Polyarthralgia

PolyarthralgiaPolyarthralgia

Tanya PotterTanya PotterConsultant RheumatologistConsultant Rheumatologist

UHCWUHCW

AimsAims

Differential diagnosis of Differential diagnosis of polyarthralgia/polyarthritispolyarthralgia/polyarthritis

Investigation of joint painsInvestigation of joint pains

What is polyarthralgia?What is polyarthralgia?

What conditions present with What conditions present with polyarthralgia?polyarthralgia?

InflammatoryInflammatory

MechanicalMechanical

Pain syndromesPain syndromes

How do you differentiateHow do you differentiate

between mechanical andbetween mechanical and

inflammatory symptoms?inflammatory symptoms?

Mechanical vs InflammatoryMechanical vs Inflammatory

Inflammatory Inflammatory MechanicalMechanical Immobility stiffness Immobility stiffness latter daylatter day EMS>30-60 minsEMS>30-60 mins EMS<30-60 EMS<30-60

minsmins Better with activity and NSAIDsBetter with activity and NSAIDs worse with worse with

activityactivity Joint swelling, erythema,heat Joint swelling, erythema,heat instabilityinstability Systemic symptoms Systemic symptoms lockinglocking Multi-organ involvement Multi-organ involvement trauma, straintrauma, strain

overusage overusage

Age and sex IncidenceAge and sex Incidence

AGEAGE FEMALEFEMALE MALEMALE

Young adultsYoung adults

Middle ageMiddle age

Old ageOld age



Young adultsYoung adults RARA Reactive arthritis Reactive arthritisSLESLE (Sero-ve)(Sero-ve)

Middle ageMiddle age

Old ageOld age




Psoriatic arthritisPsoriatic arthritis(Sero-ve)(Sero-ve)

Middle ageMiddle age RARA

Old ageOld age




Psoriatic arthritisPsoriatic arthritis(Sero-ve)(Sero-ve)

Middle ageMiddle age RARA

Old ageOld age OAOACrystal arthritisCrystal arthritis

OAOA

Clinical featuresClinical features

OsteoarthritisOsteoarthritis

Mechanical Mechanical symptomssymptoms

Bony swelling, Bony swelling, crepituscrepitus

DIP (Heberden), PIP DIP (Heberden), PIP (Bouchard), 1(Bouchard), 1stst CMCJ, neck, lower CMCJ, neck, lower back, hips, knees, back, hips, knees, 11stst MTP MTP

Pathophysiology?Pathophysiology?

PathophysiologyPathophysiology

Imbalance between degradative and Imbalance between degradative and reparative connective tissue reparative connective tissue processes within joint leading to processes within joint leading to failure of jointfailure of joint

Occasional genetic associationOccasional genetic association Pathological stresses may lead to Pathological stresses may lead to

micro trauma and inflammatory micro trauma and inflammatory changechange

Radiology - OA Radiology - OA

Radiology - OA Radiology - OA

Four cardinal Four cardinal features:features: Joint space Joint space

narrowingnarrowing SclerosisSclerosis Subchondral cystsSubchondral cysts OsteophytesOsteophytes

Other features associated with Other features associated with athralgiaathralgia

Prodromal eventsProdromal events

Associated conditionsAssociated conditions

CLUESCLUES

Prodromal event eg GI/GU infection – Prodromal event eg GI/GU infection – reactive arthritisreactive arthritis

Associated conditions eg psoriasis, Associated conditions eg psoriasis, colitis, iritiscolitis, iritis

Pattern and Symmetry?Pattern and Symmetry?

CLUESCLUES

Multi-organ diseaseMulti-organ disease

Fibromyalgia symptomsFibromyalgia symptoms

RheumatoidRheumatoid

Female ~ 1 in 100Female ~ 1 in 100 symmetrical polyarthritis, targeting small symmetrical polyarthritis, targeting small

joint and largejoint and large DIP sparing DIP sparing

PathophysiologyPathophysiology

Inflammatory conditionInflammatory condition Strong genetic component- HLA DR4Strong genetic component- HLA DR4 Environmental effectsEnvironmental effects Inflammation of synovium with high Inflammation of synovium with high

levels of chemokines and cytokines levels of chemokines and cytokines and resultant tissue damageand resultant tissue damage

o Systemic features?Systemic features?

Psoriatic arthritisPsoriatic arthritis

Psoriasis 2-3% populationPsoriasis 2-3% population 5-10% of these will develop Ps 5-10% of these will develop Ps

arthritisarthritis Family history 55X more likely (40%)Family history 55X more likely (40%)

Pathophysiology?Pathophysiology?

