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PolyarthralgiaPolyarthralgia
Tanya PotterTanya PotterConsultant RheumatologistConsultant Rheumatologist
UHCWUHCW
AimsAims
Differential diagnosis of Differential diagnosis of polyarthralgia/polyarthritispolyarthralgia/polyarthritis
Investigation of joint painsInvestigation of joint pains
What is polyarthralgia?What is polyarthralgia?
What conditions present with What conditions present with polyarthralgia?polyarthralgia?
InflammatoryInflammatory
MechanicalMechanical
Pain syndromesPain syndromes
How do you differentiateHow do you differentiate
between mechanical andbetween mechanical and
inflammatory symptoms?inflammatory symptoms?
Mechanical vs InflammatoryMechanical vs Inflammatory
Inflammatory Inflammatory MechanicalMechanical Immobility stiffness Immobility stiffness latter daylatter day EMS>30-60 minsEMS>30-60 mins EMS<30-60 minsEMS<30-60 mins Better with activity and NSAIDsBetter with activity and NSAIDs worse with worse with
activityactivity Joint swelling, erythema,heat Joint swelling, erythema,heat instabilityinstability Systemic symptoms Systemic symptoms lockinglocking Multi-organ involvement Multi-organ involvement trauma, straintrauma, strain
overusage overusage
Age and sex IncidenceAge and sex Incidence
AGEAGE FEMALEFEMALE MALEMALE
Young adultsYoung adults
Middle ageMiddle age
Old ageOld age
Age and sex IncidenceAge and sex Incidence
AGEAGE FEMALEFEMALE MALEMALE
Young adultsYoung adults RARA Reactive arthritis Reactive arthritisSLESLE (Sero-ve)(Sero-ve)
Middle ageMiddle age
Old ageOld age
Age and sex IncidenceAge and sex Incidence
AGEAGE FEMALEFEMALE MALEMALE
Young adultsYoung adults RARA Reactive arthritis Reactive arthritisSLESLE (Sero-ve)(Sero-ve)
Psoriatic arthritisPsoriatic arthritis(Sero-ve)(Sero-ve)
Middle ageMiddle age RARA
Old ageOld age
Age and sex IncidenceAge and sex Incidence
AGEAGE FEMALEFEMALE MALEMALE
Young adultsYoung adults RARA Reactive arthritis Reactive arthritisSLESLE (Sero-ve)(Sero-ve)
Psoriatic arthritisPsoriatic arthritis(Sero-ve)(Sero-ve)
Middle ageMiddle age RARA
Old ageOld age OAOACrystal arthritisCrystal arthritis
OAOA
Clinical featuresClinical features
OsteoarthritisOsteoarthritis
Mechanical Mechanical symptomssymptoms
Bony swelling, Bony swelling, crepituscrepitus
DIP (Heberden), PIP DIP (Heberden), PIP (Bouchard), 1(Bouchard), 1stst CMCJ, neck, lower CMCJ, neck, lower back, hips, knees, back, hips, knees, 11stst MTP MTP
Pathophysiology?Pathophysiology?
PathophysiologyPathophysiology
Imbalance between degradative and Imbalance between degradative and reparative connective tissue reparative connective tissue processes within joint leading to processes within joint leading to failure of jointfailure of joint
Occasional genetic associationOccasional genetic association Pathological stresses may lead to Pathological stresses may lead to
micro trauma and inflammatory micro trauma and inflammatory changechange
Radiology - OA Radiology - OA
Radiology - OA Radiology - OA
Four cardinal Four cardinal features:features: Joint space Joint space
narrowingnarrowing SclerosisSclerosis Subchondral cystsSubchondral cysts OsteophytesOsteophytes
Other features associated with Other features associated with athralgiaathralgia
Prodromal eventsProdromal events
Associated conditionsAssociated conditions
CLUESCLUES
Prodromal event eg GI/GU infection – Prodromal event eg GI/GU infection – reactive arthritisreactive arthritis
Associated conditions eg psoriasis, Associated conditions eg psoriasis, colitis, iritiscolitis, iritis
Pattern and Symmetry?Pattern and Symmetry?
CLUESCLUES
Multi-organ diseaseMulti-organ disease
Fibromyalgia symptomsFibromyalgia symptoms
RheumatoidRheumatoid
Female ~ 1 in 100Female ~ 1 in 100 symmetrical polyarthritis, targeting small symmetrical polyarthritis, targeting small
joint and largejoint and large DIP sparing DIP sparing
PathophysiologyPathophysiology
Inflammatory conditionInflammatory condition Strong genetic component- HLA DR4Strong genetic component- HLA DR4 Environmental effectsEnvironmental effects Inflammation of synovium with high Inflammation of synovium with high
levels of chemokines and cytokines levels of chemokines and cytokines and resultant tissue damageand resultant tissue damage
o Systemic features?Systemic features?
