Transcript monoarthritis-polyarthritis powerpoint presentation

Arthritis
from 36,000 feet
An Overview
Paul F. Howard MD, FACP, FACR
Director, Arthritis Health
9097 E. Desert Cove #100
Scottsdale, AZ, 85260
[email protected]
Close Up View =
Individual Diagnoses
Overview from 36,000 ft
Overview
•Impact of Arthritis
–Prevalence
–Economic
–Social
•Clinical Approach to Arthritis
-Monoarthritis
-Polyarthritis
-Gout
•Laboratory Tests
Arthritis - Scope of the Problem
• Increasing Incidence
– Affects ~46 million Americans
• 15% of U.S. population has some form of arthritis or rheumatic
condition
• Estimated to increase to 18.2% by 2020
• Second leading cause of work disability
– Arthritis is a more frequent cause of functional impairment
(activity limitation) than heart disease, cancer or diabetes
– Health-related quality of life measures are consistently
worse for people with arthritis
Escalating Prevalence of Arthritis
60
50
40
Arthritis Prevalence
30
Arthritis Causing Activity
Limitation
20
10
0
1990
2020
This represents
a 57% increase
in 30 years
Economic Impact
Arthritis and musculoskeletal conditions account
for 13% of all health care spending
• 315 million physician visits per year
• 8,000,000 hospitalizations
• 1.5 billion days of restricted activity per year
• #1 most common reason for doctor visits
• #2 most common reason for hospitalization
• #4 most common reason for surgery
Healthy People 2010; Yelin, Callahan. Arthritis Rheum; 38:1351-1362
Economic Impact
Arthritis and other rheumatic conditions
(AORC)
Direct Medical Costs
$ 80.8 billion
Indirect Costs
$ 47.0 billion
Total Costs
$ 127.8 billion
The total cost of arthritis accounts for nearly 38% of all musculoskeletal conditions
Arthritis and Rheumatism 2007;56(5):1397-1407
Work Loss Due to Illness
23%
Musculoskeletal
Upper Respiratory
47%
5%
Headache/Migraines
Lower Respiratory
Upper GI
7%
Cardiovascular
4%
5% 4% 5%
Ob/Gyn
Other
Musculoskeletal Illness is #1 Cause for Loss of Work
Quality of Care Issues
• 40% of US individuals reporting chronic joint
symptoms were not diagnosed by a doctor
• Up to 50 % of those diagnosed are not
receiving treatment
• 30-53% of patients diagnosed with arthritis do
not know what kind they have
MMWR 1998; 47(17):345-350
Cause of Arthritis
• Traumatic
• Mechanical / Degenerative
• Metabolic
------------------------------------------• Infectious
• Inflammatory
• Crystal related
------------------------------------------3 Non Inflammatory
• Malignancy
3 Inflammatory
1 other
Data Collection
and Decision Making
Careful History and Physical Exam will yield the 1st
set of decision in the differential diagnosis
Acute vs Chronic
Articular vs Periarticular
Non inflammatory vs Inflammatory
Cadence/pattern of involvement
Additional - associated findings
Note
- labs or x-rays are not initially required
Onset
• Acute or chronic
– Extremely rapid (seconds to minutes)
• Internal derangement, fracture, trauma, loose body
– Acute onset (several hours to 2 days)
• Typical of most inflammatory arthritis, bacterial
infection or crystal arthritis
– Long standing problems - subacute or chronic
• Acute on chronic problem (flare of OA or RA)
• Second superimposed process (infection)
Localization
What site is involved?
– Joint
– Adjacent bone
– Soft tissue
• Ligaments, tendons, bursae
– Referred pain
• Nerve root impingement - sciatica
• Entrapment neuropathy -carpal tunnel
• Pathology in another joint
– hip arthritis → referred knee pain
– Subacromial Bursitis → referred upper arm pain
You must determine where the pain is coming from !
