Approach to arthritis

interesting case of reactive arthritis, stanley medical college

1. INTERESTING CASE OF ARTHRITIS DR.PROF. ANUSYA ‘(M7) UNIT DR. PRASADH RAO .L

2. 40 YR old admitted with chief complaints of fever since 2 weeks, acute onset, high grade , continuous relieved on drugs for 6 hours, chills + and no rigors Loose stools since 2 weeks; 4 to 5 episodes/day, foul smelling with blood in stools 2 episode in last 2 days. Abdominal pain since 2 weeks; diffuse around umbilicus not radiating on and off Vomiting 4 episodes for last 2 days, aggravated on taking food, not blood or bile stained No hematuria/cough with expectoration/arthralgia/myalgia/chest pain/ syncope/palpitations/ No h/o rashes/burning micturition/generalized lymphadenopathy/ decreased urine output/ eye discharge/Skin lesions.

3. PAST HISTORY - A known case of RHD- MS+/ mild MR/AR since MVA – 1.1 CM2 history of similar episodes in past, dysentery followed by arthritis (joint swelling/ pain) three episodes in past 5 years, diagnosed as ? rheumatoid arthritis since RF was positive started on steroids and indomethacin. He stopped drugs for past 7 months. He is also on penicillin prophylaxis,enalapril , spironolactone . PERSONAL HISTORY – smoker and alcoholic (last intake 1 month ago) normal bowel and bladder habits mixed diet

4. On examination conscious, oriented, afebrile ,thin built, no pallor/ icterus /cyanosis/pedal edema/ lymphadenopathy clubbing grade 2, dehydration+, jvp – normal BP- 110/70 mm hg in supine position(right hand) PR- 112/ min, regularly regular spo2 – 98% with RA CVS- s1 loud, MDM heard, palpable p2 RS – bilateral air entry+ /vesicular breath sounds/ no added sounds P/A – soft , diffuse tenderness CNS – NFND MUSKULOSKELETAL SYSTEM – normal

5. COURSE IN HOSPITAL Afebrile since admission as he was started on iv cipro and metronidazole, later next day patient developed knee pain and swelling initially right knee followed by left knee pain, left ankle pain , bilateral elbow pain , interphalangeal right (3,4,5 th ), left wrist and right wrist , left sternoclavicular joint, bilateral hip pain, with early morning stiffness on examination: right knee – swelling, effusion +, tenderness +, rom restricted , left ankle, bilateral elbow, left wrist, b/l hip, left knee - painful restricted range of movements and tenderness + left sternoclavicular, interphalangeal (left 3, 4, 5 pip joint) tenderness + No enthesitis

6. INVESTIGATIONS Cbc hb – 12 Tc - 16000 Dc- 90/8/2 Plt – 1.9 L Rbs-102 T.B -0.5 OT/PT – 101/82 Urea-34 Creat - 1.2 ECG – NSR,RAD/RBBB incomplete, PR- 160 msec ECHO – PML/AML thickened mva-1.1 cm2, LA dilated Severe MS, MR moderate,AR mild No RWMA, normal LV systolic function USG ABDOMEN – NORMAL USG KNEE – synovitis with effusion

7. STOOL C/S – NEG STOOL for OVA/CYST – NEG Urine/blood culture - NEG HIV - NEGATIVE HBSAG , ANTI HCV – NEG RPR – NEG ESR – ½ HR – 15 1 HR – 40

8. RF – neg ASO – neg ANA – neg CRP – POSITIVE ANTI CCP – neg HLA B 27 - NEG Synovial fluid analysis – straw colored Protein – 4.3 sugar – low Uric acid – 4.8 cell count: total – 1600 cells/mm3 N- 60% L – 10% degenerated cells – 30% Gram stain – no pus / no organisms AFB – smear negative No crystals

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10. MRI screening of hip joints done revealed effusion of left sacroiliac joint with synovitis

11. Differential diagnosis Rheumatic fever Reactive arthritis Enteropathic arthritis Ankylosing spondylitis /PSORIATIC ARTHRITIS Palendromic rheumatism Rheumatoid arthritis

12. Acute rheumatic fever Jones criteria recurrent attack in established RHD 2 MINOR WITH EVIDENCE OF PRECEDING GAS INFECTION ( FEVER/POLYARTHRALGIA/ INCREASED ESR) Arthritis 2 – 3 weeks after throat infection 6 – 16 joints, migratory or additive , asymmetric , involves 1 or both knees (76%) One or both ankles (50%) Elbow wrist hips small joints of feet (12 to 15 %0 Shoulder/small joint of hands (7 to 8%) Lumbosacral 2% Sternoclavicular 0.5% Radiographs show effusion no other abnormalities synovial fluid analysis – sterile inflammatory fluid

13. POINTS AGAINST ARF no recent fever / throat infection/ skin lesions in past 6 weeks No response to high dose aspirin for 3 days ASO TITRE NEGATIVE

