clinical approach to new onset arthritis jeffrey carlin, md division of rheumatology, vmmc clinical...
TRANSCRIPT
![Page 1: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/1.jpg)
Clinical Approach to New Onset Arthritis
Jeffrey Carlin, MD Division of Rheumatology, VMMCClinical Associate Professor, UW
![Page 2: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/2.jpg)
Nothing to declare
![Page 3: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/3.jpg)
Acute Arthritis• The sudden onset of inflammation of the joint,
causing severe pain, swelling, and redness.• Structural changes in the joint itself may result
from persistence of this condition.
![Page 4: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/4.jpg)
Key Points1. Distinguish arthritis from soft tissue non- articular
syndromes (discrepancy between “active” and “passive” ROM suggests periarticular/soft tissue)
2. If the problem is articular distinguish single joint from multiple joint involvement
3. Inflammatory or non-inflammatory disease4. Always consider septic arthritis!
![Page 5: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/5.jpg)
Inflammatory Vs. Noninflammatory
Feature Inflammatory Noninflammatory
Pain (when?)
Swelling
Erythema
Warmth
AM stiffness
Systemic features
î ESR, CRP
Synovial fluid WBC
Examples
Yes (AM)
Soft tissue
Sometimes
Sometimes
Prominent
Sometimes
Frequent
WBC >2000
Septic, RA, SLE, Gout
Yes (PM)
Bony
Absent
Absent
Minor (< 30 ‘)
Absent
Uncommon
WBC < 2000
OA, AVN
![Page 6: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/6.jpg)
Acute Monoarthritis• Inflammation (swelling, tenderness,
warmth) in one joint• Occasionally polyarticular diseases can
present with monoarticular onset: (RA, JRA,Reactive and enteropathic arthritis, Sarcoid
arthritis, Viral arthritis, Psoriatic arthritis)
![Page 7: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/7.jpg)
Acute Monoarthritis - Etiology
• THE MOST CRITICAL DIAGNOSIS TO CONSIDER: INFECTION !
![Page 8: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/8.jpg)
Acute Monoarthritis - Etiology
• Septic• Crystal deposition (gout, pseudogout)• Traumatic (fracture, internal derangement)• Other (hemarthrosis, osteonecrosis,
presentation of polyarticular disorders)
![Page 9: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/9.jpg)
Questions to Ask – History Helps in Differential Diagnosis
• Pain come suddenly, minutes? – fracture.• 0ver several hours or 1-2 days? –infectious, crystals,
inflammatory arthropathy.• History of IV drug abuse or a recent infection? –
septic joint.• Previous similar attacks? – crystals or inflammatory
arthritis.• Prolonged courses of steroids? – infection or
osteonecrosis of the bone.
![Page 10: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/10.jpg)
Acute Monoarthritis
![Page 11: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/11.jpg)
Indications for Arthrocentesis
– SYNOVIAL FLUID ANALYSIS: The single most useful diagnostic study in initial evaluation of monoarthritis
– 1. Suspicion of infection– 2. Suspicion of crystal-induced arthritis– 3. Suspicion of hemarthrosis– 4. Differentiating inflammatory from
noninflammatory arthritis
![Page 12: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/12.jpg)
Tests to Perform on Synovial Fluid
• Gram stain and cultures • Total leukocyte count/differential
– Inflammatory vs. non-inflammatory• Polarized microscopy to look for crystals• Not necessary routinely:
– Chemistry (glucose, total protein, LDH) unlikely to yield helpful information beyond the previous tests.