Character of the Arthritis
Inflammatory vs Mechanical
– Inflammatory
• Waxing and waning disease activity
• >1 hour of morning stiffness
• Improvement with use
• Systemic symptoms (fever or malaise)
– Mechanical
• Pain after use
• Improvement with rest
• No systemic symptoms
Physical Examination
• Isolated vs Multiple Sites
Mono
Oligo (Pauci)
Polyarthritis
• Symmetric / Asymmetric involvement
Pattern of Pain
Cadence and Pattern of Involvment
•Episodic
•Migratory
•Additive
•Progressive
Additional - Associated findings
•Demographic and historical information
•Family history
•Social and travel information
•Physical examination findings
Case #1
20 year old female student (accounting major) at ASU present with
a swollen left knee x 1 day
Ski trip with friends
Woke this am with pain, stiffness and severe swelling left knee
Very stiff for hours this morning.
PMH +UTI 10 days ago treated with AB -x 2 days and symptoms
resolved. Sexually active with new partner on ski trip.
ROS No trauma, rashes, or other pain. + fever, chills, nausea
Meds/Supplements None
Exam T 101.4 BP 132/90 P 124 R 20
Ill appearing, sweating, with swollen left knee
Knee Effusion
Case Example
Building a Differential DX
Data Collection - Decision Making
Careful History and Physical Exam will yield the 1st set of decision in
the differential diagnosis
Acute vs Chronic
Articular vs Periarticular
Non inflammatory vs Inflammatory
Mono, Oligo or Poly(articular)
Cadence: Episodic, Migratory, Additive, Progressive
Additional - associated findings
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Diagnostic Studies
•
•
•
•
•
CBC WBC 15,5000 with left shift
CMP normal
U/A normal
ESR 25 mm/hr
Arthrocentesis - Synovial fluid 58,000 WBC
1000 RBC
• Knee X-ray - no apparent fracture
• Pelvic exam and cultures, GC PCR,
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Septic Arthritis
•
•
•
•
•
First question: to hospitalize or not?
Intense local pain
Resistive to motion
Swelling, heat, redness
Persons at high risk
–
–
–
–
–
Steroid therapy
Immunodeficiency/Immunosuppression
Diabetes
IV drug abuse
Other focus of infection (eg. UTI, pneumonia, etc.)
• Staph aureus = most common
• Ortho Consult
– Repetitive arthrocentesis vs. open drainage in OR
Causes of Septic Arthritis
• Bacterial
– Staph
– Strep
E. Coli
Lyme Disease
Pseudomonas Anaerobes
• Tuberculosis
– TB vs atypical TB
• Fungal
– Coccidiodomycosis (Valley Fever)
– Candida
– Histoplasmosis
Arthrocentesis - Arthrocentesis - Arthrocentesis
Septic Arthritis
Osteopenia
Joint space
Narrowing
Erosions
Dissolution
of joint
Septic Arthritis
Tuberculosis
Case #2
20 year old female student (accounting major) at ASU present with a
swollen right knee x 2 day
Ski trip with friends
Woke this am with pain, stiffness and severe swelling right knee
PMH +UTI 10 days ago treated with AB -x 2 days and symptoms
resolved. Sexually active with new partner on ski trip.
ROS No trauma or other pain. + fever, chills, nausea, rash, am stiff
Meds/Supplements None
Exam T 101.4 BP 132/90 P 124 R 20
Ill appearing, sweating, with swollen right knee
Rash on legs and arms
Knee Effusion
Case Example
Associated Findings
Pustular/
Encrusted
Skin
Lesions
Building a Differential DX
Data Collection - Decision Making
Careful History and Physical Exam will yield the 1st set of decisions
in the differential diagnosis
Acute vs Chronic
Articular vs Periarticular
Non inflammatory vs Inflammatory
Mono, Oligo or Poly(articular)
Cadence: Episodic, Migratory, Additive, Progressive
Additional - associated findings
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Diagnostic Studies
•
•
•
•
•
CBC WBC 15,5000 with left shift
CMP normal
U/A normal
ESR 25 mm/hr
Arthrocentesis - Synovial fluid 15,600 WBC
1000 RBC
• Knee X-ray - no apparent fracture + effusion
• Pelvic Exam – culture and GC PCR -
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Gonococcal Arthritis
Associated Findings
Pustular/
Encrusted
Skin
Lesions
Case #3
20 year old female student (accounting major) at ASU present with a
swollen right knee x 2 day
Ski trip with friends
Woke yesterday am with pain, stiffness and severe swelling right knee
PMH +UTI 10 days ago treated with AB -x 2 days and symptoms
resolved. Sexually active with new partner on ski trip.