Psoriatic arthritisPsoriatic arthritis
Psoriasis 2-3% populationPsoriasis 2-3% population 5-10% of these will develop Ps 5-10% of these will develop Ps
arthritisarthritis Family history 55X more likely (40%)Family history 55X more likely (40%)
Pathophysiology?Pathophysiology?
HLA B27 related arthritisHLA B27 related arthritis Arthritis and enthesitis possibly Arthritis and enthesitis possibly
T cell driven, with tissue damageT cell driven, with tissue damage
Sero-ve Spondyloarthritis – Sero-ve Spondyloarthritis – psoriatic arthritispsoriatic arthritis
DIP, poly, DIP, poly, dactylitis, dactylitis,
enthesitis, spinalenthesitis, spinal Younger age Younger age
Soft tissue swellingSoft tissue swelling Joint space Joint space
narrowingnarrowing Mouse ear erosionsMouse ear erosions Periostitis with new Periostitis with new
bone formationbone formation DIP joint DIP joint
involvementinvolvement
Polyarticular crystal Polyarticular crystal arthropathy eg goutarthropathy eg gout
ChronicChronic TophiTophi ErosionsErosions Older ageOlder age
Nb pseudogoutNb pseudogout
polyarthalgia/polyarthritispolyarthalgia/polyarthritis
‘‘o Multi-organ disease – CTD and Multi-organ disease – CTD and
vasculitisvasculitis
o Viral arthritis (eg parvovirus, rubella, Viral arthritis (eg parvovirus, rubella, hepatitis)hepatitis)
o Medical conditions egMedical conditions ego diabetic cheiroarthropathydiabetic cheiroarthropathyo Sarcoidosis-Sarcoidosis-
SarcoidSarcoid
Acute or chronicAcute or chronic Multisystem disorder, non caseating Multisystem disorder, non caseating
granulomasgranulomas Acute: spring time (?viral) young Acute: spring time (?viral) young
adults sudden onset of lower limb adults sudden onset of lower limb arthritis and erythema nodosum & red arthritis and erythema nodosum & red eyes eyes
Fever and coughFever and cough
IxIx
Raised serum ACERaised serum ACE Raised CaRaised Ca ESR, CRPESR, CRP Chest xrayChest xray
Outcome of acute: Outcome of acute: good, NSAIDs, oral good, NSAIDs, oral prednisoloneprednisolone
Chronic: afrocarribeanChronic: afrocarribean Grumbling lung Grumbling lung
disease, jt, muscle, disease, jt, muscle, liver diseaseliver disease
Treatment unclear- Treatment unclear- prednisolone, prednisolone, methotrexatemethotrexate
What are CTD?What are CTD?
Symptoms and signs?Symptoms and signs?
Connective tissue diseaseConnective tissue disease
Eg SLE, scleroderma, polymyositis, Eg SLE, scleroderma, polymyositis, Sjogren’sSjogren’s
Auto-immuneAuto-immune Multi-organMulti-organ Anti-nuclear antibodiesAnti-nuclear antibodies
SLESLE
RaynaudsRaynauds RashesRashes ArthralgiaArthralgia HaemHaem CNSCNS RenalRenal SerositisSerositis thrombosisthrombosis
Sle- skinSle- skin
o Photosensitive Photosensitive rashes eg SLErashes eg SLE
o Discoid lupusDiscoid lupus
Sle- renalSle- renal
Significant cause of Significant cause of morbidity and morbidity and mortality- condition mortality- condition and treatmentand treatment
Sjogrens syndromeSjogrens syndrome
o Destruction of exocrine glandsDestruction of exocrine glands
o Dry eyes and mouth- cariesDry eyes and mouth- carieso Liver, lungs, gut, arthralgia, MNMLiver, lungs, gut, arthralgia, MNMo Increased B cell lymphoma riskIncreased B cell lymphoma risk
SclerodermaSclerodermao Localised (CREST)Localised (CREST)o DiffuseDiffuseo Raynauds, finger Raynauds, finger
ulcersulcerso Sclerosis of most Sclerosis of most
organsorganso GI, skin, ILD, renal GI, skin, ILD, renal
crisiscrisis
Myositis Myositis
Inflammatory Inflammatory muscle conditionmuscle condition
Demato or Demato or polymyositspolymyosits
Proximal painless Proximal painless weaknessweakness
What are the vasculitides What are the vasculitides andand
what type of symptoms andwhat type of symptoms and
signs?signs?
VasculitisVasculitis
Small, medium, Small, medium, large vessellarge vessel
Eg MPA, Churg Eg MPA, Churg Strauss, PAN, Strauss, PAN, Wegeners, GCA Wegeners, GCA
ANCAANCA
Vasculitis- skinVasculitis- skin
o Vasculitis – Vasculitis – petechial, purpura, petechial, purpura, ulcer ulcer
VasculitisVasculitis
Systemic, vasculitic Systemic, vasculitic ulcers/rashes, ulcers/rashes, arthralgias/arthritis arthralgias/arthritis – non deforming– non deforming
Pulmonary – Pulmonary – haemoptysis haemoptysis
VasculitisVasculitis
RENAL – URINE DIP RENAL – URINE DIP + BP+ BP
ENT –eg Wegener’sENT –eg Wegener’s
Neuropathy eg Neuropathy eg footdropfootdrop
PMR and GCA features?PMR and GCA features?
