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APPROACH TO POLY-ARTHRITIS

DR CB NEL

Joints cartilage/synovium

Arthritis

Degenerative

Osteoartritis

Inflammatory

Rheumatoid arthritis

Seronegative

spondiloarthropaties

Gout

Septic

Lower back pain

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Diagnostic approach

• Inflammatory vs. Noninflamatory

• Acute vs. Chronic

• Temporal pattern of joint involvement

• Distribution of joint involvement

• Age of patient

• Sex of patient

• Systemic involvement

Inflammatory vs Mechanical

Morning stiffness>1 hr

FatigueProfound

ActivityImproves symptoms

RestWorsens symptoms

Systemic involvementYes

Swelling, warmth, erythema,

tenderness, loss of function

• Morning stiffness

– <30 min

• Fatigue

– Minimal

• Activity

– Worsens symptoms

• Rest

– Improves symptoms

• Systemic involvement

– No

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Acute vs. Chronic

Acute Polyarthritis

• Infection

– Gonococcal

– Meningococcal

– Acute rheumatic fever

– Bacterial endocarditis

– Viral(esp.. rubella,

hepatitis B, parvovirus,

Epstein-Barr, HIV)

• Other inflammatory

– Rheumatoid arthritis

– Juvenile chronic arthritis

– SLE

– Reactive arthritis

– Psoriatic arthritis

– Polyarticular gout

– Sarcoid arthritis

– Serum sickness

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Chronic Polyarthritis (>6 weeks)

• Inflammatory

– Rheumatoid arthritis

– Polyarticular Juvenile

chronic arthritis

– SLE

– Progressive systemic

sclerosis

– Polymyositis

– Reiter’s syndrome

– Psoriatic arthritis

– Enteropathic arthritis

– Polyarticular gout

– Pseudogout (CPPD)

– Sarcoid arthritis

– Vasculitis

– Polymialgia rheumatica

Chronic Polyarthritis (>6 weeks)

• Noninflammatory

– Osteoarthritis

– Pseudogout (CPPD)

– Polyarticular gout

– Paget’s disease

– Fibromyalgia

– Benign hypermobility syndrome

– Hemochromatosis

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Temporal patterns of joint

involvement

• Migratory

– Rheumatic fever

– Gonococcal arthritis

• Additive

– Nonspecific

• Rheumatoid arthritis

• SLE

• Intermittent

– Rheumatoid arthritis

– Psoriatic arthritis

– Reactive Arthritis

• Palandromic

– Gout

– Rheumatoid arthritis

Distribution of joint involvement

• Rheumatoid arthritis

– Commonly involved

• Wrist, MCP, PIP, elbow, glenohumeral, cervical spine,

hip, knee, ankle, tarsal, MTP

– Commonly spared

• DIP, thoracolumbar spine

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Distribution of joint involvement

• Osteoarthritis

– Commonly involved

• First CMC, DIP, PIP, cervical spine, thoracolumbar spine,

hip, knee, first MTP, toe IP

– Commonly spared

• MCP, wrist, elbow, glenohumeral, ankle, tarsal

Distribution of joint involvement

• Reactive arthrits

– Commonly involved

• Knee, ankle, tarsal, MTP, toe IP, elbow, axial

• Gonococcal arthritis

– Commonly involved

• Knee, wrist, ankle, hand IP

– Commonly spared

• Axial

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RHEUMATOID ARTHRITIS

CLINICAL FEATURES

• Prolonged morning stiffness

• Synovitis of small joints of hands, wrists and feet

• Other synovial structures (tenosynovitis, bursae) also common

• Typical hand features:

o Symmetrical swelling of the MCP and PIP joints

o Tenderness of involved joints

o Swan neck deformities

o Boutonniére deformities

o Z-deformity of the thumb

o Dorsal subluxation of the ulna styloid

o Triggering of the fingers

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EXTRA-ARTICULAR MANIFESTATIONS

• Systemic

Fever, fatigue, weight loss, increased infection risk

• MSK

Muscle-wasting, tenosynovitis, bursitis, osteoporosis

• Haematological

Reactive thrombocytosis, microcytic anaemia, anaemia of

chronic disease(normochromic, normocytic)

• Lymphatic

Splenomegaly, Felty’s syndrome(RA, splenomegaly,

neutropenia)