ROS No trauma, rashes, or other pain.
Meds/Supplements None
Exam T 98.6 BP 132/90 P 88 R 16
Healthy appearing in obvious distress due to pain and swelling
in the right knee
Knee Effusion
Case Example
Building a Differential DX
Data Collection - Decision Making
Careful History and Physical Exam will yield the 1st set of
decisions in the differential diagnosis
Acute vs Chronic
Articular vs Periarticular
Non inflammatory vs Inflammatory
Mono, Oligo or Poly(articular)
Cadence: Episodic, Migratory, Additive, Progressive
Additional - associated findings
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Diagnostic Studies
•
•
•
•
•
CBC normal
CMP normal
U/A normal
ESR normal
Arthrocentesis - Synovial fluid 1,750,000 RBC
100 WBC
• Knee X-ray - no apparent fracture
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Hemarthrosis
Differential DX
•Trauma
•Infection
•Malignancy
–Lymphoma, sarcoma, PVS
•Metabolic - Bleeding Disorder
–Primary coagulopathy
–Medications
–Platelet disorder
–Malignancy
Case # 4
45 year old female accounting professor at ASU present with a swollen
left knee x 2 day
Ski trip with friends
Woke yesterday am with pain, stiffness and swelling left knee
PMH +UTI 10 days ago treated with AB -x 2 days and symptoms
resolved. + chronic pain in knee, flares x 2 in past three years
related to activity
ROS No trauma, rashes, or other pain. No fever, chills, systemic sympt
Meds/Supplements None
Exam T 98.6 BP 132/90 P 88 R 16
Healthy appearing in obvious distress due to pain and swelling
in the left knee, no increase in warmth of the knee, no tenderness
Knee Effusion
Building a Differential DX
Data Collection - Decision Making
Careful History and Physical Exam will yield the 1st set of decisions
in the differential diagnosis
Acute vs Chronic
Articular vs Periarticular
Non inflammatory vs Inflammatory
Mono, Oligo or Poly(articular)
Cadence: Episodic, Migratory, Additive, Progressive
Additional - associated findings
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Diagnostic Studies
•
•
•
•
•
CBC WBC normal
CMP normal
U/A normal
ESR 5 mm/hr
Arthrocentesis - Synovial fluid
1000 RBC
200 WBC
• Knee X-ray - no apparent fracture
+ joint space narrowing, sclerosis
and spur formation
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Mechanical / Traumatic / Metabolic
• Osteoarthritis
– Most common form of arthritis
– Single or multiple joints
– Asymmetric
– Not inflammatory
– Hands, spine, hip, knee most common sites
Osteoarthritis
Osteoarthritis
Joint space
narrowing
Sclerosis
Osteophytes
Kellgren
Grading
I - IV
Osteoarthritis
Grade IV
Severe
Joint space
Narrowing
Sclerosis
Osteophytosis
Osteoarthritis
Most Common Sites
Spine
Cervical
Lumbar
Thoracic
Hands
Knees
Hips
Feet
Other
Osteoarthritis
Treatment of Osteoarthritis
•
•
•
•
•
•
•
•
Joint Protection
Conditioning around damaged joints
Weight reduction
Analgesics
MSM, Glucosamine
NSAID’s
Bracing
Surgery
Case # 5
45 year old male accounting professor at ASU present with a swollen left
great toe and ankle x 2 days
Ski trip with friends
Woke yesterday am with pain, stiffness and swelling left ankle
PMH Occurred last June after a golf tournament - resolved in 7 days
ROS No trauma, rashes, or other pain. + fever, no chills or systemic
symptoms
Meds/Supplements None
Exam T 98.6 BP 132/90 P 88 R 16
Healthy appearing in obvious distress due to pain and swelling
in the left ankle and great toe (1st MTP)
Building a Differential DX
Data Collection - Decision Making
Careful History and Physical Exam will yield the 1st set of decisions
in the differential diagnosis
Acute vs Chronic
Articular vs Periarticular
Non inflammatory vs Inflammatory
Mono, Oligo or Poly(articular)
Cadence: Episodic, Migratory, Additive, Progressive
Additional - associated findings