14. Points against rheumatoid arthritis ACUTE onset Asymmetric joint involvement Axial joints ( sacro iliac involvement) Anti ccp , RF negative , No residual deformity Palindromic rheumatism abortive form of rheumatoid arthritis, presentation similar to rheumatoid arthritis lasting only for a short period

15. Enteropathic arthritis Assosiated with IBD Closely resembles ankylosing spondylitis and psoriatic arthritis May also run a course independent of bowel activity, It may precede the onset of IBD by many years PAUCIARTICULAR - <5 joints , Self limited attacks of asymmetric oligoarthritis coincides with relapse of IBD. POLYARTICULAR - >5 JOINTS symmetric chronic polyarthritis independent of bowel activity 30 – 70 % carry HLA B 27 positivity Controlling intestinal inflammation usually eliminates arthritis.

16. Reactive arthritis Acute non purulent arthritis complicating an infection elsewhere in the body Following enteric infection or urogenital infection Enteric infection with shigella , salmonella, Yersinia, campylobacter Urogenital infections with chlamydia trachomatis Although asymptomatic infection with chlamydia can cause arthritis , it is termed as undifferentiated spondyloarthropathy as no clinical infection precedes the episode.

17. Common between 18 to 40 yrs age, rarely in children occasionally in older adults. Male female ratio 1:1 Can be a first manifestation of HIV Classical Triad of conjunctivitis, arthritis, urethritis in some patients ( reiters syndrome)

18. pathogenesis All those organisms share a common feature Invade mucosal surface and replicate intracellularly Contain lipopolysaccharide in outer membrane salmonella ,Chlamydia, Yersinia are found in synovial tissues and fluids in reactive arthritis. HLA B 27 prolongs intracellular survival of Yersinia and salmonella, which may permit trafficking of intestinal leucocytes to joints , where innate and adaptive immune response to bacterial antigens promote arthritis In patients who are HLA-B27 positive, there is evidence of misfolding of the HLA-B27 protein inside the endoplasmic reticulum. This results in heightened cellular stress that leads to activation of NF- kB and release of proinflammatory cytokines, creating an inflammatory response in the joint.

19. clinical Asymmetric , additive with new joints involvement occurring over few days to weeks Usually knee, ankle, subtalar,mtp,toe ip, wrist and fingers Painful, rarely tense joint effusion usually in knee Peripheral spondyloarthropathy , low back pain with stiffness , enthesitis Ocular – uveitis or conjunctivitis Mucocutaneous – keratoderma blenorhagica, pustules, vesicles that become hyperkeratotic circinate balanitis

20. HLA B27 predicts a bad outcome, seen associated in 50% ReA ESR,CRP elevated during acute phase Synovial fluid nonspecifically inflammatory Culture organism during enteric infection Serology is nonspecific but supportive Radiographic – juxta articular osteoporosis Sacroilitis and spondylitis as late sequence

21. Diagnostic criteria

22. treatment high dose NSAIDS indomethacin 75 to 150 mg/day in divided doses Other NSAIDS may also be effective Antibiotics in chlamydial reactive arthritis - rifampicin 300 mg daily with azithromycin 500 mg od daily for 5 days followed by twice weekly for 6 months Chronic course – sulfasalazine 3g/day , azathioprine or methotrexate also effective Counselling the patient to avoid exposure to enteropathogens as they are prone for recurrent attacks and continued surveillance for ankylosing spondylitis.

23. Approach to arthritis articular Decreased range of movements Swelling of joint Pain on active and passive movement Crepitation, joint instability deformity may be present Non articular Tenderness localized away from joint Painful active movements, normal passive motion Swelling, instability,deformity are rare

24. Inflammatory non inflammatory Infection Crystal Immunologic Reactive Idiopathic Warmth/pain/swelling/erythema Increased esr / crp /thrombocytosis Early morning stiffness >1 hr , relieved on work Anemia of chronic disease/ hypoalbuminemia trauma Repeated use (bursitis/tendinitis) Neoplasm (pigmented villonodular synovitis ) Pain amplification(fibromyalgia) Gel phenomenon – intermittent stiffness lasting less than 60 min precipitated by a brief period of rest

25. take home points The differential diagnosis of fever and arthritis is fairly limited in children and adults. ReA usually occurs one to four weeks after gastrointestinal or genitourinary infection. ReA presents with painful arthritis predominantly affecting lower extremites , and can cause enthesitis, dactylitis , and systemic symptoms. ReA is most often caused by Chlamydial infections in adults, while gastrointestinal infections are the most common cause of ReA in children. ReA and the spondylarthropathies appear to fall within the spectrum of the polygenic autoinflammatory diseases. Treatment may include NSAIDs, DMARDs, systemic corticosteroids, and  biologics  for recalcitrant disease. Prognosis is good, although the presence of HLA-B27 may raise the risk for severe disease and a more chronic course.