Post on 17-Dec-2015
transcript
A BASIC APPROACH TO DIAGNOSIS
IN
JOINT DISEASES
IS IT ARTHRITIS OR NOT?
ARTHRITIS OR ARTHRALGIA
AN IDENTIFIABLE
PATHOLOGICAL PROCESS
INVOLVING JOINTS MUST BE
PRESENT
IS IT AN INFLAMMTORY PROCESS
OR
NOT
INFLAMMATION
SYSTEMIC EFFECTS
TARGET ORGAN EFFECTS
• REDNESS
• HEAT
• SWELLING
• PAIN
• LOSS OF FUNCTION
• Soft tissue swelling
• Early morning joint pain and stiffness
INFLAMMATORY >5,000 white cells/ mm³
“NON-INFLAMMATORY” <1,000 white cells/mm³
SYSTEMIC EFFECTS OF INFLAMMATION
1. CLINICALtirednesswt lossfevergrowth retardation
2. LABORATORYacute phase reactants
• Haemoglobin ↓
• White cell count ↑ or normal
• Platelets ↑ or normal
• ESR ↑
CRP (C reactive protein) ↑
Gamma globulins (immunoglobulins) ↑
Albumin ↓
Alkaline phosphatase (ALP) ↑
Iron and TIBC ↓
Ferretin ↑
WHICH INFLAMMATORY JOINT DISEASE?
COMMON MODES of PRESENTATION of
RHEUMATIC DISEASES
SYSTEMIC
POLYARTICULAR
MONO / OLIGOARTICULAR
AXIAL
• ACUTE
• CHRONIC
JOINT FLUID
• White cell count
• Examination for crystals
• Culture and sensitivity
• Multiple pathologies can coexist in the one joint
PATTERN OF JOINT INVOLVEMENT
NON-JOINT MANIFESTATIONS
Pattern of Involvement
• In distribution symmetrical or notsmall or large jointsaxial or peripheralmany, few or single joint
• In time episodicflittingconstantadditive
Associated extra-articular problems
Joints
Skin
Eyes
Lymph nodes – spleen
Lungs
Kidneys
Rheumatoid Factor ≠ Rheumatoid arthritis
ANA ≠ Systemic lupus
HLA B27 ≠ Ankylosing spondylitis
High urate ≠ Gout
HLA B27
• ANKYLOSYNG SPONDYLITIS 90%
• NORMAL POPULATION 9%
BACK PAIN THAT IMPROVES WITH ACTIVITY
CONSIDER THE POSSIBILITY of INFLAMMATORY
SPONDYLARTHROPATHY
Rheumatoid arthritis: hands, advanced deformity
(radiograph)
Klareskog L et al Arthritis Rheumatism 2006
Rheumatoid Arthritis
• Early intervention matters
• Smoking is a risk factor
Hypouricaemic therapy
• Can precipitate gout in the introductory phase of treatment & needs to be covered
• Do not stop because of breakthrough flare
• Treat to target serum urate level
• Multiple pathologies can coexist in the one joint
• REDNESS
• HEAT
• SWELLING
• PAIN
• LOSS OF FUNCTION
Tendinitis
Enthesitis
Fibrositis
DIAGNOSIS
EVALUATION
SYSTEMIC
MONO or OLIGOARTICULAR
Rheumatoid Arthritis
A systemic inflammatory disease of unknown cause, with a particular predilection to involve the synovium
Osteoarthritis
A localised disease of joints, thought to arise as a consequence of cartilage degeneration
POLYARTICULAR
Basics of diagnosis
by G Major