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Clinical approach to Arthritis

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APPROACH TO A CASE OF ARTHRITIS Dr.S.SRIRAM Prof.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…
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  1. APPROACH TO A CASE OF ARTHRITIS Dr.S.SRIRAM Prof.Dr.GOWRISHANKAR’S M5 UNIT
  2. HISTORY
    • Joint pain
      • inflammatory arthritis.
      • noninflammatory arthritis.
      • arthralgia.
  3. 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
            • congenital
            • developmental
            • metabolic,
            • 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.
  6. Symptoms of joint disease
    • Pain
      • 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
    • Mono arthritis - one joint.
    • Oligo arthritis - 2-4 joints.
    • Poly arthritis -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

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