HLA B27 related arthritisHLA B27 related arthritis Arthritis and enthesitis possibly Arthritis and enthesitis possibly

T cell driven, with tissue damageT cell driven, with tissue damage

Sero-ve Spondyloarthritis – Sero-ve Spondyloarthritis – psoriatic arthritispsoriatic arthritis

DIP, poly, dactylitis, DIP, poly, dactylitis, enthesitis, spinalenthesitis, spinal Younger age Younger age

• Soft tissue swellingSoft tissue swelling• Joint space narrowingJoint space narrowing• Mouse ear erosionsMouse ear erosions• Periostitis with new bone Periostitis with new bone

formationformation• DIP joint involvementDIP joint involvement

Polyarticular crystal arthropathy eg goutPolyarticular crystal arthropathy eg gout

ChronicChronic TophiTophi ErosionsErosions Older ageOlder age Nb pseudogoutNb pseudogout

polyarthalgia/polyarthritispolyarthalgia/polyarthritis

o Multi-organ disease – CTD and Multi-organ disease – CTD and vasculitisvasculitis

o Viral arthritis (eg parvovirus, rubella, Viral arthritis (eg parvovirus, rubella, hepatitis)hepatitis)

o Medical conditions egMedical conditions ego diabetic cheiroarthropathydiabetic cheiroarthropathyo Sarcoidosis-Sarcoidosis-

SarcoidSarcoid

Acute or chronicAcute or chronic Multisystem disorder, non caseating Multisystem disorder, non caseating

granulomasgranulomas Acute: spring time (?viral) young Acute: spring time (?viral) young

adults sudden onset of lower limb adults sudden onset of lower limb arthritis and erythema nodosum & red arthritis and erythema nodosum & red eyes eyes

Fever and coughFever and cough

IxIx

Raised serum ACERaised serum ACE Raised CaRaised Ca ESR, CRPESR, CRP Chest xrayChest xray

Outcome of acute: Outcome of acute: good, NSAIDs, oral good, NSAIDs, oral prednisoloneprednisolone

Chronic: afrocarribeanChronic: afrocarribean Grumbling lung Grumbling lung

disease, jt, muscle, disease, jt, muscle, liver diseaseliver disease

Treatment unclear- Treatment unclear- prednisolone, prednisolone, methotrexatemethotrexate

What are CTD?What are CTD?

Symptoms and signs?Symptoms and signs?

Connective tissue diseaseConnective tissue disease

Eg SLE, scleroderma, polymyositis, Eg SLE, scleroderma, polymyositis, Sjogren’sSjogren’s

Auto-immuneAuto-immune Multi-organMulti-organ Anti-nuclear antibodiesAnti-nuclear antibodies

SLESLE

RaynaudsRaynauds RashesRashes ArthralgiaArthralgia HaemHaem CNSCNS RenalRenal SerositisSerositis thrombosisthrombosis

Sle- skinSle- skin

o Photosensitive Photosensitive rashes eg SLErashes eg SLE

o Discoid lupusDiscoid lupus

Sle- renalSle- renal

Significant cause of Significant cause of morbidity and morbidity and mortality- condition mortality- condition and treatmentand treatment

Sjogrens syndromeSjogrens syndrome

o Destruction of exocrine glandsDestruction of exocrine glandso Dry eyes and mouth- cariesDry eyes and mouth- carieso Liver, lungs, gut, arthralgia, MNMLiver, lungs, gut, arthralgia, MNMo Increased B cell lymphoma riskIncreased B cell lymphoma risk

SclerodermaSclerodermao Localised (CREST)Localised (CREST)o DiffuseDiffuseo Raynauds, finger Raynauds, finger

ulcersulcerso Sclerosis of most Sclerosis of most

organsorganso GI, skin, ILD, renal GI, skin, ILD, renal

crisiscrisis

Myositis Myositis

Inflammatory Inflammatory muscle conditionmuscle condition

Demato or Demato or polymyositspolymyosits

Proximal painless Proximal painless weaknessweakness

What are the vasculitides What are the vasculitides andand

what type of symptoms andwhat type of symptoms and

signs?signs?

VasculitisVasculitis

Small, medium, Small, medium, large vessellarge vessel

Eg MPA, Churg Eg MPA, Churg Strauss, PAN, Strauss, PAN, Wegeners, GCA Wegeners, GCA

ANCAANCA

Vasculitis- skinVasculitis- skin

o Vasculitis – Vasculitis – petechial, purpura, petechial, purpura, ulcer ulcer


Systemic, vasculitic ulcers/rashes, Systemic, vasculitic ulcers/rashes, arthralgias/arthritis – non deformingarthralgias/arthritis – non deforming

Pulmonary – haemoptysis Pulmonary – haemoptysis


RENAL – URINE DIP RENAL – URINE DIP + BP+ BP

ENT –eg Wegener’sENT –eg Wegener’s

Neuropathy eg Neuropathy eg footdropfootdrop

PMR and GCA features?PMR and GCA features?