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Diagnostic Studies
•
•
•
•
•
•
CBC WBC 13,000 with left shift
CMP normal
U/A normal
ESR 25 mm/hr
Arthrocentesis - refused
Knee X-ray - no apparent fracture
soft tissue swelling about ankle
and great toe
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Podagra =
( most of the time)
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Podagra = gout
( most of the time)
50% 1st episode
90% of all gout
patients over time
will have podagra
Gout
Clinical Presentation
History of recurrent, self-limited (3-10 days) attack
Severe pain and inflammation extending into the local tissue
Abrupt onset of severe joint inflammation often at night
May have hyperuricemia
Monosodium urate crystals - + 95% time arthrocentesis
Podagra is characteristic (75% of cases) but not pathognomonic
Gradually increasing to become polyarticular and chronic (years)
Gout
•Impact of Gouty Arthritis
–Prevalence
–Impact Economic Social
•Clinical Presentations
•Diagnosis
•Treatment - Acute and Long Term Management
Clinical Presentations
• Acute episodic inflammatory arthritis
–Lower extremity - esp great toe 50% 1st episode 90% cases
–Men in middle life - obese, drink regular alcohol
–Women - post menopause, on diuretics, heavy alcohol drinkers
–Upper extremities in chronic tophaceous gout - - esp DIP’s
–Associations with HTN, hypertriglyceridemia, renal insufficiency
–HPRT deficiency, PRPP synthetase overactivity, heritable renal
disease should be suspected in young adults, adolescents or
young adults with gout.
Clinical Presentations
Clinical Presentations
Diagnosis of Gout
Rome Criteria
• Serum urate > 7.0 men , >6.0 women
• Acute onset inflammatory arthritis, resolves 1-2 wk
• Presence of urate crystals in synovial fluid
• Presence of tophi
Gout = Urate Crystals
Needle shaped -pointed
Negatively Birefringent
YUP
yellow - urate - parallel
What Is New in Gout Management
Old
Episodic Arthritis
Focus on Joints
Episodic Tx
No prophylaxsis
New
Chronic Accumulation UA
Focus on Serum Uric Acid
Chronic Uric Acid lowering
6 months prophyaxsis
Colchicine or low dose NSAID’s
Expanded drug options
Treatment - Acute Gout
Goal is to reduce inflammation
Key points
NSAID’s
Steroids
It will improve usually over days -We can help it along
Indomethacin - or any Nsaid in full dose.
Caution in “older patients, or renal insufficiency, HTN, GI Hx
Intraarticular injection
- triamcinalone, methylprednisilone
Intramuscular injection - triamcinalone, methylprednisilone
Oral burst of steroids
- prednisone, methylprednisone
x 3-6 day
Colchicine Not preferred but can use 1.2mg followed by 0.6 mg x1 day
Long Term Management
• seek and correct contributing factors to hyperuricemia
–Regular alcohol intake ( esp beer)
–High purine diet
–Obesity
–Diuretic therapy
–Renal insufficiency
–hypertension
Long term management of Gout
Goal is to reduce uric acid - not prevent gout flares !!!
Begin a uric acid lowering agent - allopurinol or febuxostat
Target level of uric acid < 6.0mg
Ensure hitting target - increase meds as needed
Colchicine prophylaxis 1st six to twelve month
Once started, stay with stable dose of uric acid lowering
agent irrespective of the occasional gout flares
Other Crystal Induced Arthritis
•
•
•
•
•
Pseudogout/CPPD
Calcium Oxylate
Basic Calcium Phosphate
Cholesterol
Steroids - iatrogenic
Calcium Pyrophosphate Crystals
Pseudogout
Rods -blunt
+birefringent
Condrocalcinosis
Case # 6
20 year old female student (accounting major) at ASU present with a
swollen right knee x 2 day
Ski trip with friends
Woke yesterday am with pain, stiffness and severe swelling right knee
PMH +UTI 28 days ago treated with AB -x 2 days and symptoms
resolved. Sexually active with new partner on another ski trip
one month ago.
