ARTHRITIS & RHEUMATOLOGY by DR K. DELE

This presentation focuses on different types of arthritis/joint disorders. It provides stepwise approach to evaluation and diagnoses and it's truly wonderful to have a broad overview of many joint conditions in one presentation - ranging from osteoarthritis, gout, rheumatoid arthritis, septic arthritis, to ankylosing spondilitis, and many others, including fibromyaligia.

1. ARTHRITIS BY: DR KD DELE DEPT OF FAMILY MEDICINE DORA NGINZA HOSPITAL

2. INTRODUCTION Joint pain can originate from the joint itself or from the surrounding tissues. More than 100 rheumatic conditions Overlap in clinical presentations Initial presentation may not lead to a precise diagnosis in up to 50% of cases Over time most patients will have characteristic features of a disease

3. INTRODUCTION, cont. Patients will typically complain of: “Dr I have Arthritis” Pain specific to certain joints or groups of joints “My Body Is Sore!” Careful History and Physical examination is required to discern between pathologies and to make a diagnosis. DIAGNOSIS CAN BE MADE BASED ON HISTORY AND PHYSICAL EXAM FINDINGS 80-90% OF THE TIME

4. THE RHEUMATOLOGIC HISTORY Pain is the cardinal symptom of musculoskeletal disorders DIAGNOSTIC APPROACH : Establish the demographics of the patient: Age Gender Ethnicity Family History Characterize joint pain and ask about associated features Characterize the pain: Inflammatory vs. Non inflammatory Constitutional symptoms

5. EVALUATION OF A PATIENT WITH ARTHRITIS IN RHEUMATOLOGY OPD Articular or non articular Inflammatory or non inflammatory Acute or chronic Monoarticular or polyarticular Extra articular signs

6. History cont.

7. History cont.

8. History cont.

9. History cont. Relieving Factors: Rest Analgesia – simple; NSAIDS; Opiates Effect on Activities of Everyday Living. Age and Gender of Patient.

10. CHRONOLOGY OF COMPLAINTS

11. CHRONOLOGY OF COMPLAINTS cont.

12. History cont. Organ specific symptoms

13. Physical Examination

14. RHEUMATIC DISEASE SIGNS

15. Differential Diagnosis Monoarthritis 1 Joint Oligoarthritis 2-4 joints or joint groups Polyarthritis 5 or more joints Septic Arthritis Crystal Synovitis Gout Pseudogout Hemarthrosis Foreign Body / Trauma Neoplasm Avascular necrosis Monoarticular presentation of oligo- or polyarticular disease Osteoarthritis Seronegative spondylo-arthropathy Erythema Nodosum Infection Neisseria Mycobacteria Bacterial Endocarditis Generalised osteoarthritis Rheumatoid Arthritis Seronegative spondylo-arthopathy Lupus Chronic Gout Scleroderma JRA

16. Articular and non-articular pain

17. Articular and non-articular pain Articular structures include the synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule, and juxta-articular bone. Non articular (or periarticular) structures include: supportive extra articular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin,

18. Monoarticular vs polyarticular

19. Inflammatory vs non-inflammatory

20. Inflammatory Acute arthritis Chronic arthritis Monoarthritis e.g. Crystal induced arthritis (gout and pseudogout) Septic arthritis Gonococcal arthritis Acute onset of inflammatory polyarthritis (like RA, SLE) Monoarthritis e.g. Tubercular arthritis Fungal arthritis Other infections ( e.g Brucellosis) Immunoinflammatory arthritis Crystal induced arthritis Polyarthritis e.g. acute onset of polyarthritis, reactive arthritis Polyarthritis e.g. RA, psoriatic arthritis, spondyloarthritis

21. Non-Inflammatory Acute arthritis Chronic arthritis Monoarthritis Hemarthrosis Trauma Monoarthritis Single joint osteoarthritis Neuropathic arthropathy Osteonecrosis Pigmented villo nodular synovitis Polyarthritis Polyarthritis (e.g., osteoarthritis)

22. Laboratories: Results must be interpreted in light of the clinical findings Three areas of interest: Blood, Urine, Synovial fluid

23. Laboratories: Blood • CBC: Anaemia, leukopaenia , thrombocytopenia • Chemistries: renal insufficiency, elevated LFT’s, uric acid • ESR/CRP: non specific • Autoantibodies: RF, ANA, ENA, dsDNA, ANCA • HLA B-27, HLA B-51 • ASO • Ferritin • Lyme titre

24. Laboratories: Urine Proteinuria Haematuria Active sediment

25. Laboratories: Synovial fluid Cell count Gram stain and culture Crystal analysis

26. DIAGNOSTIC IMAGING Plain X-ray Ultrasonography Scintigraphy-Tc-99,Ga-67 CT Scan MRI

27. Septic Arthritis

28. intro Medical Emergency! Rapid onset monoarticular joint inflammation Rapid destructive joint disease Morbidity and mortality of 10% Patients with septic arthritis already have a bacteraemia!

