Transcript Definitions,Causes,History,Examination,Investigation,Conclusion

This lecture was conducted during the Nephrology Unit Grand
Ground by Medical Student under Nephrology Division under
the supervision and administration of Prof. Jamal Al Wakeel,
Head of Nephrology Unit, Department of Medicine and Dr.
Abdulkareem Al Suwaida, Chairman of Department of
Medicine and Nephrology Consultant. Nephrology Division is
not responsible for the content of the presentation for it is
intended for learning and /or education purpose only.
Arthritis
Mono vs. Poly
Presented By:
Ali Al-blowi
Medical Student
Defenitions
Causes
History
Examination
Investigation
Conclusion
Definitions
Arthritis = inflammation of a joint.
Inflammation = Joint pain, stiffness, tenderness,
redness, hotness, swelling & limited movement.
Mono arthritis = one joint affected.
Poly arthritis > 4 joints affected.
Oligo/pausi-arthritis = 2-4 joints affected.
Acute = < 6 weeks
Chronic = > 6 weeks
Symptoms:
Articular symptoms
Non articular symptoms
Causes
Monoarthritis mimickers:
• Common inflammatory processes occur in the
soft tissues around joints:

Tendonitis of the shoulder.

Olecranon bursitis of the elbow.

Prepatellar bursitis of the knee.
Diseases Causing Monoarticutar
Symptoms:
A) Septic
• Bacterial
• Mycobocterial
• Lyme disease
• Fungal
B) Traumatic
• Fracture
• Internal derangement
• Hemarthrosis
C) Crystal deposition dis
 Gout
Osteoarthritis
 CPPD
 Hydroxyapatite DD
 Calcium oxalate DD
 Palindromic rheumatism
D) Others
 Juvenile RA
 (Pseudogout)
 Avascular N
 Foreign-body S
 Pigmented
villonodular syno.
 Synovioma
 Coagulopathy
Polyarticular diseases occasionally
present with a monoarticular onset?
• Rheumatoid arthritis
• Reiter's syndrome/reactive arthritis
• Juvenile rheumatoid arthritis
• Psoriatic arthritis
• Viral arthritis
• Enteropathic arthritis
• Sarcoid arthritis
• Whipple's disease
The most likely causes of chronic monoarthritis
(inflammation within a single joint for > 6 weeks).
INFLAMMATORY
NON-INFLAMMATORY
Inflammatory synovial fluid
Mycobacterial infection
Fungal infection
Lyme arthritis
Monoarticular presentation
of RA
Seronegauve
spondyloarthropathies
Sarcoid arthritis
Foreign-body synovitis
Structural abnormality
Internal derangement
Osteoarthritis
Internal derangement of the
knee
Avascular necrosis of bone
Pigmented villonodular
synovitis
Synovioma
Causes of acute
polyarthritis:
Infection
Other Inflammatory
Gonococcal
Meningococcal
RA
Polyarticular and syst
JRA
Polyarticular gout
SLE
Reiter's syndrome
Psoriatic arthritis
Sarcoid arthritis
Lyme arthritis
Acute rheumatic fever
Bacterial endocarditis
Viral (rubella, H BV &
HCV, EBV& HIV)
Causes of chronic polyarthritis:
INFLAMMATORY
• RA
• Enteropathic arth
• Polyarticular JRA
• SLE * SSc
• CPPD, Polyarticular gout
• Polymyositis
• Sarcoid arthritis
• Reiter's syndrome
• Vasculitis
• Psoriatic arthritis
• Polymyalgia Rh.
NON-INFLAMMATORY
 OA
 Paget's disease
 CPPD
 Fibromyalgia
 Benign hypermobility
syndrome
 Polyarticular gout
 Hemochromatosis
Rheumatologic emergency
• Acute monoarthritis = the joint is infected
until proven otherwise.
• The septic joint must be diagnosed quickly
and managed aggressively to avoid
permanent structural damage.
History
History taking from a patient with
monoarthritis
1. Onset of pain: sudden, in seconds or minutes?
(Consider fracture and internal derangement).
2. Over several hours or 1-2 days? (Consider
infection, crystal deposition diseases,
inflammatory arthritis and palindromic
rheumatism).
3. Insidiously over days to weeks? (Consider indolent
infections, such as mycobacteria and fungi,
osteoarthritis, tumor, and infiltrative diseases).
4. Overused or damaged joint, either recently
or in the past? (Consider traumatic causes).
5. History of IV drug abuse? Recent infection of
any kind? (Consider septic arthritis).
6. Previous acute attacks of joint pain and
swelling that resolved spontaneously?
(Consider crystal deposition and other
inflammatory arthritis).
7. Treatment with a prolonged course of
corticosteroids? (Consider infection or
osteonecrosis of bone).