ROS No trauma, rashes, or other pain. + conjunctivitis one week ago
Meds/Supplements None
Exam T 98.6 BP 132/90 P 88 R 16
Healthy appearing in obvious distress due to pain and swelling
in the right knee which is warm, right eye injected with no
discharge
Knee Effusion
Building a Differential DX
Data Collection - Decision Making
Careful History and Physical Exam will yield the 1st set of decisions
in the differential diagnosis
Acute vs Chronic
Articular vs Periarticular
Non inflammatory vs Inflammatory
Mono, Oligo or Poly(articular)
Cadence: Episodic, Migratory, Additive, Progressive
Additional - associated findings
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Diagnostic Studies
•
•
•
•
•
CBC WBC normal
CMP normal
U/A 2+ WBC, - nitrates, gram stain
ESR 45 mm/hr
Arthrocentesis - Synovial fluid 1000 RBC
20,500 WBC
• Knee X-ray - no apparent fracture
+ effusion
Monoarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
-----------------------------------------• Infectious
• Inflammatory
• Crystal related
-----------------------------------------• Malignancy
Inflammatory Monoarthritis
• Reactive Arthritis (Post infectious)
• Psoriatic Arthritis
• Ankylosing Spondylitis
• Juvenile Inflammatory Arthritis JIA
• Onset of a chronic polyarthritis - ? rheumatoid arthritis
Malignancy
•
•
•
•
Osteosarcoma
Metastatic Tumor
Pigmented Villonodular Synovitis
Rare tumor of cartilage, bone and muscle
Polyarthritis
Differential Diagnosis
• Traumatic
• Mechanical / Degenerative
• Metabolic
--------------------------------------------• Infectious - extremely rare
• Inflammatory
• Crystal related
---------------------------------------------• Malignancy
Metabolic Arthropathy
• Hematologic
– Coagulopathies
– Dialysis Arthropathy
– Hemoglobinopathies
• Endocrine
– Hypothyroidism
– Hyperthyroidism
– Adrenal syndromes
Inflammatory Polyarthritis
• Hypersensitivity - Serum Sickness Arthritis
•
•
•
•
•
•
•
RA
SLE
Sjogren’s Syndrome
Scleroderma
Psoriatic Arthritis
Reiter’s Disease
Vasculitis
Additive Chronic Symmetric Inflammatory
Polyarthritis
Additive Chronic Symmetric Inflammatory
Polyarthritis
Clinical Features
Symmetric inflammatory progressive destructive polyarthritis
Characteristics of RA
Demographics
World wide
Female > male 3:1
Onset - any age
40-50 most common
+ Genetic predilection
Criteria based not laboratory based
RA Criteria ( ACR)
AM stiffness > 1 hour
Three or more joint areas
Symmetric
Involving hands
+RF
Joint erosions
Nodules
ACR 1987
Stages of RA
Early
Courtesy of J. Cush, 2002.
Intermediate
Late
RA Progression
Early RA
Intermediate
Late
Severity (arbitrary units)
Inflammation
Disability
Radiographs
© ACR
0
5
10
15
20
Duration of Disease (years)
Graph: Adapted from Kirwan JR. J Rheumatol. 2001;28:881-886.
Photo: Copyright © American College of Rheumatology.
25
30
Treatment and Outcomes of RA
Aggressive control of inflammation
NSAID’s -- Steroids -- Synthetic DMARD’s -- Biologic
DMARD’s
Historically
RA results in inexorable chronic pain
Erosions begin within months and progressive destructive
erosive change in multiple joints
Within 10 years, nearly 50% disabled -- reduce QOL
7-10 year reduced life expectance
Today, 80% of RA is able to be arrested =
Arresting disease symptoms - joint damage - disability = Higher
QOL
Sjogren’s Syndrome
• Second most common autoimmune arthritis - 0.5% of pop
• Immunologic disorder of B Cells
–
–
–
–
Dry Eyes and Mouth
Polyarthritis - non erosive
Adenopathy and Glandular Hypertrophy
Multisystem lymphocytic infiltration
– Women predominate 9:1 Onset 30-50 years old
– progressive but treatable and controllable
– MUST BE RECOGNIZED - THIS CONDITION IS OFTEN NOT
CONSIDERED IN A DIF DX OF JOINT PAIN.
