Inflammatory arthritis
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Internal Medicine Core Curriculum lecture on inflammatory arthritis
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Inflammatory arthritis
- 1. Inflammatory Arthritis Michael Aref, MD, PhD Hospitalist, Carle Physician Group Department of Nuclear, Plasma, and Radiological Engineering, UIUC Department of Medicine, UICOM-UC
- 2. Objectives • Review the history and physical examination findings of inflammatory arthritis • Define and categorize inflammatory arthritis • Understand the initial laboratory and radiological evaluation of suspected rheumatological disease • Increase clinical sensitivity and specificity to rheumatological disease
- 3. Chest pain rule-out • 45 y/o WM • Persistent, bilateral shoulder, elbow, and hand pain, worse with activity. Associated fatigue. • Smoker, mother has history of rheumatoid arthritis. • VSS, decreased ROM of shoulders, with bilateral finger, elbow, and shoulder synovitis. • Mild normochromic, normocytic anemia and hypokalemia; EKG and chest x-ray benign. • What test(s) would you like to order next?
- 4. Objectives • Review the history and physical examination findings of inflammatory arthritis • Define and categorize inflammatory arthritis • Understand the initial laboratory and radiological evaluation of suspected rheumatological disease • Increase clinical sensitivity and specificity to rheumatological disease
- 5. History Aggravating and alleviating factors Severity Character Location Associated symptoms Setting Timing • Does activity make your symptoms better or worse? • Probably pretty bad, or they wouldn’t be in the hospital. • Are the same joints affected persistently or are different joints affected? • How many joints are affected? 1 (monoarticular), 2-4 (oligoarticular), or more (polyarticular)? • Any association with your back, particularly your spine? • Joint swelling? Low grade temperature? Rash? Fatigue? • When you wake up in the morning, how long do your symptoms last? • How long have you been noticing these symptoms?
- 6. Physical Examination • Main signs of active inflammation include Erythema (Rubor) Warmth (Calor) Swelling (Tumor) Tenderness (Dolor) Loss of Function • Enthesopathy Pathology or lesions of enthesis (the site where ligament or tendon inserts into bone) Examples include: plantar fasciitis,Achilles tendonitis. • Dislocation Articulating surfaces are displaced and no longer in contact • Subluxation Partial dislocation • Synovitis Inflammation of the synovial membrane • Valgus Lower limb deformity whereby distal part is directed away from the midline e.g. hallux valgus • Varus Lower limb deformity whereby distal part is directed towards the midline e.g. varus knee with medial compartment OA GALS Screen Basic Rheumatologic Examination
- 7. The Clinical Examination of the Rheumatic Disease Patient
- 8. The Clinical Examination of the Rheumatic Disease Patient
- 9. Objectives • Review the history and physical examination findings of inflammatory arthritis • Define and categorize inflammatory arthritis • Understand the initial laboratory and radiological evaluation of suspected rheumatological disease • Increase clinical sensitivity and specificity to rheumatological disease
- 10. Inflammatory vs. Non- inflammatory FeaturesFeatures InflammatoryInflammatory Non-inflammatoryNon-inflammatory Hx Morning stiffness > 1 hour Low-grade temperature Fatigue Rash Morning stiffness < 1 hour Px Erythema (Rubor) • Warmth (Calor) • Swelling (Tumor) • Tenderness (Dolor) • Loss of Function Bony proliferation in osteoarthritis Labs (+)ve ESR ± CRP Anemia of chronic disease (+)ve rheumatoid factor or anti-CCP antibodies Within normal limits Radiographs Erosions Periostitis Joint-space narrowing Joint-space narrowing Osteophytes Subchondral sclerosis Synovial Fluid Non-infectious Infectious Leukocyte count < 2,000/uL < 50% neutrophilsLeukocyte count > 2,000 /uL Predominantly neutrophils Leukocyte count > 50,000 /uL MKSAP 15 Rheumatology
