic arthritisInflammatory bowel disease
Uncommon-rare inflammatory arthritis
Subacute bacterial endocarditisSarcoidosisBehçet diseaseCeliac disease
Common non-inflammatory causesOsteoarthritisUncommon-rare non inflammatoryHypotyroidismamyloidosis
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CHRONIC OLIGOARTHRITIS
• Spondyloartropathies are the most common cause of chr. Oligoarthritis
• Early onset rheumatoid arthritis must be distinquished.
• Osteoarthritis presents as oligoarthritis of the hips or knees
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CHRONIC OLIGOARTHRITIS
• Laboratory evaluation• Synovial fluid analysis- culture- crystals
• RF-dd(x) of RA
• HLA B 27- limited value
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CHRONIC OLIGOARTHRITIS
• Radiographs and Imaging studies-considerable value
• Evidence of sacroitis indicates a spondyloarthropaty and narrow dd(x)
• Erosions of RA and Gout
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CHRONIC OLIGOARTHRITIS
• Spondyloartropaties- asymmetric oligoarthritis
• RA- symmetric poliarthritis• İn early RA- oligoartitis
• Stiffness and pain in low back- Spa• RA- only cervical spine
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CHRONIC OLIGOARTHRITIS
• Dactylitis(sausage digits)- sPA, gout, sarcoidosis• Extraarticular manifestations that point to
correct diagnosis
• Psoriasis –umblicus, external auditory canal, scalp and anal creft
• Diarrea- inflammatory bowel disease.• Anterior uveitis
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CHRONIC POLYARTHRITIS
• ESSENTIAL FEATURES• Rheumatoid arthritis and Osteoarthritis are
leading causes.• Careful delineation of the joints involved,
particularly in the hands, can help to the correct d(x)
• The distinction between inflammatory non inflammatory is critical
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CHRONIC POLYARTHRITISInflammatory –Common
Rheumatoid arthritisSLEspondyloartropaties (especiaally Psoriatic art)GoutChronic hepatitis C infectionDrug induced lupus syndrome
Inflammatory-Uncommon
Paraneoplastic polyarthritisRemitting seronegative symmetric polyarthritis with pitting edema (RS3PE)Adult onset still disease
Inflammatory- uncommon
VasculitiitisSjögren’s syndromeViral infections other than hepatitis C
Non inflammatory
OsteoarthritisHemachromatosis
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CHRONIC POLYARTHRITIS
• Laboratory evaluatıon• If arthrosentesis is feasible- joint aspiration-
cell count and crystals• CBC• RFT• Urine analysis• ESR_CRP• RF-ANA- hepatitis B and C serology
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CHRONIC POLYARTHRITIS
• Radiographs are indicated in most cases of chronic polyarthritis
• Erosion-RA-OA-hemachromatosis-gout- SPA
• Non-erosive- SLE-drug induced SLE-chronic hepatitis C.
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DD(x) of chronic polyarthritis
• Osteoarthritis and Rheumatoid arthritis have different patterns of joint involvement in the hand.
• OA- involves DIP, PIP and first MCP joints.
• RA- PIP- MCP and wrist
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• Osteoarthritis and Rheumatoid arthritis spare certain joints
• OA- does not involve MCP, wrist, elbow, ankles• • RA- spare DIP, thoracic and lumbosacral spine
and sacroiic joints• Psoriatic arthritis- DIP joints
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ASSOCIATED HISTORY
• •Predisposing factors• •Medication• •Bowels• •Urinary• •Rashes• •Eyes• •Raynaud’s• •Sicca• •Family History
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EXAMINATION
•Multi-system•Disability•Range of movement•Signs of inflammation
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INVESTIGATIONS
• •FBE/E/LFT• •ESR/CRP• •Iron studies• •Uric Acid• •Auto antibodies• •HLA-B27• •Viral serology• •Joint fluid• •Imaging
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Skin and nail findings and arthritis
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Skin rashes
• Diffuse eruption with fever and systemic findings
• Generally viral or due to primary immunological disease
• Must be differentiated from bacterial diseases
• SLE, DM
• Rheumatic fever
• Still disease
• Kawasaki disease
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Adult still disease
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Papulosquamaus lesions
• Psoriatic arthritis
• Reiter Syndrome
• SLE
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SLE
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Annular lesions
• Rheumatic fever
• Subcutaneous Lupus
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Facial lesions
• Malar and discoid rash
• Lupus pernio: Sarcoidosis
• Dermatomyositis-gottron papules-heliotrope rash
• Lupus vulgaris: cutanous tuberculosis
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Nodular lesions
• RA, ARA, crystal artropathies
• Erythema nodosum: Behçet’s disease,Sarcoidosis, spondyloartropathies, tbc
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Erysipel like rash (FMF)
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Acneiform lesions( behçet’s disease)
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Purpura
• purpura:vasculitis
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Skin thickening
• Scleroderma
• Eosinophilic fasitis and eosinophilic myalgia
syndrome.
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Photosensitive skin eruption
• Connective tissue diseases, SLE, DLE,
DM...
• Phototoxic drug allergies (sulfa,
thiazid..)
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Oral ulcers
• Behçet ‘s disase
• Crohn disease
• Spondyloarthropathies
• SLE
Genital ulcers
Behçets disease
Reactive arthritis
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Sousage digits/Enthesopathy
• Reactive arthritis
• Psoriatic arthritis
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Sousoge digits
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Achille tendinitis
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Raynaud
• Primary or secondary
• Primary- female- %5-8
• Secondary – connective tissue disorders
• Scleroderma, SLE, SS, RA, DM/PM...
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Fever, weight loss, malaise and arthritis
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Fever and rheumatological diseases
• ARA
• FMF
• JRA/JİA
• Adult onset Still disease
SLE
Vasculitis
Behcet ‘s disease
Scleroderma
DM/PM
Sarcoidosis
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Eye and arthritis
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Eye and rheumatological diseases
Uveitis
• Anterior uveitis: BH, Spondyloarthropathies,
Sarkoidosis, JRA..
• Posterior Uveitis: BH, SLE, Sarkoidosis...
Cornea Involvement
• Marginal erosion: RA
• Skleritis/episkleritis: RA
Keratoconjonktivitis sicca
• Primary or secondary Sjögren syndrome
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Anterior uveitis an hypopyon
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Dry eye and sclera erosions
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Abdominal symptoms and arthritis
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Abdominal symptoms and arthritis
• Diarrea
• Abdominal pain
• Intestinal bleeding
• Enteropahtic arthritis
• Reactive arthritis
• Behcet disease
• FMF
• Vasculitis
• Connective tissue
diseases
Mono-oligoarthritis
Poliarthritis
Axial involvement