![Page 13: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/13.jpg)
Synovial Fluid Analysis
Joint Fluid Appearance Cell Count
Normal Clear/Yellow <200 WBC’s
Non-Inflammatory
Clear/Yellow <2000 WBC’s
Inflammatory Turbid/Yellow <50,000 WBC’s
Septic Pus >50,000 WBC’s
![Page 14: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/14.jpg)
Other Tests Indicated for Acute Arthritis
1. Almost always indicated: RadiographsCBCESR/CRP
2. Indicated in certain patients: Cultures
3. Rarely indicated: Serologic: ANA, RF, HLA-B27Serum Uric acid level
![Page 15: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/15.jpg)
Tests of Acute Phase Reactants
• Erythrocyte Sedimentation Test• C-Reactive Protein
![Page 16: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/16.jpg)
Patterns of Response of Acute Phase Reactants
Gabay C, Kushner I, NEJM , 1999;340:450
![Page 17: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/17.jpg)
ESR’s
• Non-specific marker- elevated in rheumatic diseases, infection, malignancy
• Can be artificially elevated by:• Pregnancy• Anemia• Nephrotic Syndrome• Benign/Malignant Monoclonal Gammopathies• Age• Obesity
• Can be normal in some inflammatory conditions
![Page 18: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/18.jpg)
Formula for Age- Related Normals
• Men: ESR(mm/hr)= (age in years)/2
• FemalesESR (mm/hr)= (age in years + 10)/2
![Page 19: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/19.jpg)
C- Reactive Protein
• Produced in liver in response to IL-1 & IL-6
• Rapid rise in response to inflammatory stimuli • Can be affected by:
– Obesity/Metabolic Syndrome– Age
![Page 20: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/20.jpg)
Formula for Age-Related Normals
• Men CRP = (age/65) +.1 mg/dl
• WomenCRP = (age/65) + .7 mg/dl
![Page 21: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/21.jpg)
Septic Joint• Most articular infections – a single joint• 15-20% cases polyarticular• Most common sites: knee, hip, shoulder• 20% patients afebrile• Joint pain is moderate to severe• Joints visibly swollen, warm, often red• Comorbidities: RA, DM, SLE, cancer,etc
![Page 22: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/22.jpg)
Septic Joint - Nongonococcal
• 80-90% monoarticular• Most develop from hematogenous spread• Most common:
– Gram positive aerobes (80%)– Majority with Staph aureus (60%)– Gram negative 18%
![Page 23: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/23.jpg)
Likely Causes of Septic ArthritisGram Stain Pt Characteristic Organism of Concern
No Bacteria Young, healthy GC, Staph
No Bacteria Hx of RA Staph
No bacteria Immunosupression, IV drugs, Hx gm- infection
Staph, Strep, Pseudomonas,
fungal
No Bacteria or Gm - Recent cat/dog bite Pasteurella multocida
Gm+ None Staph/Strep
Gm- diplococci None GC ( consider meningococcemia)
Gm - None Rx for possible pseudomonas
Gm - SLE or Sickle Cell Include coverage for Salmonella & Psudomonas
No bacteria Hx prosthetic joint Staph epidermidis, Staph aureus
No bacteria HX fresh/salt H20 exposure + injury; chronic swelling
Mycobacterium marinum
![Page 24: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/24.jpg)
Initial Empirical Antibiotic RxGram Stain Drug of Choice Alternative Drug
Gm + Cocci (small) in pairs & chains
Vancomycin 1 gm IV 12 h Cefotaxime 2.0 gm Iv q6-8h
Gm+ Cocci (large) singly or in large groups
Vancomycin 1 gm IV q12 h Nafcillen 2.0gm Iv q 4h
Gm - Bacilli Ceftriaxone 2.0 gm q 24h Imipenem .5 gm IV q 6h
Gm- Bacilli Cefotaxime 2.0 gm IV q 6h Imipenem .5 gm IV q 6h
None- (Healthy young pt- Assume GC but include Gm + coverage
Ceftriaxone 2.0 gm q 24h Imipenem .5 gm IV q 6h
None- (Underlying disease or Immunosupression
Vancomycin 1 gm IV 12 h + Cipro 400mg q 12 h
Imipenem .5 gm IV q 6h
![Page 26: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/26.jpg)
Gout• Caused by monosodium urate crystals• Most common type of inflammatory monoarthritis• Typically: first MTP joint, ankle, midfoot, knee• Pain very severe; cannot stand bed sheet• May be with fever and mimic infection• The cutaneous erythema may extend beyond the
joint and resemble bacterial cellulitis
![Page 27: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/27.jpg)
Urate Crystals
• Needle-shaped
• Strongly negative birefringent
![Page 28: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/28.jpg)
Gouty Arthritis
![Page 29: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/29.jpg)
Pseudogout
![Page 30: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/30.jpg)
Pseudogout• Can cause monoarthritis clinically indistinguishable
from gout.• Often precipitated by illness or surgery.• Pseudogout is most common in the knee (50%) and
wrist.• Reported in any joint (Including MTP).• CPPD disease may be asymptomatic (deposition of
CPP in cartilage).
