A BASIC APPROACH TO DIAGNOSIS

IN

JOINT DISEASES

IS IT ARTHRITIS OR NOT?

ARTHRITIS OR ARTHRALGIA

AN IDENTIFIABLE

PATHOLOGICAL PROCESS

INVOLVING JOINTS MUST BE

PRESENT

IS IT AN INFLAMMTORY PROCESS

OR

NOT

INFLAMMATION

SYSTEMIC EFFECTS

TARGET ORGAN EFFECTS

• REDNESS

• HEAT

• SWELLING

• PAIN

• LOSS OF FUNCTION

• Soft tissue swelling

• Early morning joint pain and stiffness

INFLAMMATORY >5,000 white cells/ mm³

“NON-INFLAMMATORY” <1,000 white cells/mm³

SYSTEMIC EFFECTS OF INFLAMMATION

1. CLINICALtirednesswt lossfevergrowth retardation

2. LABORATORYacute phase reactants

• Haemoglobin ↓

• White cell count ↑ or normal

• Platelets ↑ or normal

• ESR ↑

CRP (C reactive protein) ↑

Gamma globulins (immunoglobulins) ↑

Albumin ↓

Alkaline phosphatase (ALP) ↑

Iron and TIBC ↓

Ferretin ↑

WHICH INFLAMMATORY JOINT DISEASE?

COMMON MODES of PRESENTATION of

RHEUMATIC DISEASES

SYSTEMIC

POLYARTICULAR

MONO / OLIGOARTICULAR

AXIAL

• ACUTE

• CHRONIC

JOINT FLUID

• White cell count

• Examination for crystals

• Culture and sensitivity

• Multiple pathologies can coexist in the one joint

PATTERN OF JOINT INVOLVEMENT

NON-JOINT MANIFESTATIONS

Pattern of Involvement

• In distribution symmetrical or notsmall or large jointsaxial or peripheralmany, few or single joint

• In time episodicflittingconstantadditive

Associated extra-articular problems

Joints

Skin

Eyes

Lymph nodes – spleen

Lungs

Kidneys

Rheumatoid Factor ≠ Rheumatoid arthritis

ANA ≠ Systemic lupus

HLA B27 ≠ Ankylosing spondylitis

High urate ≠ Gout

HLA B27

• ANKYLOSYNG SPONDYLITIS 90%

• NORMAL POPULATION 9%

BACK PAIN THAT IMPROVES WITH ACTIVITY

CONSIDER THE POSSIBILITY of INFLAMMATORY

SPONDYLARTHROPATHY

Rheumatoid arthritis: hands, advanced deformity

(radiograph)

Klareskog L et al Arthritis Rheumatism 2006

Rheumatoid Arthritis

• Early intervention matters

• Smoking is a risk factor

Hypouricaemic therapy

• Can precipitate gout in the introductory phase of treatment & needs to be covered

• Do not stop because of breakthrough flare

• Treat to target serum urate level

• Multiple pathologies can coexist in the one joint

• REDNESS

• HEAT

• SWELLING

• PAIN

• LOSS OF FUNCTION

Tendinitis

Enthesitis

Fibrositis

DIAGNOSIS

EVALUATION

SYSTEMIC

MONO or OLIGOARTICULAR

Rheumatoid Arthritis

A systemic inflammatory disease of unknown cause, with a particular predilection to involve the synovium

Osteoarthritis

A localised disease of joints, thought to arise as a consequence of cartilage degeneration

POLYARTICULAR

Basics of diagnosis

by G Major