- 11. Autoimmune SymmetricSymmetric AsymmetricAsymmetric SpineSpine MonoarticularMonoarticular OligoarthritisOligoarthritis PolyarthritisPolyarthritis MigratoryMigratory Rheumatoid Arthritis ++++ - Cervical - + ++++ Ankylosing Spondylitis ++++ ++++ Psoriatic Arthritis ++ +++ + ++ +++ ++ Inflammatory Bowel Disease Associated ++ +++ + ++ +++ ++ MKSAP 15 Rheumatology
- 12. Infectious SymmetricSymmetric AsymmetricAsymmetric SpineSpine MonoarticularMonoarticular OligoarthritisOligoarthritis PolyarthritisPolyarthritis MigratoryMigratory Non-gonococcal - ++++ ++ ++++ +++ + - Disseminated gonococcal ++++ ++++ ++++ Late Lyme Disease ++++ ++++ ++++ MKSAP 15 Rheumatology
- 13. Post-Infectious SymmetricSymmetric AsymmetricAsymmetric SpineSpine MonoarticularMonoarticular OligoarthritisOligoarthritis PolyarthritisPolyarthritis MigratoryMigratory Reactive Arthritis ++++ ++ ++++ ++ Acute Rheumatic Fever ++++ ++ +++ ++++ Up-To-Date and MKSAP 15 Rheumatology
- 14. Crystalline Arthropathies SymmetricSymmetric AsymmetricAsymmetric SpineSpine MonoarticularMonoarticular OligoarthritisOligoarthritis PolyarthritisPolyarthritis MigratoryMigratory Gout + ++++ + +++ +++ + + Pseudogout ++ +++ - +++ ++ ++ MKSAP 15 Rheumatology
- 15. Objectives • Review the history and physical examination findings of inflammatory arthritis • Define and categorize inflammatory arthritis • Understand the initial laboratory and radiological evaluation of suspected rheumatological disease • Increase clinical sensitivity and specificity to rheumatological disease
- 16. Erythrocyte Sedimentation Rate (ESR) • Conditions with increased immunoglobulins • Age • Normal males = age/2 • Normal females = (age + 10)/2 • Myeloma,Waldenström’s, 1° amyloid • SLE, Sjogren’s • Chronic liver disease/cirrhosis Miller ML, The Little Black Book of Rheumatology
- 17. “C-Reactive Protein” Cytokine Response Protein (CRP) Cytokine Response Protein (CRP) • ESR and CRP both elevated: • Infection • Inflammatory States • Trauma • Cancer Miller ML, The Little Black Book of Rheumatology
- 18. Serology • Rheumatoid Factor (RF) • Titer of IgM against IgG • Present in 80% of rheumatoid arthritis • Sensitivity 69% / Specificity 85% • Anti-citrulline-containing peptide antibody (Anti- CCP Ab) • Associated the development of erosive disease • Sensitivity 67% / Specificity 95% Miller ML, The Little Black Book of Rheumatology Ann Int Med, 2007; 146:797
- 20. Objectives • Review the history and physical examination findings of inflammatory arthritis • Define and categorize inflammatory arthritis • Understand the initial laboratory and radiological evaluation of suspected rheumatological disease • Increase clinical sensitivity and specificity to rheumatological disease
- 21. Rheumatoid Arthritis 2010 Rheumatoid Arthritis Classification Criteria, Arthritis & Rheumatism, Sep 2010, 62(9):2569–2581
- 23. Ankylosing Spondylitis Modified NewYork Criteria (1984) • Definite ankylosing spondylitis is present if • Radiologic criterion is present in addition to at least one clinical criterion. • Probable ankylosing spondylitis is present if • Three clinical criterion are present alone or if • The radiologic criterion is present but no clinical criteria are present. Clinical criteria • Low back pain: present for more than 3 months, improved by exercise but not relieved by rest. • Limitation of lumbar spine motion in sagittal and frontal planes. • Limitation of chest expansion relative to normal values for age and sex. Radiologic criterion • Sacroiliitis on radiographs http://emedicine.medscape.com/article/386639-overview