29. Risk Factors Extremes of Age Pre-existing joint disease Immunosuppression Prosthetic hip / knee joint / Joint surgery Skin Infection Rheumatoid Arthritis. Diabetes Mellitus. Elderly patients over age 80 years old. Intravenous drug use (unusual joints affected).

30. aetiology Young sexually active adults Neisseria gonorrhoeae (most common, and more common in women Staphylococcus aureus Streptococcus Older adults Staphylococcus aureus (50%) Streptococcus species Gram Negative Bacilli Most common organism Staph. Aureus, however important to rule out disseminated gonococcal infection in young sexually active patient.

31. Clinical feature of Septic Arthritis Acute onset Typical joints include knee and hip Swollen joint. Erythema Warm joint. Held in position of least resistance

32. Clinical feature of Septic Arthritis Joints affected in bacterial infection Septic Knee (50% of cases), Hip (children), Ankle, Shoulder Joints affected with intravenous Drug Abuse SI joint, SC joint. Pubic symphysis, Vertebral spaces

33. Investigation: Joint Aspiration and MCS Sterile procedure Fluid may appear purulent / turbid, bloodstained or normal Infective Markers Blood Culture

34. Management: Hospitalization Analgesia IV Antibiotics: e.g. Cloxacillin 200mg / kg / day Surgical Drainage Rehabilitation Oral Antibiotics: e.g. Flucloxacillin 100mg / kg / day for 3 weeks

35. Gout

36. GOUT: URIC ACID CRYSTALS Pathological reaction of the joint and periarticular tissue to presence of sodium monourate crystals.

37. GOUT: URIC ACID CRYSTALS

38. pathophysiology

39. RISK FACTOR -Obesity -Diabetes Mellitus - Hyperlipidemia -Hypertension -Atherosclerosis -Alcohol use -Thiazide Diuretics -Renal insufficiency - Myeloproliferativedisease

40. Clinical feature Gout: Joint Inflammation - Asymmetric joint involvement. May only involve one side with the first attack Acute , intermittent and recurrent Chronic Tophaceous Gout Severe pain (Worst ever) Extreme tenderness Swelling, erythema and hot joint. Fever and chills

41. Most common joints 1st Metatarsophalangeal joint (MTP) – 50% Ankle Midfoot Knee Small joints of hand Wrist Elbow

42. Most common joints

43. Most common joints

44. Investigation: It is a clinical diagnosis investigations is to rule out other pathology: Aspiration of Synovial Fluid: Sodium urate crystals / Neutrophils Serum Urate / Uric Acid: No bearing on diagnosis and management as often is normal during attacks UEC FBC / ESR - Rule out myeloproliferative disorders X-rays

45. Management: Acute Attack NSAIDS (not aspirin) Colchicine Joint aspiration and intraarticular steroids Rule out Septic Arthritis

46. Management: Chronic management Patient education Correction of Lifestyle (Gout Diet) Allopurinol Recurrent attacks Tophaceous gout Bone / joint damage Associated renal disease Greatly elevated sUrate Surgery Removal of chronic deposits Repair damaged soft tissue Joint repair

47. Osteoarthritis

48. Osteoarthritis Most common form of arthritis. Results from disparity between stress applied to a joint and the ability of the joint to withstand the stress Degenerative disorder characterised by progressive loss of articular cartilage, capsular fibrosis and new bone formation

49. Osteoarthritis Prevalence directly increases with age: Almost universal after 65 years but only 50% of patients are symptomatic Associated functional impairment Primary - No demonstrated cause Secondary - Due to abnormal stress on joint Marginal osteophytes

50. Clinical features of Osteoarthritis Pain: Aggravated by stress on joint / motion; and relieved by rest. Stiffness: Progressive loss of range of motion (initially after use of joint). Typically Morning stiffness of short duration (<30 minutes) Crepitus Deformity Swelling - Persistent or intermittent

