Rheumatology teachingRheumatology teaching

Pilot 4 sessionsPilot 4 sessions Consultant Rheumatologist/student Consultant Rheumatologist/student

presentationpresentation Based on Phase II objectivesBased on Phase II objectives Polyarthritis, Monoarthritis, Back pain, Polyarthritis, Monoarthritis, Back pain,

Soft-tissue disordersSoft-tissue disorders Ward 2 RheumatologyWard 2 Rheumatology

Approach to PolyarthralgiaApproach to Polyarthralgia

Dr Jaya RavindranDr Jaya RavindranConsultant RheumatologistConsultant Rheumatologist

UHCWUHCW

Approach to PolyarthralgiaApproach to Polyarthralgia

AimsAims

Differential diagnosis of Differential diagnosis of polyarthralgia/polyarthritispolyarthralgia/polyarthritis

InvestigationsInvestigations

What conditions present What conditions present withwith

polyarthalgia?polyarthalgia?

Differential diagnosis of Differential diagnosis of polyarthalgia/polyarthritispolyarthalgia/polyarthritis

‘‘Poly` > 4 jointPoly` > 4 jointo Rheumatoid arthritis Rheumatoid arthritis

o Polyarticular OAPolyarticular OA

o Sero-ve Spondyloarthropathy (eg psoriatic, reactive)Sero-ve Spondyloarthropathy (eg psoriatic, reactive)

o Polyarticular crystal arthropathy Polyarticular crystal arthropathy

o Multi-organ disease – CTD and vasculitisMulti-organ disease – CTD and vasculitis

o Viral arthritis (eg parvovirus, rubella, hepatitis)Viral arthritis (eg parvovirus, rubella, hepatitis)

o (Polymyalgia rheumatica/GCA) (Polymyalgia rheumatica/GCA)

Differential diagnosis of Differential diagnosis of polyarthalgia/polyarthritispolyarthalgia/polyarthritis

‘‘Poly` > 4 jointsPoly` > 4 joints

o Medical conditions Medical conditions o thyroid disease / hyperparathyroidism / osteomalacia thyroid disease / hyperparathyroidism / osteomalacia o diabetic cheiroarthropathydiabetic cheiroarthropathyo paraneoplastic syndromes, multiple myelomaparaneoplastic syndromes, multiple myelomao infective endocarditisinfective endocarditiso sarcoidosissarcoidosis

o FibromyalgiaFibromyalgia

Age and sex IncidenceAge and sex Incidence

AGEAGE FEMALEFEMALE MALEMALE

Young adultsYoung adults RARA Reactive Reactive arthritisarthritis SLESLE (Sero-(Sero-ve)ve)

Psoriatic arthritisPsoriatic arthritis(Sero-ve)(Sero-ve)

Middle ageMiddle age RARA RARAOAOA GoutGout

Old ageOld age OAOAPMRPMRCrystal arthritisCrystal arthritis

What clues are there toWhat clues are there to

diagnosis?diagnosis?

CLUESCLUES

Prodromal event eg GI/GU infection Prodromal event eg GI/GU infection Associated conditions eg psoriasis, Associated conditions eg psoriasis,

colitis, iritiscolitis, iritis Inflammatory or mechanical*Inflammatory or mechanical* Pattern of joint and symmetry eg RA Pattern of joint and symmetry eg RA

vs PsA vs OA*vs PsA vs OA* Multi-organ disease*Multi-organ disease* Fibromyalgia symptoms* Fibromyalgia symptoms*

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

Pattern and Symmetry?Pattern and Symmetry?

Pattern and symmetryPattern and symmetry

RA - PIP, MCP, wrists, elbows, shoulders, RA - PIP, MCP, wrists, elbows, shoulders, neck, knee, ankle, MTP, symmetricalneck, knee, ankle, MTP, symmetrical

Sero-ve – DIP, asymmetrical, dactylitis, Sero-ve – DIP, asymmetrical, dactylitis, enthesitis, spinal enthesitis, spinal

OA – DIP, PIP, CMC, ACJOA – DIP, PIP, CMC, ACJWeight bearing jointsWeight bearing joints

Sero-ve Spondyloarthritis – Sero-ve Spondyloarthritis – psoriatic arthritispsoriatic arthritis

DIP, poly, DIP, poly, dactylitis, dactylitis,

enthesitis, spinal enthesitis, spinal

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

Polyarticular crystal eg goutPolyarticular crystal eg gout

ChronicChronic TophiTophi ErosionsErosions

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

What are CTD and whatWhat are CTD and what

symptoms and signs are symptoms and signs are seen?seen?

