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APPROACH TO A CASE OF ARTHRITIS
Dr.S.SRIRAMProf.Dr.GOWRISHANKAR’S M5
UNIT
HISTORY
Joint pain•inflammatory arthritis.• noninflammatory arthritis.• arthralgia.
Inflammatory arthritis
characterized by inflammation affecting −Synovium− synovial cavity−entheses.
• alterations in the structure or mechanics of the joint.
• may occur as a result of (1) cartilage or meniscal damage (2) alterations in joint anatomy
congenitaldevelopmentalmetabolic,past inflammatory diseases.
Non inflammatory arthritis.
• joint tenderness, without abnormalities
• Also includes• altered pain sensation (eg,
fibromyalgia) • early rheumatic syndrome (eg,
arthralgias of systemic lupus erythematosus [SLE]).
Arthralgia.
Symptoms of joint diseasePain
• inflammatory joint disease• pain is present both at rest and with motion• worse at the beginning than at the end of usage.
• Noninflammatory
• pain occurs mainly or only during motion and improves quickly with rest
• Pain that arises from small peripheral joints • more accurately localized than pain arising from
larger proximal joints.
Stiffness
• sensation of tightness when attempting to move joints after a period of inactivity
• subsides over time
• inflammatory arthritis •present upon waking • typically lasts 30-60 minutes or longer.
• noninflammatory arthritis
•experienced briefly (eg, 15 min) upon waking in the morning
• following periods of inactivity.
Swelling
• inflammatory arthritis•synovial hypertrophy• synovial effusion• inflammation of periarticular structures
• noninflammatory arthritis• formation of osteophytes •synovial cysts•Thickening•effusions
Limitation of motion
• structural damage • Inflammation• contracture of surrounding
soft tissues
Weakness
• result of disuse atrophy
•Weakness with pain •musculoskeletal cause (eg, arthritis, tendonitis) rather than a pure myopathic or neurogenic cause.
Fatigue
• inflammatory polyarthritis•noted in the afternoon or early
evening.
• psychogenic disorders•upon arising in the morning • related to anxiety, muscle tension,
and poor sleep.
Temporal pattern of arthritis
• abrupt or insidious.
• abrupt onset • symptoms develop over minutes to hours• occur in trauma, crystalline synovitis, or
infection.
• insidious pattern• symptoms develop over weeks to months• rheumatoid arthritis (RA) and osteoarthritis.
Duration of symptoms • Acute <6 weeks in duration; • chronic is 6 or more weeks in duration.
• The temporal patterns • migratory• additive or simultaneous• intermittent.
• migratory pattern• inflammation for only a few days in each joint
(eg, acute rheumatic fever, disseminated gonococcal infection).
• additive or simultaneous pattern• inflammation persists in involved joints as new
ones become affected.
• intermittent pattern• episodic involvement occurs, with intervening
periods free of joint symptoms (eg, gout, pseudogout, Lyme arthritis).
Number of involved joints
• Monoarthritis - one joint. • Oligoarthritis - 2-4 joints. • Polyarthritis -5 or more
joints.
•Symmetry of joint involvement
• Symmetric arthritis• involvement of the same joints on each
side of the body. •RA and SLE.
• Asymmetric arthritis •psoriatic arthritis, reactive arthritis
(Reiter syndrome), and Lyme arthritis.
•Distribution of affected joints
• The distal interphalangeal joints of the fingers
• involved in psoriatic arthritis, gout, or osteoarthritis
• spared in RA.
• Joints of the lumbar spine
• involved in ankylosing spondylitis • spared in RA.
• Distinctive types of musculoskeletal involvement
• Spondyloarthropathy• involves entheses, •dactylitis (sausage digits)• tendonitis•back pain (sacroiliitis and vertebral disc
insertions).
• Gout
• involves tendon sheaths and bursae•superficial inflammation.
• Extra-articular manifestations
• Constitutional symptoms –• underlying systemic disorder.• include fatigue, malaise, and weight loss.
• Skin lesions
• SLE, dermatomyositis, scleroderma, Lyme disease, psoriasis, Henoch-Schönlein purpura, and erythema nodosum.
• Ocular symptoms or signs • Episcleritis and scleritis -RA or Wegener
granulomatosis• anterior uveitis - ankylosing spondylitis, • iridocyclitis - juvenile RA• Conjunctivitis -reactive arthritis
• Signs of inflammatory joint disease
• Synovial hypertrophy • most reliable sign• chronic inflammatory arthritis- synovial
membrane has a doughy or boggy consistency.