![Page 31: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/31.jpg)
CPPD Crystals
• Rod or rhomboid-shaped
• Weakly positive birefringent
![Page 32: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/32.jpg)
Algorithm for w/u of Monoarticular Arthritis
![Page 33: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/33.jpg)
Polyarthritis• Definite inflammation (swelling,
tenderness, warmth of > 5 joints• A patient with 2-4 joints is said to
have pauci- or oligoarticular arthritis
![Page 34: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/34.jpg)
Acute PolyarthritisInfection• Gonococcal• Meningococcal• Lyme disease• Rheumatic fever• Bacterial endocarditis• Viral (rubella,
parvovirus, Hep. B)
![Page 35: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/35.jpg)
Acute PolyarthritisInfection• Gonococcal• Meningococcal• Lyme disease• Rheumatic fever• Bacterial endocarditis• Viral (rubella,
parvovirus, Hep. B)
Inflammatory• RA• JRA• SLE• Reactive arthritis• Psoriatic arthritis• Polyarticular gout• Sarcoid arthritis
![Page 36: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/36.jpg)
Inflammatory Vs. Noninflammatory
Feature Inflammatory Mechanical
Morning stiffness
Fatigue
Activity
Rest
Systemic
Corticosteroid
>1 h
Profound
Improves
Worsens
Yes
Yes
< 30 min
Minimal
Worsens
Improves
No
No
![Page 37: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/37.jpg)
Temporal Patterns in Polyarthritis
• Migratory pattern: – Rheumatic fever, gonococcal (disseminated
gonococcemia), early phase of Lyme disease
• Additive pattern – RA, SLE, psoriasis
• Intermittent: – Gout, reactive arthritis
![Page 38: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/38.jpg)
Patterns of Joint Involvement
• Symmetric polyarthritis involving small and large joints: viral, RA, SLE, one type of psoriatic (the RA-like).
• Asymmetric, oligo- and polyarthritis involving mainly large joints, preferably lower extremities, especially knee and ankle : reactive arthritis, one type of psoriatic, enteropathic arthritis.
• DIP joints: Psoriatic.
![Page 39: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/39.jpg)
Acute Polyarthritis - RA
![Page 40: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/40.jpg)
Rheumatoid Arthritis• Symmetric, inflammatory polyarthritis, involving
large and small joints• Acute, severe onset 10-15 %; subacute 20%• Hand characteristically involved• Acute hand deformity: fusiform swelling of fingers
due to synovitis of PIPs• RF/Anti-CCP Ab may be negative at onset and
may remain negative in 15-20%! • RA is a clinical diagnosis, no laboratory test is
diagnostic, just supportive!
