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Approach To Arthritis
T.P. Sudha Rao, MD McGuire VA Medical CenterRichmond, VA
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Objectives
• Evaluation of joint pain• Diagnostic studies• Differential diagnosis
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History
• Onset• Localization of pain• Character of pain• Morning stiffness• Weakness• Other
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Review of Systems
• Pertinent to CTD
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Malar rash
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Discoid rash
2
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Heliotrope
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Gottrons papules
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Small vessel vasculitis
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Psoriasis with nail changes
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Alopecia aerata
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Episcleritis
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Barium swallow showing achalasia
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Chest x-ray with interstitial lung disease
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Raynauds phenomena
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SLE: Nervous System Disorders
• Seizures• Headache• Stroke syndromes• Transverse myelitis• Coma• Demetia
• Ataxia• Rigidity, tremor• Chorea• Aseptic meningitis• Psychiatric disorders
ACR
17
Diagnostic Tests
• Blood work• Urinalysis• Radiography• Synovial fluid analysis
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Rheumatoid Factors
ACR
4
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Diseases Associated With Positive RF
• Rheumatic diseases• Acute viral infections• Parasite infections• Chronic inflammatory diseases• Hyperglobulinemic states
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ANA Pattern and Disease
• Homogeneous– SLE, DLE, SJOGRENS, PSS
• Speckled– MCTD, SLE, PSS, SJOGRENS
• Nucleolar– SLE, PSS, SJOGRENS
• Rim– SLE
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ANA Patterns, upper right: homogenous, lower right: nucleolar, lower left: speckled, upper left: rim pattern
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X-ray of knees: OA
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X-ray of knees: RA
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Synovial Effusions: Classification
<200(<25% PMNs)
Clear, ColorlessViscous
Normal
Leukocytes/mm3Special FeaturesType of Fluid
>80,000(75% PMNs)
PurulentGlucose very low
Septic
2,000-100,000(>50% PMNs)
Cloudy, Yellow,Watery, Glucose may be low
Inflammatory
200-2,000(<25% PMNs)
Clear, YellowViscous
Noninflammatory
ACR
5
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Monosodium urate crystals in PMN
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Urate crystals, negative birefringence
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CPPD crystals
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Differential Diagnosis
• Inflammatory monoarthritis• Inflammatory polyarthritis• Inflammatory spondyloarthritis• Degenerative arthritis
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Acute Monoarthritis: Selected Causes
• Noninflammatory– Trauma– Sickle Cell disease– Osteonecrosis
• Inflammatory– Crystals– Bacteria– Spondyloarthropathies– Palindromic rheumatism– Rheumatoid arthritis– Juvenile chronic arthritis
ACR 30
Differential Diagnosis Of Inflammatory Polyarthritis
• Rheumatoid arthritis• SLE• MCTD• Crystal induced arthritis• Polymyalgia rheumatica
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Differential Diagnosis Of Spondyloarthritis
• Ankylosing spondylitis• Reiters syndrome• Psoriatic arthritis• Inflammatory bowel disease
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Hand RA, has swelling of wrists, MCPs and PIPs, which is symmetric.
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Hand OA, swelling of 2nd and 4th PIPs on both hands, Heberdens nodes on the 2nd, 3rd, 4th
DIPs on the right, and 4th DIP on the left.
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Erosive OA of hands, changes involve several PIPs and DIPs, no MCP involvement.
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Gout, involvement of several hand joints with tophi, can look like Rheumatoid arthritis.
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Psoriatic arthritis, inflammation of the DIP with nail changes.
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Hand x-ray, early RA, periarticularosteopenia of the wrists and MCPs.
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Hand x-ray, OA, joint space narrowing of 1st
carpo metacarpal joint, 2nd and 3rd MCPs, several PIPs and DIPs, with osteophyteformation of PIPs and DIPs.
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Systemic vasculitis, hand findings: periungual and subungual petecheallesions.
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Hypersensitivity vasculitis of hands, purpuric lesions over the fingers.