EXTRA-ARTICULAR MANIFESTATIONS

• Ocular

Episcleritis, scleritis, scleromalacia, keratoconjunctivitis

sicca

• Vasculitis

Nailfold infarcts, skin ulcers, pyoderma gangrenosum,

mononeuritis multiplex, visceral arteritis

• Cardiac

Pericarditis, myocarditis

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EXTRA-ARTICULAR MANIFESTATIONS

• Neurological

Atlantoaxial subluxation, carpal tunnel syndrome, peripheral

neuropathies, mononeuritis multiplex

• Pulmonary

Nodules, pleural effusions, pulmonary fibrosis, bronchiolitis, Caplan’s

syndrome(RA plus pneumoconiosis), bronchiectasis

• Nodules

Subcutaneous, lungs, pericardium

• Amyloidosis

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Early RA

RA HANDS

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Extensor tenosinovitis

Olecranon

bursitis and

subcutaneous

nodules

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Baker’s popliteal sist

RA FEET

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RA feet

SPECIAL INVESTIGATIONS

• CRP and ESR usually elevated

• Rheumatoid factor positive in 70%

• Anti-CCP positive in a sub-population

• X-rays: periarticular osteopenia and marginal erosion

(x-ray changes takes months to develop)

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CLASSIFICATION CRITERIA OF RA

NEW CRITERIA HAS BEEN PUBLISHED IN 2010

TREATMENT• A multidisciplinary team approach is followed

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PATIENT EDUCATION• The nature of the disease as well as its chronic

course

• Disease is characterised by fluctuations

• It takes a considerable time before the therapy

starts to show results

• Ignorance and especially the fear of becoming

an invalid must be adressed

PHYSIOTHERAPY

• Exercise programme– Maintain muscle strength– Maintain joint mobility as well as prevent

contractures

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OCCUPATIONAL THERAPY

• Patient guidance with regard to work activities

and joint-saving techniques, as well as the

positions of joints during sleep

• Rest and night splints are also important

• Other aids for daily activies are also provided

PHARMACOLOGICAL THERAPY

• Analgesics

• DMARD (changes the course of the disease)

• Corticosteroids

• Immunotherapy

• Other

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ANALGESICS

• Oral analgesics (Paracetamol, tramadol)• NSAID’s

– gastro-intestinal and renal side-effects– high-risk cases

• Misoprostol (Cytotec)• Proton pump inhibiters• H2 antagonists

• Coxibs

CORTICOSTEROIDS

• Low dose oral (chronic as a “DMARD”)

• Intra-articular steroids

• Pulse high dose treatment

– Flares

– Treatment of complications

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DMARD’S

• Chloroquine• Sulphasalazine• Methotrexate• Other immunosuppressants• Combination therapy

Biologic agents when patients fail DMARD therapy

- TNF alpha inhibiters

- B cell inhibiters

- Interleukin 6 inhibiters

OTHER

• Orthopaedic aids

• Orthopaedic surgical treatment

• Rx extra-articular complications

• Supportive therapy

– education

– anxiety

– depression

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OSTEOARTHRITIS

OSTEOARTHRITIS

• Most common arthritis

• Strongly associated with aging

• Characterised by focal loss of articular cartilage with new bone

proliferation and remodelling of the joint contour

• Inflammation is NOT a prominent feature

• Risk factors

– Family history

– Caucasians

– Women

– Trauma

– Adverse loading(obesity,sport,profession)

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PATHOLOGICAL CHANGES IN OA

SYMPTOMS

• Artralgia and functional restriction

• Insidious onset of symptoms

• Pain worsened by movement and relieved by rest

• Brief (<15min.) morning stiffness and brief “gelling” after rest

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PHYSICAL SIGNS

• Bony swelling and deformity around joint margins

• Joint-line tenderness

• Decreased range of movement

• Palpable coarse crepitations

• Muscle wasting

• Antalgic gait common with involvement of lower limbs

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OA HANDS

SPECIAL INVESTIGATIONS

• NO impact on inflammatory markers(CRP, ESR)