51. DISTRIBUTION OF OSTEOARTHRITIS Typical joints involved: Small joints in hands DIP (Heberden’s Nodes) PIP (Bouchard's Nodes) First CMC joint (thumb) Hip / Knee / Feet and Shoulder joint. Cervical and lumbar spine

52. DISTRIBUTION OF OSTEOARTHRITIS

53. DISTRIBUTION OF OSTEOARTHRITIS

54. Investigation: It is a clinical diagnosis. X ray is non essential but may help in differentiating OA from other arthritis XR Features of OA: Joint space narrowing Subchondral sclerosis Osteophyte formation Bone Cysts formation. No osteopenia Evidence of previous disorders e.g. trauma or congenital problem.

55. Management: Early Reduce Load: Reduce weight / Avoid abnormal loading / Use walking stick Increase Movement: Physiotherapy Pain Relief: Simple analgesia NSAIDS if inflammatory component noted. Hyaluronic Acid (still no compelling evidence)

56. Management: Late This is when there's failure of conservative management Joint debridement Osteotomy Arthroplasty Arthrodesis Decompression

57. Management: Late When to Operate Patient’s symptoms are interfering with ADL Benefits of surgery outweigh risks Preventative surgery

58. Rheumatoid Arthritis

59. Rheumatoid Arthritis Symmetrical, deforming small and large joint polyarthritis, often associated with systemic disturbance and extra articular features 3% of population Affects all ethnic groups Peak incidence 4-6th decades Lowest in Black Males / Highest in White Females Pathology is based on synovial proliferation with inflammatory destruction of the joint

60. Clinical feature Rheumatoid Arthritis: 1. Morning stiffness: in and around the joint lasting 1 hr before maximal improvement. 2. Arthritis of 3 or more joint area observed by the physician: 14 possible joint area involved are Right &Left PIP,MCP, wrist, elbow, knee, ankle and MTP joint. 3. Arthritis of hand joints: wrist, MCP & PIP joint. 4. Symmetrical arthritis. 5. Rheumatoid nodule. 6. Serum Rheumatoid factor (supports diagnosis – 20% are seronegative). 7. Radiographic changes – erosion or bony decalcification in or adjacent to involved joints. NEED TO HAVE 4 OF 7

61. scoring criteria- American college of Rheumatology 2010 A. Joint involvement 1 large joint: 0 2-10 large joints: 1 1-3 small joints (+/- large joints): 2 4-10small joints (+/- large joints): 3 >10 joints (at least 1 small joints): 5

62. scoring criteria- American college of Rheumatology 2010 B. Serology. At least 1 test result is needed for scoring: Neg RF + & ACPA* (</= ULN**): 0 Low positive RF or ACPA (</=3 X ULN): 2 High positive RF or ACPA(>3 X ULN): 3 *ACPA – Anti-citrullinated protein antibody **ULN – upper limit of normal + RF – Rheumatoid Factor

63. scoring criteria- American college of Rheumatology 2010 C. Acute phase reactants (at least 1 test result needed for classification) Normal CRP or ESR: 0 Abnormal CRP or ESR: 1

64. scoring criteria- American college of Rheumatology 2010 D. Duration of symptoms <6 weeks: 0 >/= 6 weeks: 1

65. NB Score >/= 6/10 is RA Large joints: shoulders, elbows, hips, knees, ankles Small joints: PIP, MCP, MTP, wrists (Spares DIP) Diff diagnosis: SLE, Psoriatic arthritis, etc. Duration of symptoms is as self reported by patient

66. DEFORMITIES Z deformity Swan neck deformity Boutonniere deformity

67. Swan neck deformity

68. Z - deformity

69. Subcutaneous nodules

70. Extraarticular Features: Systemic Musculoskeletal Haematological Lymphatic Ocular Vasculitis Cardiac Pulmonary Neurological

71. Investigation: Confirmed according to clinical criteria Rheumatoid Factor : Not positive in all patients, and Not all positive pts. have RA X-ray Features: Periarticular Soft Tissue Swelling Joint Space Narrowing Bony erosions Subchondral cysts Periarticular Osteopenia

72. X-ray Features:

73. X-ray Features:

74. Management: Team Approach Goals Stop Synovitis Prevent Deformity Reconstruct Rehabilitate

75. 1. Stop Synovitis: NSAIDS: Gives Symptomatic relief, non curative DMARDS: Corticosteroids: Ineffective Response to DMARDs Acutely ill Significant systemic disease Social Problems