Features of Sjogren’s Syndrome
Systemic Lupus Erythematosus
Multisystem autoimmune disorder with immune complexes
Rashes
Polyarthritis - non deforming
Glomerulonephritis
Pleuropericarditis
Central Nervous System
Hematologic - low WBC, RBC, Platelets
Serologic
ACR SLE Criteria 4 of 11 findings needed
Systemic Lupus Erythematosus
Malar Rash
Sun sensitivity
Discoid Lupus
Oral ulcers
Non deforming
polyarthritis
Renal disease
Pericarditis Pleurisy
Neurologic
Hematologic Low counts
+ ANA
+ dsDNA, low C3/C4
+ SM Ab
Demographics of SLE
Worldwide distribution
Female > male 9:1
Age most common 13 - 30
Younger = more renal disease
Darker skin races have greater prevalence
+ genetic links Population studies, twins
Treatments for SLE
• Treatment is directed toward reducing inflammation to
prevent damage
•
•
•
•
•
NSAID’s
Antimalarial agents
Steroids
Cytotoxic - MTX, Myophenylate , Cyclophosphamide
Anti B cell tx - Rituximab
Treatments have resulted reduced mortality - 50% to <5%
Scleroderma
Scleroderma
Systemic disorder of fibrosis of skin and multiple
organs
Joint - symmetric inflammatory polyarthritis
Skin - sclerodactyl - scleroderma - telangectasia
Lungs - interstitial fibrosis
GI
- esophageal dysmotility
Renal - afferent arteriole fibrosis - HTN - renal crisis
Neuro - neuropathies
Psoriatic Arthritis
Psoriatic Arthritis
• Skin and/or nail involvement
•
•
•
•
•
Oligoarthritis
Classic - DIP
Polyarthritis
Arthritis Mutilans
Spondyloarthropathy
Arthritis Type?
Reactive Arthritis
Asymmetric oligo-polyarthritis
Rash - lesions on hands, feet, penis
Urethritis
Iritis
Outcome - 50% remission 25% episodic 25% chronic
Cause -- Post infectious
– Urethritis - Chlamydia
– Dysentery - bacterial
Ankylosing Spondylitis
• Inflammatory Spinal Involvement - SI joints start
• Progressive Fusion
• Common peripheral joint involvement
• Male 3:1
• + HLA B 27 90%
• Treat stepwise and aggressively to control
inflammation and preserve function
Laboratory Tests
ESR / CRP
RF Anti CCP Antibodies
ANA
Anti Ds DNA
Anti SM and RNP
Anti Ro (SSA) and Anti La (SSB)
Anti Centromere
Anti SCL 70
P and C ANCA
ESR CRP
•Both tests are Acute Phase Reactants
•Reflect ongoing inflammation
•Monitoring levels helps to assess inflammatory disease activity
•FACTORS - INCREASE ACUTE PHASE REACTANTS
Infections
Trauma
Malignancy
Inflammmatory rheumatic diseases
Reactions to medications
ESR
• ESR “sed rate” of RBC’s in glass column
• RBC’s are held in suspension by their negative surface charge
from Sialic adic residues.