• Joint effusions • in response to
• synovial inflammation• Trauma• anasarca• intra-articular hemorrhage (hemarthrosis)• sympathetic effusion
• detected by fluid ballottement or cross-fluctuation through the synovial cavity.
• Pain throughout the whole range of motion -
acutely inflamed joint. • Pain as the joint is gently forced (ie,
stressed) towards its limitation of range -synovitis.
• Pain not present throughout the entire range of motion - extra-articular source eg.tendinitis.
Erythema and warmth • Erythema of the joint -acute inflammatory
forms of arthritis, such as gout, septic arthritis, or acute rheumatic fever.
• Warmth of the joint - inflammatory arthritis
•Joint tenderness
• sensitive sign, but not specific for inflammatory arthritides.
• Focal tenderness - focus of inflammation outside the joint, such as tendinitis, osteomyelitis, or fracture.
• Signs of degenerative or mechanical joint disease
• Bony overgrowth of the joints (osteophytes)-• at the distal interphalangeal joints -
Heberden nodes, • at the proximal interphalangeal joints
are called Bouchard nodes.
• Limited range of motion:
• intra-articular loose bodies,• osteophyte formation, or subluxation.
• Crepitus during active or passive range of motion
• Joint deformity:
• Restriction of motion
• malalignment of the articulating bones(eg.ulnar deviation of the fingers)
• alteration in the relationship of the two articulating surfaces, such as subluxation
Acute monoarthritis • Inflammatory
• Septic Arthritis• Gout and Pseudogout• Systemic rheumatic disease
manifesting as monoarticular involvement
• Noninflammatory • Juxta-articular fracture • Trauma • Hemarthrosis • Osteonecrosis
Chronic monoarthritis
Inflammatory • Chronic infectious arthritis • Lyme Disease• Crystalline synovitis • Pauciarticular juvenile rheumatoid arthritis • Systemic rheumatic disease presenting with
monoarticular involvement
Noninflammatory • Osteoarthritis• Ischemic necrosis • Hemarthrosis • Paget disease involving the joint• Stress Fracture• Osteomyelitis• Osteosarcoma • Metastatic tumor • Synovial osteochondromatosis
Acute polyarthritis • Rheumatic fever• Gonococcal Arthritis • Polyarticular gout• Polyarticular pseudogout • Viral arthritis (eg, hepatitis B infection,
parvovirus B-19 infection) • Bacterial endocarditis • Rheumatoid Arthritis • Still disease • Systemic Lupus Erythematosus • Reactive Arthritis • Acute sarcoid arthritis • Mediterranean Fever, Familial• Enteropathic Arthropathies
Chronic polyarthritis • Inflammatory
• Rheumatoid Arthritis • Systemic Lupus Erythematosus • Viral arthritis • Psoriatic Arthritis • Reactive Arthritis • Enteropathic Arthropathies • Behçet Disease • Ankylosing Spondylitis and Undifferentiated
Spondyloarthropathy
• Noninflammatory • Osteoarthritis • Traumatic osteoarthritis• Hemochromatosis • Ochronosis • Hypertrophic pulmonary osteoarthropathy • Amyloidosis • Acromegaly
Screening tests for acute polyarthritis
• Blood cultures • Antistreptolysin O titer • Parvovirus B-19 immunoglobulin G and
immunoglobulin M levels • Hepatitis B serology • ANA • Others : HIV test, a rubella titer, an
angiotensin-converting enzyme level and chest radiograph, and ANCA
Screening tests for chronic polyarthritis • Complete blood cell count • ESR and CRP level • ANAs • Rheumatoid factor and CCP antibody • liver function tests , serum creatinine level • Serum uric acid level • Urinalysis • Others : thyroid-stimulating hormone level,
a serum ferritin level, and an iron saturation of serum transferrin.
Screening tests for diffuse arthralgias and myalgias
• ESR and CRP - inflammatory disease, including
polymyalgia rheumatica
• Creatine kinase and aldolase level - myositis
• Thyroid testing • Chemistry profile (ie, calcium, phosphorus, electrolyte,
glucose, total protein) - metabolic or endocrine disorders
• Others • 25-hydroxy vitamin D level - osteomalacia • sacroiliac joint radiography - ankylosing spondylitis,
especially in woman <45 y with neck, chest wall, and low back pain),
• HLA-B27 - reactive arthritis,• hepatitis B and C serology testing, • serum and urine protein electrophoresis - multiple
myeloma• ANA and rheumatoid factor (if clinical features suggest
RA, SLE, or another connective-tissue disease).
THANK YOU