APPROACH TO A CASE OF ARTHRITIS

Dr.S.SRIRAMProf.Dr.GOWRISHANKAR’S M5

UNIT

HISTORY

Joint pain•inflammatory arthritis.• noninflammatory arthritis.• arthralgia.

Inflammatory arthritis

characterized by inflammation affecting −Synovium− synovial cavity−entheses.

• alterations in the structure or mechanics of the joint.

• may occur as a result of (1) cartilage or meniscal damage (2) alterations in joint anatomy

congenitaldevelopmentalmetabolic,past inflammatory diseases.

Non inflammatory arthritis.

• joint tenderness, without abnormalities

• Also includes• altered pain sensation (eg,

fibromyalgia) • early rheumatic syndrome (eg,

arthralgias of systemic lupus erythematosus [SLE]).

Arthralgia.

Symptoms of joint diseasePain

• inflammatory joint disease• pain is present both at rest and with motion• worse at the beginning than at the end of usage.

• Noninflammatory

• pain occurs mainly or only during motion and improves quickly with rest

• Pain that arises from small peripheral joints • more accurately localized than pain arising from

larger proximal joints.

Stiffness

• sensation of tightness when attempting to move joints after a period of inactivity

• subsides over time

• inflammatory arthritis •present upon waking • typically lasts 30-60 minutes or longer.

• noninflammatory arthritis

•experienced briefly (eg, 15 min) upon waking in the morning

• following periods of inactivity.

Swelling

• inflammatory arthritis•synovial hypertrophy• synovial effusion• inflammation of periarticular structures

• noninflammatory arthritis• formation of osteophytes •synovial cysts•Thickening•effusions

Limitation of motion

• structural damage • Inflammation• contracture of surrounding

soft tissues

Weakness

• result of disuse atrophy

•Weakness with pain •musculoskeletal cause (eg, arthritis, tendonitis) rather than a pure myopathic or neurogenic cause.

Fatigue

• inflammatory polyarthritis•noted in the afternoon or early

evening.

• psychogenic disorders•upon arising in the morning • related to anxiety, muscle tension,

and poor sleep.

Temporal pattern of arthritis

• abrupt or insidious.

• abrupt onset • symptoms develop over minutes to hours• occur in trauma, crystalline synovitis, or

infection.

• insidious pattern• symptoms develop over weeks to months• rheumatoid arthritis (RA) and osteoarthritis.

Duration of symptoms • Acute <6 weeks in duration; • chronic is 6 or more weeks in duration.

• The temporal patterns • migratory• additive or simultaneous• intermittent.

• migratory pattern• inflammation for only a few days in each joint

(eg, acute rheumatic fever, disseminated gonococcal infection).

• additive or simultaneous pattern• inflammation persists in involved joints as new

ones become affected.

• intermittent pattern• episodic involvement occurs, with intervening

periods free of joint symptoms (eg, gout, pseudogout, Lyme arthritis).

Number of involved joints

• Monoarthritis - one joint. • Oligoarthritis - 2-4 joints. • Polyarthritis -5 or more

joints.

•Symmetry of joint involvement

• Symmetric arthritis• involvement of the same joints on each

side of the body. •RA and SLE.

• Asymmetric arthritis •psoriatic arthritis, reactive arthritis

(Reiter syndrome), and Lyme arthritis.

•Distribution of affected joints

• The distal interphalangeal joints of the fingers

• involved in psoriatic arthritis, gout, or osteoarthritis

• spared in RA.

• Joints of the lumbar spine

• involved in ankylosing spondylitis • spared in RA.

• Distinctive types of musculoskeletal involvement

• Spondyloarthropathy• involves entheses, •dactylitis (sausage digits)• tendonitis•back pain (sacroiliitis and vertebral disc

insertions).

• Gout

• involves tendon sheaths and bursae•superficial inflammation.

• Extra-articular manifestations

• Constitutional symptoms –• underlying systemic disorder.• include fatigue, malaise, and weight loss.

• Skin lesions

• SLE, dermatomyositis, scleroderma, Lyme disease, psoriasis, Henoch-Schönlein purpura, and erythema nodosum.

• Ocular symptoms or signs • Episcleritis and scleritis -RA or Wegener

granulomatosis• anterior uveitis - ankylosing spondylitis, • iridocyclitis - juvenile RA• Conjunctivitis -reactive arthritis

• Signs of inflammatory joint disease

• Synovial hypertrophy • most reliable sign• chronic inflammatory arthritis- synovial

membrane has a doughy or boggy consistency.