• X-ray changes

– Joint space narrowing

– Subchondral sclerosis

– Osteophytes

– Bone cysts

• Correlation between x-ray changes and the level of pain and

disability is variable

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TREATMENT OF OA

• Exercise

• Lose weight

• Heat or cold

• Analgesia

– Paracetamol

– Topical NSAID

– Oral NSAID

– Opioids

• Intra-articular steroids can give temporary relief

• Surgery

– For uncontrolled pain

– Progressive functional impairment

Seronegative

spondilo-arthropathies

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CLINICAL FEATURES OF THE SERONEGATIVE

SPONDARTHRITIS

• Asymmetrical inflammatory oligoarthritis (lower>upper limb)

• Sacroiliitis and inflammatory spondylitis

• Inflammatory enthesitis

• Tendency for familial aggregation

• NO association with positve Rheumatoid factor

• Absence of nodules and other extra-articular features of RA

• Strong association with HLA-B27

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ENTHESITIS: Inflammation of the attachment of tendons or ligaments to bone

(hallmark feature of the seronegative spondarthritis)

LOWER BACKPAIN

InflammatoryInflammatory MechanicalMechanical

AgeAge < 40 years< 40 years Any ageAny age

ProgressionProgression Slowly/ChronicSlowly/Chronic AcuteAcute

Duration of symptomsDuration of symptoms > 3 months> 3 months < 4 weeks< 4 weeks

Morning stiffnessMorning stiffness > 60 min.> 60 min. < 3o min.< 3o min.

Night pain(vertebral)Night pain(vertebral) CommonCommon AbsentAbsent

ExerciseExercise ImproveImprove WorsensWorsens

SISI--joint tendernessjoint tenderness CommonCommon AbsentAbsent

Vertebral mobilityVertebral mobility ↓ all directions↓ all directions ↓ flection↓ flection

Chest expansionChest expansion Decreased Decreased NormalNormal

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ANKYLOSING SPONDYLITIS

• Predilection for the sacroiliac joints and spine

• Male : female ratio of 3:1

• Progressive stiffening and fusion of axial skeleton

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SPINAL FEATURES

• Insidious onset over months to years

• Restriction of lumbar movements

• Possible involvement of the entire spine as disease progress

• Progressive spinal fusion

o Loss of lumbar lordosis

o Marked thoracic kyphosis

o Reduced chest expansion

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EXTRASPINAL FEATURES

• Plantar fasciitis and Achilles tendinitis

• Asymmetrical peripheral arthritis: shoulders, hips, knees and

ankles

• Anterior uveitis

• Aortic incompetence

• Cardiac conduction defects

• UPPER lobe pulmonary fibrosis

• Osteoporosis

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PLANTAR FASCIITIS

ACHILLES TENDON ENTHESITIS

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TREATMENT

• Physiotherapy

• Regular NSAID’s

• Sulfasalazine for peripheral arthritis

• Tumour necrosis factor(TNF)-Alpha inhibiters

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REACTIVE ARTHRITIS

• Classically young men

• Acute onset inflammatory oligoarthritis 1-3 weeks afer an infection

affecting the small and large joints of the lower limbs

• Infective “trigger”

– Bacterial dysentery (due to Salmonella, Campylobacter, Shigella,

Yersinia)

– Non-spes. urethritis (due to Clamydia)

• First attack usually self-limiting with spontaneous remission within 4-6

months

• Treatment:

– Mostly symptomatic with NSAID’S

– DMARD’s in worse cases

PSORIATIC ARTHROPATHY

• Five major articular presentations:

– Asymmetrical inflammatory oligoarthritis

– Symmetrical polyarthritis (Strongly resemble RA)

– Predominantly distal interphalangeal joint arthritis

– Psoriatic spondylitis (strongly resemle Ankylosing spondylitis)

– Arthritis mutilans

• Skin lesions

• Nail changes: pitting, onycholysis, subungual hyperkeratosis

• Treatment similar to Ankylosing spondulitis

(methotrexate will also help for peripheral arthritis)

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Symmetric psoriatic polyarthritis resembling RA

Distal interphalangeal joint involvement

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Psoriatic Arthritis

Nail pitting

Skin

Enthesophathy

Dactilitis

ARTHRITIS ASSOCIATED WITH INFLAMMATORY

BOWEL DISEASE

• Two patterns of articular involvement:

– Acute oligoarthritis with a predilection for the lower limb

joints.

– Sacroiliitis and ankylosing spondylitis

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QUESTIONS?