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

Connective tissue disease Connective tissue disease symptomssymptoms

o Photosensitive Photosensitive rashesrashes

o Skin tightnessSkin tightnesso Raynauds – late Raynauds – late

onset, trophic onset, trophic changeschanges

o Mouth ulcersMouth ulcers

Connective tissue disease Connective tissue disease symptomssymptoms

o Dry eyes and mouth Dry eyes and mouth

o Arthralgias, arthritis – non deformingArthralgias, arthritis – non deforming

o Proximal myopathy – pain and weakness Proximal myopathy – pain and weakness (PMR pain and stiffness – think also (PMR pain and stiffness – think also GCA)GCA)

Connective tissue disease Connective tissue disease symptomssymptoms

o SwallowingSwallowing

o Serositis/ILD – pleurisy, Serositis/ILD – pleurisy, dyspnoea, coughdyspnoea, cough

o RENAL DISEASE – silent, RENAL DISEASE – silent, URINE DIP + BPURINE DIP + BP

o Systemic - fatigue, Systemic - fatigue, fever, weight loss fever, weight loss

Connective tissue disease Connective tissue disease symptomssymptoms

o Vasculitis – Vasculitis – petechial, purpura, petechial, purpura, ulcer ulcer

What are the vasculitides What are the vasculitides and what type of and what type of symptoms and signs?symptoms and signs?

VasculitisVasculitis

Small, medium, large vesselSmall, medium, large vessel Eg MPA, Churg Strauss, PAN, Eg MPA, Churg Strauss, PAN,

Wegeners, GCA Wegeners, GCA ANCAANCA

VasculitisVasculitis

Systemic, vasculitic ulcers/rashes, Systemic, vasculitic ulcers/rashes, arthralgias/arthritis – non deformingarthralgias/arthritis – non deforming

ENT - sinusitisENT - sinusitis Pulmonary – haemoptysis, late onset Pulmonary – haemoptysis, late onset

asthmaasthma Cardiac failureCardiac failure RENAL – URINE DIP + BPRENAL – URINE DIP + BP Neuropathy eg footdropNeuropathy eg footdrop

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, Temporal headache,

jaw claudication visual jaw claudication visual disturbance, systemic disturbance, systemic upset upset

Raised ESR and CRP – Raised ESR and CRP – urgent steroidsurgent steroids

TA biopsyTA biopsy

InvestigationsInvestigations

Inflammatory arthritis – RAInflammatory arthritis – RA FBC, ESR, CRP, U+E, LFT, RF, XR Hands FBC, ESR, CRP, U+E, LFT, RF, XR Hands

and feetand feet ? CTD/vasculitis - ANA, ENA, RF, DNA ? CTD/vasculitis - ANA, ENA, RF, DNA

binding, ANCA, complementbinding, ANCA, complement Urine dip and BPUrine dip and BP Organ based investigations Organ based investigations Diffuse symptoms – CK, Ca, ALP, TFTDiffuse symptoms – CK, Ca, ALP, TFT Viral – Parvovirus, LFT+Hepatitis Viral – Parvovirus, LFT+Hepatitis

What other conditions What other conditions presentpresent

with elevated RF?with elevated RF?

Rheumatoid factorRheumatoid factor

Infection: Acute infection eg infectious mononucleosis; ChronicInfection: Acute infection eg infectious mononucleosis; Chronicinfection eg SBE, TB; Parasitic eg malaria; vaccinationinfection eg SBE, TB; Parasitic eg malaria; vaccination

Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic activeactive

hepatitis, cryoglobulinaemiahepatitis, cryoglobulinaemia

Malignancy: Lymphoma, leukaemia, myeloma, solid tumours Malignancy: Lymphoma, leukaemia, myeloma, solid tumours

5% healthy population 5% healthy population

RF <15 not significant unless associated with appropriate RF <15 not significant unless associated with appropriate clinical scenarioclinical scenario

What are the ANA and ENA?What are the ANA and ENA?

ANA and ENAANA and ENA

ANA 1/40 not significant unless associated ANA 1/40 not significant unless associated with appropriate clinical scenariowith appropriate clinical scenario

Also in RA, cirrhosis, ai liver disease, Also in RA, cirrhosis, ai liver disease, neoplasia, healthy populationneoplasia, healthy population

ENA – extractable nuclear antigensENA – extractable nuclear antigens Anti-Ro and anti-La - SjogrensAnti-Ro and anti-La - Sjogrens Scl 70 and anti-centromere – SclerodermaScl 70 and anti-centromere – Scleroderma 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

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

What are the radiologicalWhat are the radiological

feature of OA, RA (and feature of OA, RA (and PsA) ?PsA) ?

Radiology - OA Radiology - OA

Four cardinal Four cardinal features:features: Joint space Joint space

narrowingnarrowing SclerosisSclerosis Subchondral cystsSubchondral cysts OsteophytesOsteophytes

Radiology - RARadiology - RA

soft tissue swellingsoft tissue swelling

juxta-articular osteoporosisjuxta-articular osteoporosis

juxta-articular and juxta-articular and subchondral erosionssubchondral erosions

joint space narrowing & joint space narrowing & subluxationsubluxation

secondary OA & bony secondary OA & bony ankylosis ankylosis

Radiology - PsARadiology - PsA

ErosionErosion OsteolysisOsteolysis Bone Bone

proliferationproliferation AnkylosisAnkylosis

Thank-youThank-you