![Page 41: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/41.jpg)
Rheumatoid Factors
![Page 42: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/42.jpg)
Rheumatoid Factors
• Autoantibodies to the Fc portion of IgG. • Support a diagnosis of Rheumatoid Arthritis but
are not by themselves diagnostic. • Are seen in about 75% to 80% of patients with RA. • Are associated with a poor prognosis in patients
with RA. • Are seen in conditions other than RA
![Page 43: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/43.jpg)
Rheumatic Diseases with Positive RF
• RA 80%• JRA 20%• SLE 20%• Sjogren’s 90%• Scleroderma 20-30%
![Page 44: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/44.jpg)
Non-Rheumatic Diseases with Positive RF
• Hepatitis C < 70%• Mixed cryoglobulinemia 90%• Sarcoidosis 5-30%• Pulmonary Fibrosis 20%• Infections varies• Aging 5%
![Page 45: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/45.jpg)
RF: Clinical Significance• Highly predictive of RA in patients with identified rheumatic
disease• May be absent at the onset of disease in up to half of patients
with typical clinical picture of RA– approx 20% remain seronegative– many convert within 2 years
• Best used to confirm RA for typical presentation– inflammatory polyarthritis, “gel phenomenon,” etc.
• Not useful to follow course of illness– generally not helpful to repeat after diagnosis
![Page 46: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/46.jpg)
RF: Test Statistics
• Sensitivity 80%• Specificity 95%• PPV (unselected populations)- 20-30%
(RA population)- 80%• NPV- 95%
![Page 47: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/47.jpg)
Anti-Citrulline Antibody Assay
ELISA detects antibodies to cyclic citrullinated protein (anti-CCP)
![Page 48: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/48.jpg)
Anti-CCP Antibody Assay
• Accuracy (Anti-CCP-2 Assay)– Specificity 79% Sensitivity 96-98%
• Diagnosis more accurate when combined with RF+• Present in 50-60% early RA patients• Can be seen 1.5 -9 yrs pre-diagnosis of RA• Predictive for progressive joint damage
– Present in up to 40% percentage of RF- patients with erosions
– RF+, anti-CCP+ pts have very aggressive disease
![Page 49: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/49.jpg)
Viral Arthritis• Younger patients• Usually presents with prodrome, rash• History of sick contact• Polyarthritis similar to acute RA• Prognosis good; self-limited• Examples: Parvovirus B-19, Rubella, Hepatitis
B and C, Acute HIV infection, Epstein-Barr virus, mumps
![Page 50: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/50.jpg)
Parvovirus B-19• The virus of “fifth disease”, erythema infectiosum
(EI).• Children “slapped cheek”; adults flu-like illness,
maculopapular rash on extremities.• Joints involved more in adults (20% of cases).• Frequently RF +• Abrupt onset symmetric polyarthralgia/polyarthritis
with stiffness in young women exposed to kids with E.I.
• May persist for a few weeks to months.
![Page 51: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/51.jpg)
Spondyloarthropathy
Undifferentiated spondyloarthropathy
Arthritis associated with
inflammatory bowel disease
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis
![Page 52: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/52.jpg)
Inflammatory Back Pain
• Onset of back discomfort before age 40• Insidious onset• > 3 mths duration• Morning stiffness in the back• Improvement with exerciseIf 4 of these are met, AS is diagnosed
![Page 53: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/53.jpg)
Techniques for Imaging SIJ
Benefits Shortcomings
X-ray Quick & cheap Changes occur late
Radionuclide imaging
May indicate early changes Controversial
CT Clear imaging of early changes, may clarify dx when x-ray borderline
Radiation dose
Very early disease may still not be
detectable
MRI May show inflammation & very early changes
Price & availability
![Page 54: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/54.jpg)
Asymmetric, Inflammatory Oligoarthritis
![Page 55: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/55.jpg)
Enthesitis in Spondyloarthropathies
![Page 56: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/56.jpg)
Reactive Arthritis
• Triggered by specific gut or genito-urinary tract infections
– Salmonella, Yersinia, Campylobacter, Shigella– Chlamydia