• Indirect measure of positively charged proteins between the
RBC’s
fibrinogen dominant protein
haptoglobin, alpha 1 antitrypsin, aerum amyloid protein, Ig M
IgG, ceruloplasm,
• Greater the agglutination or RBC’s , the faster the rate of descent
• Normal < 20 mm/hr
Affected by Age, testing procedures, anemia
ESR- CRP
CRP
• Measurement of a single acute phase reactant
• Can rise > 100 x baseline level in certain inflammatory conditions
• Not affected by age, other acute phase reactants
-------------------------------------------------------------------------------------------------------------ESR
CRP
Affected by other factors
Isolated value
Half Life
10 days
2 days
Normal Values
Wide Range
Narrow Range
20-48 mm/hr
0.2-1.0mg/dl
Cost
$3
$35
Clinical knowledge of the patient is more important than any
laboratory test result
ESR - CRP
Discrepancies between ESR and CRP occur commonly especially in
• SLE and Sjogren’s Syndrome
• Waldenstrom’s macroglobulinemia
• Hypergammaglobulinemic purpura
ESR high - CRP low
Which one is “correct”?
These conditions all share high levels of agglutinating properties of
IgG or IgM when found in excessively high levels or participate in
high levels of immune complexes.
RF and anti-CCP
RHEUMATOID FACTORS
Traditionally, autoantibodies directed against the FC fragment of IgG
All classes Ig produced a the synovium
IgM and IgA detected in the serum
All tests that measure it rely on agglutination of IgG covered particles
Tests reported as a titer - 1:2 1:80
OD <10 12
1:320
25
……….
RF - anti CCP
Rheumatoid Factor
• Sensitivity
70-80% in fully established disease
less earlier on in disease ( + 30-40%)
may appear several years before disease develops
• Specificity 60-80%
many other conditions SjS, MCTD, SLE, JIA, Sarcoid
chronic infections (hepatitis B and C , SBE, TB)
RF - anti CCP
Anti CCP antibodies
• Autoantibodies directed to the citrullinated parts of proteins
result of diimination fo arginine residues during inflammation
induced apoptosis
Sensitivity
Early RA 50% to 85% in established disease
25% positive in sero -RF patients
Predicts erosive disease in sero - RF polyarthritis
Specificity
95% in many studies, recently questioned in AIM 2010
Can help to differential between future erosive disease
RF and anti CCP
Key point
RF and anti CCP do not make the diagnosis of rheumatoid arthritis
Higher the titer or level - more sensitive and specific
Higher the titer ----------- harder it is to ignore in the face of clinical
setting
Predicts --
EROSIVE , DESTRUCTIVE DISEASE
ANA
ANTI NUCLEAR ANTIBODIES
ANA found in many autoimmune disorders
SLE
MCTD
Sjogrens
Drug induced SLE
Scleroderma
RA
JIA - Pauci
Polymyositis
Discoid lupus
%
97
100
60-90
90
60-80
50
70
60
15
ANA
ANTI NUCLEAR ANTIBODIES
Sensitivity
%
Ds DNA
Anti-Ro
SLE
Renal
SjS
SLE
SCLE
Neonatal Lupus
Anti-La
SjS
SLE
RNP
correlates with active disease
with anti Ro/La - low renal involvment
MCTD
SLE
Sm (Smith) SLE
50
40-60
40-60
100
100
20
20
100
40
highly specific
20
ANA and other Labs Test
Sensitivity
%
Anti Centromere
SCL-70
ANCA
p ANCA
c ANCA
C3/C4
CREST
Scleroderma
Scleroderma
high specificity
high specificity
proteinase 3
Wegener’ granulomatosis
myeloperoxidase microscopic polyangiitis
Necrotizing GN
60
Drug induced Lupus
SLE
inverse association renal
80
20
30
85
60
90
Take Home about Labs
Lab test are for
Diagnosis
Assessment of disease activity
Prognosis
Try not to confuse the meaning of the test results
Remember - when in doubt -- lab tests are always trumped by
The patient
Overview from 36,000 ft
Conclusions
Properly identify classification of arthritis
prognosis, treatment
Aggressive management to reduce inflammation reduces risk
for permanent joint damage
Drugs are not the only answer !
Proper DX, and then diet, supplements, exercise,
preventive measures along with proper use of medications
results in optimal control of arthritis
Conclusions
Properly identify classification of arthritis
prognosis, treatment
Aggressive management to reduce inflammation reduces risk
for permanent joint damage
Drugs are not the only answer !
Proper DX, and then diet, supplements, exercise,
preventive measures along with proper use of medications
results in optimal control of arthritis