Approach To Arthritis - Virginia Commonwealth University · Approach To Arthritis ... Diseases Associated With Positive RF • Rheumatic diseases ... Hand RA, has swelling of wrists,

1

1

Approach To Arthritis

T.P. Sudha Rao, MD McGuire VA Medical CenterRichmond, VA

2

Objectives

• Evaluation of joint pain• Diagnostic studies• Differential diagnosis

3

History

• Onset• Localization of pain• Character of pain• Morning stiffness• Weakness• Other

4

Review of Systems

• Pertinent to CTD

5

Malar rash

6

Discoid rash

2

7

Heliotrope

8

Gottrons papules

9

Small vessel vasculitis

10

Psoriasis with nail changes

11

Alopecia aerata

12

Episcleritis

3

13

Barium swallow showing achalasia

14

Chest x-ray with interstitial lung disease

15

Raynauds phenomena

16

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

18

Rheumatoid Factors

ACR

4

19

Diseases Associated With Positive RF

• Rheumatic diseases• Acute viral infections• Parasite infections• Chronic inflammatory diseases• Hyperglobulinemic states

20

ANA Pattern and Disease

• Homogeneous– SLE, DLE, SJOGRENS, PSS

• Speckled– MCTD, SLE, PSS, SJOGRENS

• Nucleolar– SLE, PSS, SJOGRENS

• Rim– SLE

21

ANA Patterns, upper right: homogenous, lower right: nucleolar, lower left: speckled, upper left: rim pattern

22

X-ray of knees: OA

23

X-ray of knees: RA

24

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

25

Monosodium urate crystals in PMN

26

Urate crystals, negative birefringence

27

CPPD crystals

28

Differential Diagnosis

• Inflammatory monoarthritis• Inflammatory polyarthritis• Inflammatory spondyloarthritis• Degenerative arthritis

29

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

6

31

Differential Diagnosis Of Spondyloarthritis

• Ankylosing spondylitis• Reiters syndrome• Psoriatic arthritis• Inflammatory bowel disease

32

33

Hand RA, has swelling of wrists, MCPs and PIPs, which is symmetric.

34

35

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.

36

7

37

Erosive OA of hands, changes involve several PIPs and DIPs, no MCP involvement.

38

39

Gout, involvement of several hand joints with tophi, can look like Rheumatoid arthritis.

40

41

Psoriatic arthritis, inflammation of the DIP with nail changes.

42

8

43

Hand x-ray, early RA, periarticularosteopenia of the wrists and MCPs.

44

45

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.

46

47

Systemic vasculitis, hand findings: periungual and subungual petecheallesions.

48

9

49

Hypersensitivity vasculitis of hands, purpuric lesions over the fingers.