76. 1. Stop Synovitis: DMARDS: Chloroquine: Safe, little need for laboratory follow up / Inexpensive / Ocular Toxicity METHOTREXATE (MTX): Low dose is the Gold Standard for DMARDS Rapid Disease Suppressing effect Baseline UEC / LFT and Hep Screen LFT’s 4-8 weeks DOSAGE IS WEEKLY NEVER GIVE WITH COTRIMOXAZOLE (Haemotoxic) Others : Gold / Sulphasalazine / D-Penicillamine / Azathroprine

77. Management cont.: Prevent Deformity Physiotherapy Occupational Therapy Surgery – Tendon Repair or replacement Reconstruct Arthrodesis Arthroplasty Rehabilitate Accompanies all stages of treatment OT and work training

78. SERONEGATIVE SPONDOARTHROPATHIES Psoriatic arthritis Reactive arthritis Enteropathic arthritis Ankylosing sponylosis

79. FEATURES OF SPONDOARTHROPATHIES Absence of RA Factor, subcut nodules Sacroiliatis /spondylitis + Asymmetric peripheral joints Extra articular - ocular, oral, skin, enthesitis Familial aggregation HLA-B27 +

80. DISTRIBUTION OF SPONDOARTHROPATHIES Asymmetric arthritis Axial spine & lower limb joints Soft tissues involvement Bursitis, Achilles tendonitis, epicondylitis, plantar fasciitis

81. Ankylosing Spondylitis

82. Ankylosing Spondylitis Inflammatory arthropathy with emphasis on involvement of spine and sacroiliac joints. Characterised by progressive stiffening and fusion of the axial skeleton. Sacroiliatis / Syndesmophytes / Bamboo spine / Inflammatory Backache

83. Clinical Features: Young males (20’s-30’s / 3:1 Male: Female Ratio) Chronic insidious onset Recurrent episodes of low back pain and stiffness Radiation to buttocks and thighs (symmetrical) Marked after rest and improve with movement

84. On examination Pain on SI joint compression Restriction of movement of lumbar spine Limited Chest expansion Schober’s Test is positive

85. Schober’s Test

86. Investigation: ESR HLA B27 Antigen: Positive 95% cases X-rays: Fuzziness or Frank Erosion of SI joint, progressing to sclerosis Syndesmophytes – Ossification across intervertebral discs Bamboo spine

87. X-rays:

88. Management: Relieve Pain and Stiffness Maintain maximal mobility Avoid deformity NSAIDS particularly long acting, given at night may provide symptomatic relief Surgery: Osteotomy of spine to correct deformity Arthroplasty of destroyed joints

89. Fibromyalgia

90. Fibromyalgia Common cause of multiple regional musculoskeletal pain and disability No underlying identifiable pathology Assoc. physiological abnormalities of sleep patterns and pain processing Reduced amount of Delta sleep during night Reduced threshold to pain perception and tolerance at characteristic sites throughout the body. Associated with other medically unexplained symptoms in other systems of the body

91. Clinical Features: Multiple body pains – Eventually affecting all body quadrants Both arms, legs, neck , back Reported disability is marked – Able to dress, eat, groom Unable to work etc Fatigability is often marked – (especially in morning) On Examination No overt musculoskeletal pathology (may have signs of other arthropathy not consistent with symptoms) Hyperalgesia at recognised trigger points producing a wince / withdrawal

92. Clinical Features Cont’d: Criteria for Fibromyalgia: Appropriate symptoms including pain in all body quadrants Positive Hyperalgesic tender sites in each arm and leg and axially Negative control tender sites. (Pressure on Forehead, squeezing distal radius/ulna, pressure over proximal fibular head does not elicit any pain)

93. Investigation: Fibromyalgia is not associated with test abnormalities Tests are based on ruling out organic pathology FBC - Anemia , lymphopenia of lupus ESR, CRP - Inflammatory disease TFT’s - Hypothyroidism CMP - Hyperparathyroidism ANA - Lupus

94. Management: Education for patient and family Sleep hygiene Graded aeorobic exercise programme Low dose amitriptyline Fluoxetine

95. Musculoskeletal Manifestations of Systemic Disease

96. Musculoskeletal Manifestations of Systemic Disease Many systemic diseases result in musculoskeletal symptoms and signs. A thorough history and PE is essential to avoid treating patient’s musculoskeletal symptoms rather than their systemic disease “ALL THAT ACHES IS NOT ONLY BONE”