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APPROACH TO POLY-ARTHRITIS. DR CB NEL. Joints cartilage/ synovium. Arthritis. Inflammatory Rheumatoid arthritis Seronegative spondiloarthropaties Gout Septic. Degenerative Osteoartritis. Lower back pain. Diagnostic approach. Inflammatory vs. Noninflamatory Acute vs. Chronic - PowerPoint PPT Presentation
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APPROACH TO POLY-ARTHRITIS
DR CB NEL
Joints cartilage/synovium
Arthritis
Degenerative
Osteoartritis
InflammatoryRheumatoid arthritis
Seronegative spondiloarthropaties
GoutSeptic
Lower back pain
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 MechanicalMorning stiffness>1 hrFatigueProfoundActivityImproves symptomsRestWorsens symptomsSystemic involvementYesSwelling, warmth, erythema, tenderness, loss of function
• Morning stiffness– <30 min
• Fatigue– Minimal
• Activity– Worsens symptoms
• Rest– Improves symptoms
• Systemic involvement– No
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
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
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
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
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 jointso Tenderness of involved jointso Swan neck deformitieso Boutonniére deformitieso Z-deformity of the thumbo Dorsal subluxation of the ulna styloido Triggering of the fingers
EXTRA-ARTICULAR MANIFESTATIONS
• Systemic Fever, fatigue, weight loss, increased infection risk
• MSKMuscle-wasting, tenosynovitis, bursitis, osteoporosis
• HaematologicalReactive thrombocytosis, microcytic anaemia, anaemia of chronic disease(normochromic, normocytic)
• LymphaticSplenomegaly, Felty’s syndrome(RA, splenomegaly,
neutropenia)
EXTRA-ARTICULAR MANIFESTATIONS
• OcularEpiscleritis, scleritis, scleromalacia, keratoconjunctivitis sicca
• VasculitisNailfold infarcts, skin ulcers, pyoderma gangrenosum, mononeuritis multiplex, visceral arteritis
• CardiacPericarditis, myocarditis
EXTRA-ARTICULAR MANIFESTATIONS
• NeurologicalAtlantoaxial subluxation, carpal tunnel syndrome,
peripheral neuropathies, mononeuritis multiplex
• Pulmonary Nodules, pleural effusions, pulmonary fibrosis,
bronchiolitis, Caplan’ssyndrome(RA plus pneumoconiosis), bronchiectasis
• Nodules Subcutaneous, lungs, pericardium
• Amyloidosis
Early RA
RA HANDS
Extensor tenosinovitis
Olecranon bursitis and subcutaneous nodules
Baker’s popliteal sist
RA FEET
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)
CLASSIFICATION CRITERIA OF RA
NEW CRITERIA HAS BEEN PUBLISHED IN 2010
TREATMENT• A multidisciplinary team approach is followed
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
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
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
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
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)
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
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
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
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
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
ENTHESITIS: Inflammation of the attachment of tendons or ligaments to bone (hallmark feature of the seronegative spondarthritis)
LOWER BACKPAIN
Inflammatory
Mechanical
Age < 40 years Any ageProgression Slowly/Chronic AcuteDuration of symptoms
> 3 months < 4 weeks
Morning stiffness
> 60 min. < 3o min.
Night pain(vertebral)
Common Absent
Exercise Improve WorsensSI-joint tenderness
Common Absent
Vertebral mobility
↓ all directions ↓ flection
Chest expansion Decreased Normal
ANKYLOSING SPONDYLITIS• Predilection for the sacroiliac joints and spine
• Male : female ratio of 3:1
• Progressive stiffening and fusion of axial skeleton
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 lordosiso Marked thoracic kyphosis o Reduced chest expansion
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
PLANTAR FASCIITIS
ACHILLES TENDON ENTHESITIS
TREATMENT
• Physiotherapy• Regular NSAID’s• Sulfasalazine for peripheral arthritis• Tumour necrosis factor(TNF)-Alpha inhibiters
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)
Symmetric psoriatic polyarthritis resembling RA
Distal interphalangeal joint involvement
Psoriatic Arthritis
Nail pittingSkin
EnthesophathyDactilitis
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
QUESTIONS?