Approach to arthritis

infectious arthritis,tubercular arthritis,crystal induced arthritis,osteoarthritis or degenerative arthritis,SLE,Seronegative spondyloarthritids,Reactive arthritis,polymyalgia rheumatica

1. APPROACH TO ARTHRITIS Guide : Dr. Sanjay Dubey Sir Candidate : Dr. Sagar Dagdiya Dept. Of Medicine, M.G.M.M.C. Indore

2. Arthritis is an inflammatory process affecting a joint/joints and may present with following symptoms: 1. Pain 2. Stiffness 3. Swelling 4. Limitation of Movement 5. Weakness 6. Fatigue

3. Absent Present

4. Inflammatory Non inflammatory

5. D/D on the basis of ONSET OF SYMPTOMS Abruptly over few hours to days Trauma Crystal arthritis Septic Arthritis Insidiously over weeks to months Rheumatoid Arthritis Osteoarthritis Seronegative Spondyloarthropathies Chronic Gout

6. D/D on the basis of DURATION OF SYMPTOMS ACUTE, i.e. , <6weeks CHRONIC, i.e. , >6weeks Trauma Juxta-Articular Septic Arthritis Reactive Arthritis Gout Rheumatic Fever Rheumatoid Arthritis SLE Spondyloarthropathies OA Haemochromatosis

7. D/D on the basis of PATTERN OF JOINT INVOLVEMENT Migratory Additive/Simultaneous Intermittent Acute Rheumatic Fever Disseminated Gonococcal Infection Viral Arthritis RA SLE Spondyloarthritids Gout Viral Arthritis Lymes Disease

8. Distribution of affected joints : DIP involved in Psoriatic Arthritis, OA and Gout. Axial Skeleton is involved in AS, especially Lumbar Spine and Sacroiliac Joint. Weight bearing joints e.g. Knee and Hip Joints are especially involved in OA. 1 st Metatarsophalengeal Joint is usually first involved in Gout. Heal Pain due to inflammation at the insertion of Achilles Tendon &/or Plantar Facia is typically seen in Spondyloarthritids .

9. 6. Extra- Articular Manifestations (Constitutional Symptoms) : Presence of Skin, Nail & Mucous Membrane Lesions may points to the possibility of SLE, Psoriatic Arthritis, Scleroderma. Arthritis of IBD may present with the features of Crohns Disease or Ulcerative Colitis. Presence of Urethritis , Conjunctivitis and Arthritis may points to the possibility of Reiter Syndrome that usually follows after non-specific GI or GU Infections.

10. DIAGNOSIS TYPE ADDITIONAL FEATURES LAB & IMAGING OA Noninflammatory , mono/ oligo /poly- articular Bone Spurs; knee, hip, PIP, DIP, 1 st MTP, 1 st CMC. Normal ESR/CRP, Osteophytes , Bone Sclerosis Gout Inflammatory, mono/ oligo /poly- articular Tophi ; Acute attacks f/b spontaneous resolution Raised UA Levels, + UA Crystals in joint fluid, Raised ESR/CRP, Erosions with overhanging borders Pseudogout Inflammatory, mono/ oligo /poly- articular Acute/Chronic Attacks Raised ESR/CRP Levels, + CPPD Crystals in joint fluid Septic Joint Inflammatory Monoarticular , rerely Polyarticular Sepsis, Fever Raised ESR/CRP, + Cultures, Leucocytosis , Immunosuppressed RA Inflammatory Polyarticular Extraarticular Manifestations, DIP never Involved Periarticular Osteoporosis, +RF & Anti-CCP, Raised ESR/CRP Pso A. Inflammatory Oligo or Polyarticular Psoriatic skin rash, Asymmetric SI Joint Involvement, Syndesmophytes Erosions, Ankylosis AS Inflammatory Bamboo Spine, Symmetric SI Joint Involvement, Syndesmophytes Ankylosis , Trolly Track Sign, Dagger Sign

11. Bone Spur

12. Tophi

13. Syndesmophytes

14. Infectious Arthritis 1.Gonococcal Arthritis (50% of all septic arthritis in sexually active young adults) presents as migratory / additive polyarthralgias f/b tenosynovitis or arthritis of wrist, ankle or knee with vesiculopustular skin rashes on extremities. 2. Non Gonococcal Infectious Arthritis ( due mainly to Staphylococcus Aureus >> Streptococcus species, Gram – ve organisms are rare & typically seen in cases with IV drug abusers, neutropenia or post operative cases) usually presents as fever with acute monoarticular arthritis, though sometimes multiple joints may be involved.

15. Tubercular Arthritis Monoarticular & most commonly affects Spine and other weight bearing joints, 10-35% of extra pulmonary TB ( hematogenous spread) Active focus forms in metaphysis (in children) or epiphysis(in adults) . Sometimes the synovium is involved first to develop low grade Synovitis . Localized osteoporosis is the first radiological sign of active disease. Synovial Fluid Analysis : 1. Lymphocytes>PMN with High ADA levels 2. PCR analysis is faster and more sensitive(85-95%) but less specific(70%) 3. The gold standard for diagnosis is synovial biopsy with positive results in 90% of cases. 4. Culture is positive in 80% of cases. Sometimes a dry tap can also be seen and in such cases sterile water lavage can be helpful.