• Joint symptoms appear 1-3 week later– Oligoarthritis; usually lower extremity– Enthesitis
• Frequent association with extra-articular findings• A proportion evolve into chronic spondyloarthropathy
![Page 57: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/57.jpg)
Extra-articular Features of Reactive Arthritis
• Don’t be put off if they are not present• Ask about GI disturbance - even mild• Ask about conjunctivitis• Take a sexual history (with explanation)• Examine eyes and skin (soles/external
genitalia)• Look for enthesitis
![Page 58: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/58.jpg)
Psoriatic Arthritis
![Page 59: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/59.jpg)
Psoriatic Arthritis• Prevalence of arthritis in Psoriasis 10-20%
– Psoriasis usually precedes PSA- 75%– 10-15% arthritis precedes Psoriasis– Nail changes common
• Psoriatic plaques– Scalp, extensor surfaces, natal cleft,
umbilicus
![Page 60: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/60.jpg)
Psoriatic Arthritis
• Subtypes:– Asymmetric, oligoarticular- associated dactylitis– Predominant DIP involvement – nail changes– Polyarthritis “RA-like” – lacks RF or nodules– Arthritis mutilans – destructive erosive hands/feet– Axial involvement –spondylitis– HIV-associated – more severe
![Page 61: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/61.jpg)
Dactylitis “Sausage Toes” – Psoriasis
![Page 62: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/62.jpg)
Nail Changes in Psoriatic Arthritis
![Page 63: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/63.jpg)
Nail Pitting - Psoriasis
![Page 64: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/64.jpg)
European Criteria for Spndyloarthropathy
• Inflammatory spine pain or synovitis• And one or more of the following:
• Alternating buttocks pain• Sacroiliitis• Enthesopathy• Positive family history• Psoriasis• IBD• Recent episode of urethritis/cervicitis or
gastroenteritis
![Page 65: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/65.jpg)
HLA-B27 in the General Population
• Caucasian 6-8%• African-Americans 4%• African Blacks 0%• Japanese 1%• Koreans 3-4%• Native Americans 40-50%
(Haida, Navajo, Eskimos)
![Page 66: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/66.jpg)
HLA- B27 and Disease(Caucasians)
Disease Association Ankylosing spondylitis 90%
Reactive arthritis 60-80%
Inflammatory bowel disease 35-75%
Psoriatic arthritis
With spondylitis 50%
With peripheral arthritis 15%
Undifferentiated Spondyloarthropathy 70%
Anterior Uveitis 50%
![Page 67: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/67.jpg)
![Page 69: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/69.jpg)
Acute Sarcoid Arthritis• Löfgren’s syndrome: acute arthritis, erythema
nodosum, bilateral hilar adenopathy• Chronic arthritis- (15-20%)
– Symmetrical: wrists, pip’s, ankles, knees
• Chronic inflammatory disorder – noncaseating granulomas at involved sites
• Common with hilar adenopathy
![Page 70: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/70.jpg)
1. Wolfe F, et al Arthritis Care and Research 2010;62; 600-6102. Wolfe, F et al, Arth & Rheum 1990; 33:160-172
![Page 71: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/71.jpg)
Prognosis of Early Undifferentiated Arthritis
• Remission- 13-60%• RA or other Dx- 7-65%• Persistant Disease w/o DX- 10-40%
• Monoarticular Arthritis– Remission- 60%– Oligoarticular- 10-40%– Undifferentiated-70%
![Page 72: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/72.jpg)
Thank you!
![Page 73: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/73.jpg)
Arthritis Of SLE• Musculoskeletal manifestation 90%.• Most have arthralgia.• May have acute inflammatory synovitis RA-
like.• Do not develop erosions.• Other clinical features help with DD: malar
rash, photosensitivity, rashes, alopecia, oral ulceration.
![Page 74: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/74.jpg)
Butterfly Rash – SLE
![Page 75: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/75.jpg)
Photosensitivity
![Page 76: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/76.jpg)
Alopecia - SLE
![Page 77: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/77.jpg)
Arthritis of Rheumatic Fever
• Etiology: Streptococcus pyogenes (group A); there is damaging immune response to antecedent infection – molecular cross reaction with target organs “molecular mimicry”.