Polymyalgia rheumatica and Polymyalgia rheumatica and GCAGCA
Over 50’sOver 50’s Proximal inflammatory Proximal inflammatory
pain and stiffnesspain and stiffness GCA – large vessel GCA – large vessel
arteritisarteritis Temporal headache, jaw Temporal headache, jaw
claudication visual claudication visual disturbance, systemic disturbance, systemic upset upset
Raised ESR and CRP – Raised ESR and CRP – urgent steroidsurgent steroids
TA biopsyTA biopsy
Fibromyalgia Fibromyalgia
““All over pain”All over pain” FatigueFatigue Sleep disturbanceSleep disturbance DepressionDepression AnxietyAnxiety Irritable bowelIrritable bowel Tender spotsTender spots Diagnosis of exclusionDiagnosis of exclusion
InvestigationsInvestigations
Inflammatory arthritis – Inflammatory arthritis –
InvestigationsInvestigations
Inflammatory arthritis – RAInflammatory arthritis – RA
FBC, ESR, CRP, U+E, LFT, RF, anti-FBC, ESR, CRP, U+E, LFT, RF, anti-CCP, ANA,CCP, ANA,
XR Hands and feet and chestXR Hands and feet and chest
Viral – ParvovirusViral – Parvovirus
InvestigationsInvestigations
? CTD/vasculitis -? CTD/vasculitis -
InvestigationsInvestigations
? CTD/vasculitis - ANA, ANCA, ? CTD/vasculitis - ANA, ANCA, complementcomplement
Urine dip and BPUrine dip and BP
Organ based investigations Organ based investigations
InvestigationsInvestigations
Diffuse symptoms – CK, Ca, ALP, TFTDiffuse symptoms – CK, Ca, ALP, TFT
Crystal – joint aspirate, radiology, Crystal – joint aspirate, radiology, urate, U+E urate, U+E
What is RF and what otherWhat is RF and what other
conditions present with conditions present with elevatedelevated
RF?RF?
Rheumatoid factorRheumatoid factor
Autoantibody vs Fc portion of IgG – any isotype but typically Autoantibody vs Fc portion of IgG – any isotype but typically IgM RFIgM RF
Acute infection eg infectious mononucleosis Acute infection eg infectious mononucleosis
Chronic infection eg SBE, TBChronic infection eg SBE, TB
Inflammatory disease: CTD, Fibrosing alveolitis, Inflammatory disease: CTD, Fibrosing alveolitis,
Malignancy: Lymphoma, leukaemiaMalignancy: Lymphoma, leukaemia
5% healthy population 5% healthy population
RF <15 usually not significantRF <15 usually not significant
Anti-CCPAnti-CCP
Anti-cyclic citrullinated peptideAnti-cyclic citrullinated peptide
More specific for RA than RFMore specific for RA than RF
May predict erosive damageMay predict erosive damage
What are the ANA and ENA?What are the ANA and ENA?
ANA and ENAANA and ENA
ANA 1/40 not significant unless ANA 1/40 not significant unless associated with appropriate clinical associated with appropriate clinical scenarioscenario
Also in RA, auto immune liver Also in RA, auto immune liver disease, neoplasia, healthy disease, neoplasia, healthy population…population…
ANA and ENAANA and ENA
ENA – extractable nuclear antigens ENA – extractable nuclear antigens (ANA subtypes)(ANA subtypes)
Anti-DNA - SLE Anti-DNA - SLE Anti-Ro and anti-La - SjogrensAnti-Ro and anti-La - Sjogrens Scl 70 and anti-centromere – Scl 70 and anti-centromere –
SclerodermaScleroderma Anti-RNP – mixed CTDAnti-RNP – mixed CTD Anti-Jo1 - myositis Anti-Jo1 - myositis
What is ANCA ?What is ANCA ?
ANCAANCA Antibodies vs specific antigens in Antibodies vs specific antigens in
cytoplasm of neutrophilscytoplasm of neutrophils ANCA reactive to myeloperoxidase ANCA reactive to myeloperoxidase
(MPO) – perinuclear pattern of (MPO) – perinuclear pattern of staining P-ANCA eg microscopic staining P-ANCA eg microscopic polyarteritispolyarteritis
ANCAANCA
ANCA reactive to proteinase 3 (PR3) ANCA reactive to proteinase 3 (PR3) – cytoplasmic pattern of staining C-– cytoplasmic pattern of staining C-ANCA eg Wegener’s granulomatosisANCA eg Wegener’s granulomatosis
Thank-youThank-you