Polymyalgia rheumatica and Polymyalgia rheumatica and GCAGCA

Over 50’sOver 50’s Proximal inflammatory pain Proximal inflammatory pain

and stiffnessand stiffness GCA – large vessel arteritisGCA – large vessel arteritis Temporal headache, jaw Temporal headache, jaw

claudication visual claudication visual disturbance, systemic upset disturbance, systemic upset

Raised ESR and CRP – Raised ESR and CRP – urgent steroidsurgent steroids

TA biopsyTA biopsy

Fibromyalgia Fibromyalgia

““All over pain”All over pain” FatigueFatigue Sleep disturbanceSleep disturbance DepressionDepression AnxietyAnxiety Irritable bowelIrritable bowel Tender spotsTender spots Diagnosis of exclusionDiagnosis of exclusion

InvestigationsInvestigations

Inflammatory arthritis – Inflammatory arthritis –


Inflammatory arthritis – RAInflammatory arthritis – RA

FBC, ESR, CRP, U+E, LFT, RF, anti-FBC, ESR, CRP, U+E, LFT, RF, anti-CCP, ANA,CCP, ANA,

XR Hands and feet and chestXR Hands and feet and chest

Viral – ParvovirusViral – Parvovirus


? CTD/vasculitis -? CTD/vasculitis -


? CTD/vasculitis - ANA, ANCA, ? CTD/vasculitis - ANA, ANCA, complementcomplement

Urine dip and BPUrine dip and BP

Organ based investigations Organ based investigations


Diffuse symptoms – CK, Ca, ALP, TFTDiffuse symptoms – CK, Ca, ALP, TFT

Crystal – joint aspirate, radiology, Crystal – joint aspirate, radiology, urate, U+E urate, U+E

What is RF and what otherWhat is RF and what other

conditions present with conditions present with elevatedelevated

RF?RF?

Rheumatoid factorRheumatoid factor

Autoantibody vs Fc portion of IgG – any isotype but typically Autoantibody vs Fc portion of IgG – any isotype but typically IgM RFIgM RF

Acute infection eg infectious mononucleosis Acute infection eg infectious mononucleosis

Chronic infection eg SBE, TBChronic infection eg SBE, TB

Inflammatory disease: CTD, Fibrosing alveolitis, Inflammatory disease: CTD, Fibrosing alveolitis,

Malignancy: Lymphoma, leukaemiaMalignancy: Lymphoma, leukaemia

5% healthy population 5% healthy population

RF <15 usually not significantRF <15 usually not significant

Anti-CCPAnti-CCP

Anti-cyclic citrullinated peptideAnti-cyclic citrullinated peptide

More specific for RA than RFMore specific for RA than RF

May predict erosive damageMay predict erosive damage

What are the ANA and ENA?What are the ANA and ENA?

ANA and ENAANA and ENA

ANA 1/40 not significant unless ANA 1/40 not significant unless associated with appropriate clinical associated with appropriate clinical scenarioscenario

Also in RA, auto immune liver Also in RA, auto immune liver disease, neoplasia, healthy disease, neoplasia, healthy population…population…

ANA and ENAANA and ENA

ENA – extractable nuclear antigens ENA – extractable nuclear antigens (ANA subtypes)(ANA subtypes)

Anti-DNA - SLE Anti-DNA - SLE Anti-Ro and anti-La - SjogrensAnti-Ro and anti-La - Sjogrens Scl 70 and anti-centromere – Scl 70 and anti-centromere –

SclerodermaScleroderma Anti-RNP – mixed CTDAnti-RNP – mixed CTD Anti-Jo1 - myositis Anti-Jo1 - myositis

What is ANCA ?What is ANCA ?

ANCAANCA

Antibodies vs specific antigens in Antibodies vs specific antigens in cytoplasm of neutrophilscytoplasm of neutrophils

ANCA reactive to myeloperoxidase ANCA reactive to myeloperoxidase (MPO) – perinuclear pattern of (MPO) – perinuclear pattern of staining P-ANCA eg microscopic staining P-ANCA eg microscopic polyarteritispolyarteritis

ANCAANCA

ANCA reactive to proteinase 3 (PR3) ANCA reactive to proteinase 3 (PR3) – cytoplasmic pattern of staining C-– cytoplasmic pattern of staining C-ANCA eg Wegener’s granulomatosisANCA eg Wegener’s granulomatosis

Thank-youThank-you

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Polyarthralgia