• Onset approximately 3wks after exposure• Migratory polyarthritis, large joints: knees, ankles,
elbows, wrists.• Major manifestations: carditis, polyarthritis, chorea,
erythema marginatum, subcutaneous nodules.
![Page 78: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/78.jpg)
Erythema Marginatum – Rheumatic Fever
• Circinate• Evanenscent• Nonpruritic rash
![Page 79: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/79.jpg)
Rheumatic Fever – Subcutaneous Nodes
![Page 80: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/80.jpg)
Post-Strep Reactive Arthritis
• Onset 7-10 days after Strep A• Oligoarthritis lasting >3weeks• Evidence for recent infection: Throat culture,
+ASO titers
![Page 81: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/81.jpg)
Adult Still’s Disease and JRA Rash
• Salmon or pale-pink • Blanching• Macules or
maculopapules• Transient (minutes or
hours)• Most common on
trunk• Fever related
![Page 82: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/82.jpg)
Disseminated Gonococcemia – Pustules
![Page 83: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/83.jpg)
Septic Joint - Gonococcal
• Most common cause of septic arthritis• Often preceded by disseminated gonococcemia• Sexually active individual, 5-7 days h/o fever, chills,
skin lesions, migratory arthralgias and tenosynovitis persistent monoarthritis
• Women often menstruating or pregnant• Genitourinary disease often asymptomatic
![Page 84: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/84.jpg)
Viral Arthritides - Parvovirus
![Page 85: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/85.jpg)
Rubella Arthritis• German measles.• Young women exposed to school-aged children.• Arthritis in 1/3 of natural infections; also following
vaccination.• Morbilliform rash, constitutional symptoms.• Symmetric inflammatory arthritis (small and large
joints).
![Page 86: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/86.jpg)
1987 ACR Criteria for Rheumatoid Arthritis
• 4/7 Criteria– AM Stiffness lasting > 1 hr– Swelling in >3 joint areas simultaneously– Swelling in Wrist, MCP or PIP joint– Symmetrical Arthritis– Rheumatoid Nodules– Positive RF (or Anti-CCP AB)– XRay Changes
![Page 87: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/87.jpg)
Keratoderma Blenorrhagicum
![Page 88: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/88.jpg)
Circinate Balanitis – Reactive Arthritis
![Page 89: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/89.jpg)
Reactive Arthritis - Conjunctivitis
![Page 90: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/90.jpg)
Reactive Arthritis – Palate Erosions
![Page 91: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/91.jpg)
Recent Prevalence Studies of AS and Related Diseases
(Khan, MA, Annals of Internal Medicine.2002;136:896-907)
Ethnic Groupor Region
Frequencyof
HLA-B27 inPopulation
Prevalence of AS inAdults
Prevalence of AllSpondyloarthropathies inAdults
GeneralPopulation
HLA-B27PositivePersons
GeneralPopulation
HLA-B27PositivePersons
Eskimos 40 0.4 2.5Eskimos(Alaska &Siberia) +Chukchi
25-50 1.6 2-3.4 4.2
Sami 24 1.8 6.8NorthernNorway
10-16 1.4
Mordovia 16 0.5WesternEurope
8 0.2 2
Germany(Berlin)
9 0.9 6.4 1.9 13.6
![Page 92: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/92.jpg)
Lyme Disease
![Page 93: Clinical Approach to New Onset Arthritis Jeffrey Carlin, MD Division of Rheumatology, VMMC Clinical Associate Professor, UW](https://reader036.vdocument.in/reader036/viewer/2022062309/56649db05503460f94a9e1d2/html5/thumbnails/93.jpg)
Lyme Arthritis• Erythema migrans 7-10 days after Borrelia
burgdorferi tick bite• Early dissemination-
– Migratory arthralgias, fever, systemic complaints
• Late dissemination/Chronic disease-– Migratory oligoarthritis– Carditis– Neurological