8. Associated skin rash, low-back pain,
diarrhea, urethral discharge, conjunctivitis,
or mouth sores? (Consider Reiter's
syndrome, psoriatic, or enteropathic
arthritis).
9. History of a bleeding diathesis? treatment
with anticoagulants? (Consider
hemarthrosis).
Is the age of the patient useful in
the differential diagnosis?
I- In children, consider:
• Congenital dysplasia of the hip.
• Slipped femoral epiphysism.
• Monoarticular presentation of JRA.
• Children are unlikely to have GOUT.
II- In young adults, consider:
•
•
•
•
•
Seronegative spondyloarthropathy.
RA.
Internal derangement of the joint.
They are less likely to have GOUT.
A septic- joint is often due to gonococcal
infection.
III- Older adults :
•
•
•
•
•
Crystalline arthritis.
OA.
Osteonecrosis.
Internal derangement of the joint.
A septic joint in these individuals is less likely
due to gonococcal organisms.
• What are the most likely diagnoses in
hospitalized patients with acute
monoarthritis?
• Acute monoarthritis:
* Pyogenic infection
* Acute crystal deposition diseases
• Risk factors known to provoke gout or
pseudogout:
trauma, surgery, hemorrhage, infection
or medical stress such as:
CRF, MI & CVS.
Polyarthritis
• Pains differ:
Polyarthritis = inflammation (swelling,
tenderness, warmth) of > 4 joints by
examination.
Polyarthralgia = pain in > 4 joints without
demonstrable inflammation; eg: SLE, systemic
sclerosis, vasculitis, polymyalgia rheumatica,
and chronic non-inflammatory.
Diffuse aches and pains are poorly localized
symptoms originating in joints, bones, muscles,
or other soft tissues. Polymyalgia rheumatica,
fibromyalgia, polymyositis, and hypothyroidism.
Sequence of joint involvement:
1- Migratory (fleeting) polyarthritis: Symptoms
disappear in the affected joints to reappear in others.
Ex.: ARF, Gonococcal, Viral, early phase of Lyme.
2- Additive: Symptoms persist with addition of new joint
inflammation Ex.: RA, SLE.
3- Intermittent: Attacks of remissions & exacerbations in
the same joint. Ex.:
Gout, sarcoid arthritis, Reiter's syndrome
and psoriatic.
What are the most likely diagnoses in
women aged 25-50 who present with
chronic polyarticular symptoms?
 OA.
 RA.
 SLE.
 Fibromyalgia.
 Benign hypemobility syndrome.
What are the most likely diagnoses in
men aged 25-50 who present with chronic
oligoarticular or polyarticular symptoms?
 Gonococcal arthritis.
 Reiter Syndrome.
 Ankylosing Spondylitis.
 OA.
 Hemochromatosis.
And in patients over age 50 presenting
with chronic polyarticular symptoms?
 OA.
 RA.
 CPPD disease.
 Polymyalgia rheumatica.
 Paraneoplastic polyarthritis.
Distribution of Joint Involvement
Ex.
Ex.
Ex.
Symmetrical
Asymmetrical
RA
SLE
Reiter
PA
AS
Axial
Peripheral
AS
PA (70% also affects IPJ--- sausage digits)
Reiter
RA
SLE
Large
Small
Seronegative
Reiter
ARF
RA
SLE
JOINTS COMMONLY
INVOLVED
DISEASE
JOINTS COMMONLY
SPARED
Gonococcal arthritis
Knee, wrist, ankle, hand IP
Axial
Lyme arthritis
Knee, shoulder, wrist, elbow
Axial
Rheumatoid arthritis
Wrist, MCP, PIP, elbow, glenohumeral, cervical spine, hip,
knee, ankle, tarsal, MTP
DIP, thoracolumbar spine
OA
First CMC, DIP, PIP, cervical spine, thoraco-lumbar spine,
hip, knee, first MTP, toe IP
MCP, wrist, elbow, shoulder,
ankle, tarsal
Reiter's syndrome
Knee, ankle, tarsal. MTP, toe IP, elbow, axial
Psoriatic arthritis
Knee, ankle, MTP. toe IP, wrist. MCP, hand IP. axial
Enteropathic arthritis
Knee, ankle, elbow, shoulder, MCP, PIP, wrist, axial
Polyarticular gout
First MTP, instep, heel, ankle, knee
Axial
CPPD disease
Knee, wrist, shoulder, ankle, MCP, hand IP, hip, elbow
Axial
Sarcoid arthritis
Ankle, knee
Axial
Heroochromatosis
MCP, wrist, knee, Hip, feet, shoulder
Extra-articular Organ Involvement:
•ARF
Ht, pleura
•Viral A.
Liver
•SBE
Ht valves & kidney
•RA
Lung, pl., ht.
•SLE
Lung, pl., ht., kidney, CNS
•Scleroderma
Lung, pl., ht., kid., GI., Liver
•PM/DM
Lung, pl., ht.
