Transcript Differential diagnosis of polyarthalgia/polyarthritis

Rheumatology teaching
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Pilot 4 sessions
Consultant Rheumatologist/student presentation
Based on Phase II objectives
Polyarthritis, Monoarthritis, Back pain, Softtissue disorders
Ward 2 Rheumatology
Approach to Polyarthralgia
Dr Jaya Ravindran
Consultant Rheumatologist
UHCW
Approach to Polyarthralgia
Aims
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Differential diagnosis of
polyarthralgia/polyarthritis
Investigations
What conditions present with
polyarthalgia?
Differential diagnosis of polyarthalgia/polyarthritis
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‘Poly` > 4 joint
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Rheumatoid arthritis
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Polyarticular OA
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Sero-ve Spondyloarthropathy (eg psoriatic, reactive)
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Polyarticular crystal arthropathy
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Multi-organ disease – CTD and vasculitis
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Viral arthritis (eg parvovirus, rubella, hepatitis)
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(Polymyalgia rheumatica/GCA)
Differential diagnosis of polyarthalgia/polyarthritis
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‘Poly` > 4 joints
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Medical conditions
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thyroid disease / hyperparathyroidism / osteomalacia
diabetic cheiroarthropathy
paraneoplastic syndromes, multiple myeloma
infective endocarditis
sarcoidosis
Fibromyalgia
Age and sex Incidence
AGE
FEMALE
MALE
Young adults
RA
SLE
Reactive arthritis
(Sero-ve)
Middle age
Old age
Psoriatic arthritis
(Sero-ve)
RA
OA
RA
Gout
OA
PMR
Crystal arthritis
What clues are there to
diagnosis?
CLUES
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Prodromal event eg GI/GU infection
Associated conditions eg psoriasis, colitis,
iritis
Inflammatory or mechanical*
Pattern of joint and symmetry eg RA vs
PsA vs OA*
Multi-organ disease*
Fibromyalgia symptoms*
How do you differentiate
between mechanical and
inflammatory symptoms?
Mechanical vs Inflammatory
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Inflammatory
Mechanical
Immobility stiffness
latter day
EMS>30-60 mins
EMS<30-60 mins
Better with activity and NSAIDs worse with
activity
Joint swelling,erythema,heat
instability
Systemic symptoms
locking
Multi-organ involvement
trauma, strain
overusage
 Pattern
and Symmetry?
Pattern and symmetry
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RA - PIP, MCP, wrists, elbows, shoulders,
neck, knee, ankle, MTP, symmetrical
Sero-ve – DIP, asymmetrical, dactylitis,
enthesitis, spinal
OA – DIP, PIP, CMC, ACJ
Weight bearing joints
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Sero-ve Spondyloarthritis –
psoriatic arthritis
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DIP, poly, dactylitis,
enthesitis, spinal
Osteoarthritis
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Mechanical symptoms
Bony swelling,
crepitus
DIP (Heberden), PIP
(Bouchard), 1st CMCJ,
neck, lower back,
hips, knees, 1st MTP
Polyarticular crystal eg gout
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Chronic
Tophi
Erosions
Fibromyalgia
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“All over pain”
Fatigue
Sleep disturbance
Depression
Anxiety
Irritable bowel
Tender spots
Diagnosis of exclusion
What are CTD and what
symptoms and signs are seen?
Connective tissue disease
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Eg SLE, scleroderma, polymyositis,
Sjogren’s
Auto-immune
Multi-organ
Anti-nuclear antibodies
Connective tissue disease
symptoms
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Photosensitive rashes
Skin tightness
Raynauds – late onset,
trophic changes
Mouth ulcers
Connective tissue disease
symptoms
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Dry eyes and mouth
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Arthralgias, arthritis – non deforming
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Proximal myopathy – pain and weakness
(PMR pain and stiffness – think also GCA)
Connective tissue disease
symptoms
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Swallowing
Serositis/ILD – pleurisy,
dyspnoea, cough
RENAL DISEASE – silent,
URINE DIP + BP
Systemic - fatigue, fever,
weight loss
Connective tissue disease
symptoms
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Vasculitis – petechial,
purpura, ulcer
What are the vasculitides and
what type of symptoms and
signs?
Vasculitis
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Small, medium, large vessel
Eg MPA, Churg Strauss, PAN, Wegeners,
GCA
ANCA
Vasculitis
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Systemic, vasculitic ulcers/rashes,
arthralgias/arthritis – non deforming
ENT - sinusitis
Pulmonary – haemoptysis, late onset
asthma
Cardiac failure
RENAL – URINE DIP + BP
Neuropathy eg footdrop
PMR and GCA features?
Polymyalgia rheumatica and GCA
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Over 50’s
Proximal inflammatory
pain and stiffness
GCA – large vessel arteritis
Temporal headache, jaw
claudication visual
disturbance, systemic
upset
Raised ESR and CRP –
urgent steroids
TA biopsy
Investigations
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Inflammatory arthritis – RA
FBC, ESR, CRP, U+E, LFT, RF, XR Hands and feet
? CTD/vasculitis - ANA, ENA, RF, DNA binding,
ANCA, complement
Urine dip and BP
Organ based investigations
Diffuse symptoms – CK, Ca, ALP, TFT
Viral – Parvovirus, LFT+Hepatitis
What other conditions present
with elevated RF?
Rheumatoid factor
Infection: Acute infection eg infectious mononucleosis; Chronic
infection eg SBE, TB; Parasitic eg malaria; vaccination
Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic active
hepatitis, cryoglobulinaemia
Malignancy: Lymphoma, leukaemia, myeloma, solid tumours
5% healthy population
RF <15 not significant unless associated with appropriate clinical
scenario
What are the ANA and ENA?
ANA and ENA
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ANA 1/40 not significant unless associated with
appropriate clinical scenario
Also in RA, cirrhosis, ai liver disease, neoplasia,
healthy population
ENA – extractable nuclear antigens
Anti-Ro and anti-La - Sjogrens
Scl 70 and anti-centromere – Scleroderma
Anti-RNP – mixed CTD
Anti-Jo1 - myositis
What is ANCA ?
ANCA
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Antibodies vs specific antigens in
cytoplasm of neutrophils
ANCA reactive to myeloperoxidase (MPO)
– perinuclear pattern of staining P-ANCA
eg microscopic polyarteritis
ANCA reactive to proteinase 3 (PR3) –
cytoplasmic pattern of staining C-ANCA eg
Wegener’s granulomatosis
What are the radiological
feature of OA, RA (and PsA) ?
Radiology - OA
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Four cardinal
features:
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Joint space narrowing
Sclerosis
Subchondral cysts
Osteophytes
Radiology - RA
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soft tissue swelling
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juxta-articular osteoporosis
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juxta-articular and subchondral
erosions
joint space narrowing &
subluxation
secondary OA & bony ankylosis
Radiology - PsA
Erosion
 Osteolysis
 Bone
proliferation
 Ankylosis
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Thank-you