• Joint effusions • in response to

• synovial inflammation• Trauma• anasarca• intra-articular hemorrhage (hemarthrosis)• sympathetic effusion

• detected by fluid ballottement or cross-fluctuation through the synovial cavity.

• Pain throughout the whole range of motion -

acutely inflamed joint. • Pain as the joint is gently forced (ie,

stressed) towards its limitation of range -synovitis.

• Pain not present throughout the entire range of motion - extra-articular source eg.tendinitis.

Erythema and warmth • Erythema of the joint -acute inflammatory

forms of arthritis, such as gout, septic arthritis, or acute rheumatic fever.

• Warmth of the joint - inflammatory arthritis

•Joint tenderness

• sensitive sign, but not specific for inflammatory arthritides.

• Focal tenderness - focus of inflammation outside the joint, such as tendinitis, osteomyelitis, or fracture.

• Signs of degenerative or mechanical joint disease

• Bony overgrowth of the joints (osteophytes)-• at the distal interphalangeal joints -

Heberden nodes, • at the proximal interphalangeal joints

are called Bouchard nodes.

• Limited range of motion:

• intra-articular loose bodies,• osteophyte formation, or subluxation.

• Crepitus during active or passive range of motion

• Joint deformity:

• Restriction of motion

• malalignment of the articulating bones(eg.ulnar deviation of the fingers)

• alteration in the relationship of the two articulating surfaces, such as subluxation

Acute monoarthritis • Inflammatory

• Septic Arthritis• Gout and Pseudogout• Systemic rheumatic disease

manifesting as monoarticular involvement

• Noninflammatory • Juxta-articular fracture • Trauma • Hemarthrosis • Osteonecrosis

Chronic monoarthritis

Inflammatory • Chronic infectious arthritis • Lyme Disease• Crystalline synovitis • Pauciarticular juvenile rheumatoid arthritis • Systemic rheumatic disease presenting with

monoarticular involvement

Noninflammatory • Osteoarthritis• Ischemic necrosis • Hemarthrosis • Paget disease involving the joint• Stress Fracture• Osteomyelitis• Osteosarcoma • Metastatic tumor • Synovial osteochondromatosis

Acute polyarthritis • Rheumatic fever• Gonococcal Arthritis • Polyarticular gout• Polyarticular pseudogout • Viral arthritis (eg, hepatitis B infection,

parvovirus B-19 infection) • Bacterial endocarditis • Rheumatoid Arthritis • Still disease • Systemic Lupus Erythematosus • Reactive Arthritis • Acute sarcoid arthritis • Mediterranean Fever, Familial• Enteropathic Arthropathies

Chronic polyarthritis • Inflammatory

• Rheumatoid Arthritis • Systemic Lupus Erythematosus • Viral arthritis • Psoriatic Arthritis • Reactive Arthritis • Enteropathic Arthropathies • Behçet Disease • Ankylosing Spondylitis and Undifferentiated

Spondyloarthropathy

• Noninflammatory • Osteoarthritis • Traumatic osteoarthritis• Hemochromatosis • Ochronosis • Hypertrophic pulmonary osteoarthropathy • Amyloidosis • Acromegaly

Screening tests for acute polyarthritis

• Blood cultures • Antistreptolysin O titer • Parvovirus B-19 immunoglobulin G and

immunoglobulin M levels • Hepatitis B serology • ANA • Others : HIV test, a rubella titer, an

angiotensin-converting enzyme level and chest radiograph, and ANCA

Screening tests for chronic polyarthritis • Complete blood cell count • ESR and CRP level • ANAs • Rheumatoid factor and CCP antibody • liver function tests , serum creatinine level • Serum uric acid level • Urinalysis • Others : thyroid-stimulating hormone level,

a serum ferritin level, and an iron saturation of serum transferrin.

Screening tests for diffuse arthralgias and myalgias

• ESR and CRP - inflammatory disease, including

polymyalgia rheumatica

• Creatine kinase and aldolase level - myositis

• Thyroid testing • Chemistry profile (ie, calcium, phosphorus, electrolyte,

glucose, total protein) - metabolic or endocrine disorders

• Others • 25-hydroxy vitamin D level - osteomalacia • sacroiliac joint radiography - ankylosing spondylitis,

especially in woman <45 y with neck, chest wall, and low back pain),

• HLA-B27 - reactive arthritis,• hepatitis B and C serology testing, • serum and urine protein electrophoresis - multiple

myeloma• ANA and rheumatoid factor (if clinical features suggest

RA, SLE, or another connective-tissue disease).

THANK YOU