•Reiter
Valves, GI.
•Enteropathic A: GI., Liver
•Gout
Kidney
•Sarcoid A:
Lung, Liver
•Vasculitis
Lung, Kidney
• Hemochromatosis:
Ht, liver, Pnc
Morning stiffness
Morning stiffness = time it takes for patients
with polyarthritis to move after arising in the
morning, or after rest.
Site: Affecting hands in RA & back in AS.
Inflammatory arthritis, morning stiffness
lasts > I hour & tends to parallel the activity.
Non-inflammatory, eg. OA, ---MS < 15
minutes.
Examination
Is Fever a useful sign?
•
•
•
•
•
•
Misleading !!
Infectious arthritis.
Acute attacks of gout and CPPD disease.
RA, juvenile RA.
Sarcoidosis.
Reiter's syndrome.
• Skin
– Nodules: RA, gout tophi
– Rash: psoriasis, lupus, Still’s, viral etc
• Inability to bear weight
– Sepsis
– Fracture
– Crystal arthritis
– Neurologic
• Signs of inflammation
– Synovitis (soft tissue swelling)
– Local heat
– Effusion
• Range of motion
–  Active, N Passive: soft tissue eg bursitis, tendinitis,
muscle
–  Active,  Passive: contracture, synovitis, structural
abnormality
Investigations
Monoarthritis
• Synovial fluid analysis.:
Most useful diagnostic study in the
initial evaluation of monoarthritis
Almost always indicated
1. Radiograph of the joint: may reveal:
• Normal, OR unsuspected fracture,
• Osteonecrosis, OA, or
• Juxta-articular bone tumor.
• Chondrocalcinosis, a radiologic feature of CPPD
• Chronic fungal or mycobacterial infection.
• Contralateral joint radiograph for comparison.
2. Complete blood count.
•
Leukocytosis + possibility of inf.
Indicated in selected patients
1. Cultures of blood, urine:
Mandatory in septic joint.
2. PT & PTT: when anticoagulation or coagulation
disorder is suspected.
3. ESR, CRP: nonspecific;
significant elevation = inflammation.
Ask for further investigations in
chronic cases:
4. Radiograph of sacroiliac joints:
asymptomatic sacroiliitis in young males
(spondyloarthropathy).
5) Chest radiograph:
pulmonary TB or sarcoidosis.
6) Tuberculin test:
negative test in excluding TB?.
7) Serologic tests: Lyme disease (Borrelia
burgdorferi), RF, ANA, and HLA-B27.
Polyarthritis
• X-ray
•
•
•
•
•
•
•
•
Laboratory testing
CBC
Serum uric acid
THS
Iron studies
Liver enzymes
Serum creatinine
Urinalysis
• ESR
• ANA
• RF
• HLA-B27 antigen
• Synovial fluid analysis
Conclusion
1.Acute monoarthritis = joint aspiration to
exclude septic & crystal- induced arthritis.
2.Chronic monoarthritis > 6 weeks of
unknown cause needs synovial biopsy.
3.Gout does not occur in premenopausal
females or in joints close to spine.
Take your time for final
diagnosis!
• Because many chronic polyarticular diseases require
months or years to diagnose, patience is often
required.
• Many diseases present insidiously with few
objective findings for prolonged times.
• Many diseases initially represent others before
finally take their usual pattern.
• RA, for example, can present as a monoarthritis
before assuming its more typical polyarticular
course.
Take your time for final diagnosis!
(cont.)
• Characteristic laboratory abnormalities may
require months or years to develop.
• The joint symptoms precede the extraarticular features by months or years.
• Joint radiographs may not show
characteristic changes of the arthritis for
months or years.
Not all pts. with +ve RF=RA, nor +ve. ANA = SLE .
Remember nothing is 100%
1
Musculoskeletal complaint
History & Examination?
Articular or non•
Acute or chr.•
Inflammatory or non.•
Number & distribution•
Articular?
Non articular
Fibromyalgia R
Hypermobility S
Acute or Chronic ?
Acute<6 W.
Acute arthritis:
Infectious•
Crystal-induced•
Reiter’s•
Presentation of Chr. Arth.•
Chronic>6W.
Inflammatory or non-infl.
2
Inflammatory or non-inflam.
Chronic non-inflammatory
arthritis
Affects Wt. Br. J.
(H & k), DIP, CMC
Chronic inflammatory arthritis=
MS>1hr, synovial swelling,
warm, tender Joint, +syst.
manifes., CRP, ESR
1=mono,
2-4=oligo
arthritis:
PA- RS- PJA
>4 J = polyarthritis
Symetrical
_
+
OA
Osteonecrosis
Charcot arthritis
PA, RS
PIP, MCP, MTP
SLE, SSc, PM
+
RA
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