- 24. Ankylosing Spondylitis The Clinical Examination of the Rheumatic Disease Patient
- 25. Genetic Predisposition for Development of Ankylosing Spondylitis (AS) HLA-B27 positive AS and HLA- B27 positive Western European Whites 8% 90% African Americans 2% to 4% 48% Guidelines in Rheumatology: Ankylosing Spondylitis
- 28. Psoriatic Arthritis • Asymmetric oligoarthritis (43%) • Symmetric polyarthritis (33%) • Sacroilitis (14%) • Predominant spondylitis (4%) • Synovitis-acne-pustulosis-hyperostosis- osteomyelitis (SAPHO) syndrome (2%) Br J Rheumatol. 1994 Feb;33(2):133-8
- 31. Infectious Arthritis • Septic arthritis is the presumed diagnosis in any patient with acute monoarthritis and fever. • Synovial fluid analysis is the diagnostic test • White cell count with differential • Gram stain (sensitivity 29-50%) • Crystal search using polarized light microscopy • Culture (positive in the majority of patients with nongonococcal bacterial arthritis) Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum 1996; 39:1
- 35. Lyme Arthritis Characterized by intermittent or persistent arthritis. Monoarthritis of the knee is most common, but can also present as asymmetric oligoarthritis, usually including the knee. •Knee > shoulder > ankle > elbow > temporomandibular joint > wrist •≤ 5 joints, large joints > small joints •Abrupt presentation, lasts from several weeks to months •Large joint effusions are common in the knees and elsewhere and often recur after aspiration •Affected joints are usually very swollen and warm Ann Intern Med 1987 Nov;107(5):725-31
- 36. Lyme Arthritis
- 37. Reactive Arthritis Willkens RF et al. Arthritis Rheum 1981;24:844-9 SensitivitySensitivity SpecificitySpecificity Episode of arthritis of more than 1 month with urethritis and/or cervicitis 84.3% (70/83) 98.2% (163/166) Episode of arthritis of more than 1 month and either urethritis or cervicitis, or bilateral conjunctivitis 85.5% (71/83) 96.4% (160/166) Episode of arthritis, conjunctivitis, and urethritis 50.6% (42/83) 98.8% (164/166) Episode of arthritis of more than 1 month, conjunctivitis, and urethritis 48.2% (40/83) 98.8% (164/166)
- 38. Reactive Arthritis • Preceding enteric infection (i.e. diarrhea) • Salmonella of various serovars • Shigella, especially Shigella flexneri, but also Shigella dysenteriae and sonnei • Yersinia includingYersinia enterocolitica 0:3 and 0:9 andYersinia pseudotuberculosis • Campylobacter especially Campylobacter jejuni • Clostridium difficile • Preceding genitourinary infection (i.e. urethritis) • Chlamydia trachomatis Up-To-Date
- 40. Gout 1977 American College of1977 American College of Rheumatology CriteriaRheumatology Criteria New York CriteriaNew York Criteria Rome CriteriaRome Criteria Monosodium urate monohydrate microcrystals in joint fluid during attack or ≥ 6 of the following MSU microcrystals in joint fluid or tissue or tophus or ≥ 2 of the following ≥ 2 of the following > 1 attack of acute arthritis 2 attacks of painful limb joint swelling Maximum inflammation developed within 1 day Abrupt onset and remission in 1-2 weeks initially Abrupt, painful joint swelling, clearing in 1-2 weeks initially Monoarthritis attack Redness observed over joints First metatarsophalangeal joint painful or swollen First metatarsophalangeal joint attack Unilateral first metatarsophalangeal joint attack Unilateral tarsal joint attack Tophus (proven or suspected) Presence of a tophus Presence of tophi Hyperuricemia Serum uric acid > 7 in males and > 6 in females Asymmetric swelling within a joint on x-ray Subcortical cysts without erosions on x-ray Joint fluid culture negative for organisms during attack Response to colchicine—major reduction in inflammation within 48 hours MSU microcrystals in joint fluid or tissueWallace SL, et al. Arthritis Rheum 1977;20:895-900 and J Clin Rheumatol. 2009 Feb;15(1):22-4