16. Variables Pyogenic Arthritis Tubercular Arthritis Radiological Progression Rapid, Short History Slow, Insidious Onset Marginal Erosions Early Late Joint Space Narrowing Early Late Periosteitis Common Rare Sclerosis Present +/- Osteoporosis Minimal Marked Ankylosis Bony (common) Fibrous, except in Spine where Bony

17. Crystal Induced Arthritis Primary Gouty Arthritis : Mainly due to underexcretion of uric acid (90%) rather than its overproduction. Pseudogout : Due to Calcium Pyrophosphate Dihydrate Crystals deposited in bone and cartilage are released in synovial fluid inducing acute inflammation (r/f older age, advanced OA, neuropathic joint, hyperparathyroidism, hemochromatosis , DM or Hypothyroidism).

18. Synovial Fluid Analysis Birifringent – ve , needle shaped Birifringent + ve , rhomboid shaped Urate Crystals CPPD Crystals Gout <2K 2K – 50k >50K Non- Inflammatory Inflammatory NSAIDS Intra- articular Steroids Septic NSAIDS Intra- articular Steroids Treat Systemic Disease Specific Antibiotics Pseudogout NSAIDS Intra- articular Steroids Colchicine Gram Stain WBC Crystals on polarising microscopy culture

19. Rheumatoid Arthritis -Peak incidence 4-6 th Decade. -Symmetric inflammatory polyarthritis with extra- articular manifestations like Rheumatoid Nodules, Pulmonary Fibrosis, Serositis , Vasculitis & + ve Serum RF. -RF may be + ve in about 75-80% and Anti-CCP Ab may be + ve in 50-60% of patients, Anti-CCP Ab more specific (>95%). -RF may be + ve in chronic infections & other CTD’s. - Felty Syndrome : Triad of RA + Spleenomegaly + Granulocytopenia . - Z Deformity, Swan Neck Deformity, Boutonniere Deformity.

20. Boutonniere Deformity Swan Neck Deformity

21. Osteoarthritis or Degenerative Joint Disease -Most common form of Arthritis (Uncommon before 40yrs of age) . -Prevalence & Impairment increases with age. - Characterised by deterioration of Articular Surface with Subsequent formation of reactive new bone at the Articular Surface & Decreased Joint Space. -Joints commonly involved are Knee, Hip, PIP (Bouchard’s) , DIP ( Haberden’s ) , 1 st CMC. -Joints spared are Wrist, MCP (except Thumb) , Elbow, Ankle. - Pathophysiology : Abnormal Cartilage repair & remodelling . ( Chondrocytes release Proteolytic Enzymes that destroy Cartilage leading to Subchondral Sclerosis and Cysts with Marginal Osteophytes .)

22. Osteoarthritis

23. Systemic Lupus Erythematosus - Characterized by Immune Complex Deposition involving many organ system. - Malar rash, Discoid rash, Photosensitivity. -Oral ulcers, Serositis , Arthritis (non erosive arthritis) . -Renal, Neurological and Hematological Disorders. -ANA, Immunological Disorder (Anti- DsDNA [70%] , Anti- Sm Ab [25%] ) . -Intermittent Polyarthritis .

24. Seronegative Spondyloarthritids - Ankylosing Spondylitis -Psoriatic Arthritis -Reactive Arthritis - Enteropathic Arthritis Characteristics -Absence of RA Factor, Sacroiliatis , Dactylitis , Asymmetric Joint Involvement, Enthesitis , HLA B27+, Familial clustering.

25. Ankylosing Spondylitis : Sacroiliatis , Syndesmophytes , Squaring of Vertebrae Bamboo Spine, Dagger Sign, Trolley Track Sign on X-Ray, Pain improves with Exercise and worsens on Rest. Psoriatic Arthritis : Psoriatic skin changes seen in 60-70% of cases whereas Nail changes seen in 90% of cases. Arthritis Mutilans and Pencil in Cup Deformity.

26. Reactive Arthritis : Triad of Urethritis , Conjunctivitis & Arthritis . Ocassionally preceded by GI or GU infections. Syndrome is transient lasting for 1 to several months but chronic arthritis may develop in 4-19% of cases.

27. Soft Tissue Rheumatism -Most common cause of Musculo -Skeletal Pain. -Mostly associated with Fibromyalgia. - Characterised by Bursitis, tendonitis or tenosynovitis . -Improves with Local Steroid Injections.

28. Polymyalgia Rheumatica (PMR) -Presents in elderly males as proximal limb girdle pain, morning stiffness and constitutional symptoms. -Associated with Temporal Arteritis (TA) in 40% of cases. -Patients with TA presents with headache, scalp tenderness, jaw & tongue claudication , vision disturbances and stroke. -PMR : Elevated ESR -TA : Elevated ESR (often >100mm/hr.)