APPROACH TO ARTHRITIS.pptx..............

Health

1. APPROACH TO ARTHRITIS Presenter Dr. Kavya PGT2 Moderator Dr. Jyoti Ranjan behera Sir

2. Why it is important to evaluate joint pain Several systemic diseases present with joint pain as a lead symptom ( Eg – leukemia, Tuberculosis etc ) Many rheumatological diseases may have significant extra articular manifestations ( Eg . SOJIA , SLE) Early recognition is important for management options and eventually outcome.

3. CONTENTS Arthritis VS Arthralgia Causes History Physical examination Extra articular signs Laboratory investigations Questions

4. 1. ARTHRITIS VS ARTHRALGIA Arthralgia ( Arth = Joint , algia = pain) Pain in the joint No signs of inflammation Arthritis (itis = inflammation) Presence of swelling of the joint or Two of the following – Limitation of motion Tenderness Pain with motion Joint warmth

5. CAUSES

6. HISTORY AGE Early childhood – JIA, Kawasaki disease , HSP Mid childhood – JDM , PAN Late childhood or adolescence – ERA , SLE SEX Many rheumatological disorders are common in girls (SLE) Vasculitides like KD , PAN and Spondyloarthropathies like IBD , ERA – Boys

7. ONSET AND DURATION Acute onset – Septic arthritis and Arthritis associated with KD/HSP. Sub acute or chronic insidious – Polyarticular JIA or Sarcoidosis. PAIN & STIFFNESS Site , No of joints , severity, frequency, Duration , pattern and association with warmth. Morning stiffness – Inflammatory arthritis Night pain – Malignancy or osteoid osteoma . CONSTITUTIONAL SYMPTOMS – Weight loss , anorexia, night sweats , Extra-articular features

8. PRECIPITATING FACTORS Trauma , Infections (Streptococcal , enteric , viral) , Immunizations , Drug exposure , Exposure to person with Tb. PERSONAL OR FAMILY HISTORY Bleeding diathesis HLA B27 associated diseases like IBD , Psoriasis, Ankylosing spondylitis.

9. PHYSICAL EXAMINATION ARTICULAR INVOLVEMENT Articular or Non articular Inflammatory or non inflammatory Acute or chronic No of joints affected Axial or peripheral joint involvement Additive , Migratory or intermittent Symmetric or asymmetric Deforming or non deforming

10. 1 . ARTICULAR VS NON ARTICULAR PAIN

11. 2 . inflammatory vs non inflammatory Signs of inflammation Presence of stiffness Systemic symptoms like fever , fatigue and weight loss Elevated ESR/CRP , Thrombocytosis Pain that occurs only after physical activity , improves with rest and worsens as day progress. Usually Lack swelling and warmth No systemic features Normal ESR, CRP.

12. 3. ACUTE VS CHRONIC …………….Acute <6 weeks ……………………. Chronic >6 weeks………...

13. 4. Joint involvement No of joint involved Monoarticular – single joint Oligo articular - <4 joint Poly articular – > 5 joint Symmetric vs Asymmetric Symmetric - SLE, polyarticular JIA and viral arthritis Asymmetric - oligoarticular JIA, psoriatic arthritis, reactive arthritis and septic arthritis Additive, Migratory or intermittent Additive – Polyarticular JIA Migratory – Rheumatic fever Intermittent – SLE or sickle cell disease Axial or peripheral involvement Deforming or non deforming Deforming - RF + ve polyarticular JIA Non deforming - SLE and inflammatory bowel disease

14. Is the joint involved characteristic of a particular disorder? Distal interphalangeal joint – Psoriatic arthritis B/L Temporomandibular joint – RF – ve JIA Lower limb joints – Reactive arthritis. Is there associated enthesitis ? Inflammation at the attachment of tendons, ligaments,fascia or joint capsule to bone Sites – Calcaneus , Tibial tuberosity , Metatarsal heads , Ischial tuberosity , Patella and iliac crest JIA – Enthesitis related arthritis

15. Extra articular features of other diseases

16. EXTRA ARTICULAR FEATURES

17. INVESTIGATIONS COMPLETE BLOOD COUNTS Anemia - Normocytic normochromic anemia is found in most inflammatory conditions Leucocytosis - active arthritis , systemic onset JIA leucopenia – SLE Thrombocytosis - Inflammatory arthropathies Thrombocytopenia - SLE or leukaemia

18. ACUTE PHASE REACTANTS - ESR and CRP are the two common tests used for assessment of degree of inflammation. CRP rises early (within 24 hrs ), significantly and falls rapidly on resolution of inflammation. ESR is an indirect measure of acute phase reactants. Increased plasma level of fibrinogen gives rise to an increased ESR. URINE ANALYSIS – Suspected SLE or vasculitis. LIVER FUNCTION TEST – Raised SGOT is seen in JIA , But significant abnormality should raise suspicion of drug toxicity (MTX) or Macrophage activation syndrome (MAS)

19. RENAL FUNCTION TESTS – Abnormal results should raise suspicion of SLE , vasculitis and drug toxicity. CREATINE PHOSPHOKINASE (CPK) – Done in those with muscle involvement JOINT ASPIRATION AND ANALYSIS OF SYNOVIAL FLUID – Suspected septic arthritis. IMAGING STUDIES SPECIFIC TESTS – ASO titer , Throat swab culture , ANA , RF , Ig profile , HLA B27

20. CLINICAL SCENARIOS 3 year old girl – H/o irritability and refusal to move her left leg X 3 days Cough and cold – 2 weeks ago No h/o trauma O/E – Temp 103F , Apprehensive and lying with his left leg flexed and externally rotated Has pain and decreased range of movements of his left hip Left knee - normal

21. Extra articular features of other diseases SYSTEM INVOLVED PHYSICAL FINDINGS DISEASE Eye Anterior or posterior Uveitis Non exudative conjunctivitis JIA , KD , Reactive arthritis, Sarcoidosis Oral Cavity Oral ulcer , Strawberry tongue , Cracked lip KD , SLE Skin Malar rash , discoid rash , Heliotrope rash , gotrrons papules ,