- 42. Pseudogout Definite diagnosis of pseudogout requires either: • The demonstration of CPPD crystals in tissue or synovial fluid by definitive means (eg, x-ray diffraction, etc) or • The presence of both positively (but weakly) birefringent crystals by compensated polarized light microscopy and typical cartilage or joint capsule calcification on x-ray examination Probable diagnosis of pseudogout occurs with either: • The identification of positively (but weakly) birefringent crystals by compensated polarized light microscopy or • The presence of typical cartilage or joint capsule calcification on radiographic examination. Up-To-Date
- 43. Pseudogout
- 45. CODE SPEED • 75 y/o WM • Admitted for fever and malaise, back pain noted on ROS • Obesity, HTN, HCL, DM, CAD, and CKD III • “Social” drinker, family history noncontributory. • Febrile, tachycardic, hypotensive, diaphoretic, examination otherwise noncontributory • Mild leukocytosis otherwise CBC and CMP benign, negative blood and urine cultures, chest x-ray negative • Patient intubated and started on vasopressors for shock • What’s the differential diagnosis?
Notas del editor
- Examination of the hand Examination of the thumb Examination of the wrist Examination of the elbow Examination of the shoulder joint Examination of the rotator cuff Examination of the acromioclavicular joint Examination of the neck
- Examination of the hip joint Examination of the trochanteric bursa Examination of the knee I Examination of the knee II Examination of the ankle Subtalar examination Examination of the tarsals Plantar Fascia and Achilles heel examination Examination of the metatarsals
- Rheumatoid arthritis is an insidious polyarthritis Ankylosing spondylitis typically presents with back and buttock pain Psoriatic and inflammatory bowel disease associated arthritis are associated with autoimmune disease of the skin and gastrointestinal system respectively
- Crystal arthropathies present like septic joints but don’t grow anything and don’t respond to antibiotics
- Genetic Predisposition for Development of Ankylosing Spondylitis (AS) Ankylosing spondylitis (AS) is a common, complex, and systemic inflammatory disease with the potential to cause severe debilitation.1-3 Although etiology remains unknown and pathogenesis is not fully understood, a strong association between AS and HLA-B27 (an allele of the major histocompatibility complex) suggests a genetic predisposition. Presence of allele and expression of the condition vary, however, among different ethnic/racial groups. For example, 8% of western European whites are positive for HLA-B27, and it is detected in over 90% of white patients with primary AS; but 2% of African Americans are positive for HLA-B27, and it is present in only 48% of African Americans with AS.4-6 Consequently prevalence rates vary between groups. Khan MA. Clinical features of ankylosing spondylitis. In: Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, eds. Rheumatology. vol 2, 3rd ed, New York, NY: Mosby; 2003:1161-1181. Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: an overview. Ann Rheum Dis. 2002;61(suppl III):iii8-iii18. Khan MA. Spondyloarthropathies. In: Hunder GG, ed. Atlas of Rheumatology. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2002. Khan MA. Update on spondyloarthropathies. Ann Intern Med. 2002;136:896-907. Khan MA. Thoughts concerning the early diagnosis of ankylosing spondylitis and related diseases. Clin Exp Rheumatol. 2002;20(suppl 28):S6-S10. 6. Khan MA, Braun WE, Kushner I, et al. HLA B27 in ankylosing spondylitis differences in frequency and relative risk in American Blacks and Caucasians. J Rheumatol. 1977;4(Suppl 3):39-43.