Painful joints

Index case Year 2

Michaelmas Term

The story…. (see www.dipex.org/)

• A 53 year old woman, divorced with 2 children born after onset of painful joints, particularly hands and feet

• Symptoms subsided during 1st pregnancy, no remission in 2nd pregnancy

• Diagnosis made 23 years ago after infection with glandular fever.

• Had foot surgery and hand surgery planned

Features of her illness:• Describes intense pain at times- counts the

hours between painkillers• Finds physiotherapy and hydrotherapy helpful in

keeping joints moving• Unhappy with results of foot surgery-still has

pain• Finds complementary therapy too expensive• On Incapacity Benefit- would like to have been

an artist

She comes to see you because:

• She is a concerned as she has recently noticed increasing shortness of breath

• She wants to know if there is any new treatment around which might help her

• If you can help provide any complementary treatments

What is the differential diagnosis?

Monoarticular or polyarticular?

Causes of polyarthritis?

Polyarthritis: osteoarthritis

• Osteoarthritis- disease of synovial joints; loss of articular cartilage and overgrowth of underlying bone

• Multifactorial causes; usually begins in middle age

• May be triggered by mechanical damage

• May be primary or secondary

Primary osteoarthritis

• Classic: pain and dysfunction of one or two weight bearing joints

• Generalised nodal: affecting finger joints of middle aged women

Secondary osteoarthritis

• Abnormal “wear and tear” following clearly defined insult to joint

• E.g. Charcot joint 2ry to diabetic neuropathy

Polyarthritis: rheumatoid arthritis

• Chronic systemic disease primarily affecting joints

• Inflammatory changes in synovial membranes and articular structures, including ligaments

• Leads to deformity: subluxation, ligament & joint disruption, joint erosion, ankylosis

• Systemic features develop as disease progresses

Rheumatoid arthritis

• 1-3% population

• Women:men 3:1

• Peak incidence 25-55

• Cause unknown ?autoimmunity triggered by viral infection

• Genetic link: HLA DR4 alleles poor prognostic factor

How would you make the diagnosis?

Diagnosis of RA: history

• Bilateral, symmetrical polyarthritis

• Involves proximal joints of hands and feet

• Present at least 6 weeks

• May have subcutaneous rheumatic nodules on hands or elbows

Diagnosis of RA: investigations• Raised ESR and CRP in active disease• +ve Rheumatoid factor in 80% cases• High seropositivity with systemic

complications• Anticitrulline antibody with erosive RA• Blood count: may have anaemia,

hypoalbuminaemia• Proteinuria• radiology

Features of radiology

• Synovitis: soft tissue swelling

• Joint destruction; erosion

• Deformity

• Evidence of previous surgery

What could be causing her shortness of breath?

Extra-articular manifestations of RA

• respiratory

• haematological

• neurological

• lymphoreticular

• ocular

• cardiac

• systemic

Respiratory complications

• pleurisy

• pleural effusion

• pleural nodules

• pulmonary fibrosis

• Caplan's syndrome

• obliterative bronchiolitis

• cricoarytenoid inflammation

Caplan’s syndrome

• Rheumatoid lung nodules with pneumoconiosis

• May resemble TB on Xray

• Restrictive and obstructive defect

• Airflow limitation and reduced gas transfer

What treatments are there for RA?

RA management

• Medical

• Surgical

• Physio

• other

Medical treatment

1. Symptom control:

• NSAIDs, including aspirin

• Selective COX-2 inhibitors

BUT remember NSAIDs may cause gastritis and affect renal function

AND COX-2 inhibitors may increase risk of cardiovascular events

• Use lowest effective dose

Medical treatment:2. Disease-Modifying Anti-Rheumatic Drugs

(DMARDs)• Low-dose weekly methotrexate• Sulfasalazine• Hydroxychloroquine, leflonamide• Azathioprine, penicillamine, gold salts• May use combination in patients at risk of

progressive disease• NEW! Infliximab tissue necrosis factor blocker

(TNF-α)

TNF-α

• Launched for Crohn’s 1999

• Very expensive: national guidelines published by BSR 2001

• Mainly used if patient resistant to standard DMARD therapy

Medical treatment

3. Corticosteroids

• May use with anti-inflammatories and DMARDs

• Helps in acute flare-ups

• Remember side effects: osteporosis, Cushing’s disease, hypertension

Surgical management

Surgical options

• Tendon repair or transfer

• Synovectomy

• Arthrodesis

• Joint replacement

• osteotomy

But remember….

Physiotherapy and other treatments?

Role of physio

• Rest inflamed joints

• Use of splints

• Exercise when inflammation subsides to strengthen surrounding muscles and reduce risk of osteporosis

Complementary treatments?

Complementary treatment on NHS:

• Variable between practices

• No evidence for homeopathy

• ?acupuncture

• ?glucosamine

• ?aromatherapy

• ?massage

Any other causes of polyarthritis?

Other causes of polyarthritis• Seronegative spondyloarthritis• SLE• Polyarteritis nodosa• Wegener’s granulomatosis• Systemic sclerosis• Post-infective: rheumatic fever, Reiter’s

syndrome, enteric infections• Infective: Lyme disease, bacterial

endocarditis, gonococcus• Sarcoidosis

And… any causes of monoarthritis?

monoarthritis

• Infection

• Haemarthrosis: trauma, esp. haemophilia

• Tumour: osteoma, sarcoma, metastasis

• Rheumatic: RA or OA

• Crystal (gout: urates, pseudogout: calcium pyrophosphate dihydrate))