2.6.4. Systemic Arthritis Cases Flashcards
How many joints must be involved for a condition to be polyarthritis?
More than 3 joints
Generally describe osteoarthritis
a disease in which all structures of the joint have undergone pathologic change
What are the clinical features of osteoarthritis?
Pain, Morning stiffness, Pain worse with activity, Stiffness after inactivity (gelling), Joint enlargement/instability, Periarticular muscle atrophy, Crepitus DIPs, PIPs, CMC (squaring), Cervical/lumbar spine, Hips, Knees, 1st MTP Joints that are not involved: wrists, elbows, ankles, MCPs, 2nd-5th MTPs
Osteoarthritis is associated with what considering age and gender?
Associated with increased age (women > men)
What is the pathology of osteoarthritis?
Early: swelling of articular, loosening of collagen framework, increased water content, increased PG synthesis and degradative enzymes Later: decreased PG content, thinning and softening of cartilage, fissuring and cracking of cartilage, exposure of underlying bone
What lab findings do we expect to see with osteoarthritis?
Rheumatoid factor (-), CBC (normal), ANA (-), ESR (Normal)
What should we see on radiographs of osteoarthritis?
A- no ankylosis; B- bony subchondral sclerosis and cysts; C- cartilage space narrowing; D- deformities common; E- erosion absent; S- soft tissue swelling
What treatments do we have for osteoarthritis?
Medications Acetaminophen, NSAIDS, Opioid analgesics Injections Corticosteroids and Viscosupplementation
What is Calcium Pyrophosphate Deposition? (CPPD)
CPPD is a syndrome caused by deposition of calcium pyrophosphate dihydrate in cartilage (called chondrocalcinosis on radiographs and pseudogout when it is present acutely like gout)
What are the risk factors for CPPD?
Previous joint surgery, epiphyseal dysplasias, hereditary Disease associated Hyperparathyroidism, Hemochromatosis, Hypophosphatasia, Hypomagnesemia, and Post-meniscectomy
What are some risk factors for osteoarthritis?
Risk factors: Age, Mechanical trauma, weight-bearing, occupational use, previous inflammatory arthritis, avascular necrosis, metabolic disorders, genetic predisposition, race/ethnicity
CPPD is most commonly associated with what?
Most commonly associated with aging and most patients are asymptomatic
What are the clinical features of CPPD?
Clinical features Asymptomatic Lanthanic Acute Pseudogout Subacute or Chronic Pseudo- rheumatoid arthritis Pseudo-osteoarthritis Pseudo-neuropathic Pseudo-spondylitic
What joints are involved in CPPD?
Joint Involvement (larger > smaller joints) Knee, wrist, MCPs, Hip, Shoulder, Spine, Elbow Gout involves smaller joints like MTP, metatarsophalangeal, etc.
What lab findings shoudl we see in CPPD?
Radiographs demonstrating punctate or linear calcifications Finding rhomboid, square, or rod-like crystals is the only way to make a definitive diagnosis Weakly positively birefringent Synovial fluid is typically inflammatory (2,000-50,000 WBCs)
Compare Gout vs. Pseudogout (CPPD)
- Crystal
- Gout: Urate
- Pseudogout: CPPD
- Shape
- Gout: Needle
- Pseudogout: Rhomboid/rectangular
- Birefringence
- Gout: Negative
- Pseudogout: Positive
- Color of crystals
- Gout: Yellow
- Pseudogout: Blue
What should we see on radiographs of CPPD?
A-ankylosis uncommon; B-bone mineralization decreased; C-calcifications; D-deformities common; E-erosions common; S-soft tissue swelling usually present
What is the treatment for CPPD?
- Treatment
- Joint aspiration
- NSAIDs, corticosteroids (oral or injection), ACTH, Colchicine
How does arthritis present in time with psoriatic arthritis when compared with the skin symptoms?
Skin precedes joint disease (60-70%), they appear within one year of each other (15-20%)
In Psoriatic Arthritis (PA), what joint involvment do we see?
DIP only (15%), Asymmetric oligoarthritis (30%), symmetric polyarthritis (40%), axial involvement (5%), arthritis mutilans (5%)
Nail changes (90%), dactylitis (>30%), enthesitis (increased, underappreciated on examination), conjunctivitis (20%), iritis (7%)
Compare Rheumatoid Arthritis (RA) to PA.
What lab work should we see with PA?
Rheumatoid factor (-), CBC (normal), Chemistry (uric acid may be elevated), ANA (-), CRP and ESR (may be elevated), synovial fluid (WBC count <1000-2000/mm3)
What should we see on radiology of PA?
A-ankylosis may be seen; B-bone mineralization decreased, C-cartilage space narrowing; D-deformities common; E-erosion common; S-soft tissue swelling usually present
What is the treatment for PA?
- Coordinate therapy for skin and joint disease
- Immunosuppressive agents
- Methotrexate, Sulfasalazine, Cyclosporine, Antimalarials
- Anti- TNF alpha therapy
- Etanercept, Infliximab, Adalimumab
What are the six key features to look for of appendicular arthritis?
Articular vs. non-articular
Acute (<6 weeks) vs. chronic (>6 weeks)
Inflammatory vs. non-inflammatory
Distribution
Pattern
Symmetry
What do we mean by articular or non-articular with appendicular arthritis?
Articular = painful with limited active/passive ROM
Peri- or non-articular = painful w/ active ROM only
What can cause non-articular pain?
Non-articular pain can be caused by trauma/fracture, fibromyalgia (nerve system responding to normal stimuli as if it were painful), bursitis, tendinitis, and polymyalgia rheumatica (whole body bursitis)
What questions should we ask to characterize a chronic symptom?
Is there prolonged morning stiffness; is there soft tissue swelling; are there systemic symptoms; is the ESR or CRP elevated
What are systemic symptoms we look for?
Systemic symptoms = fevers, weight loss, rashes, nodules, mucosal sores, weakness
What are some conditions that involve inflammatory connective tissue?
Rheumatoid, psoriatic, and reactive arthritis
SLE (picture of girl below), Scleroderma, Polymyositis
What might be some actue conditions?
Septic arthritis, Gout (picture of ear below), Pseudogout, Reactive arthritis, Initial presentation of chronic arthritis
What are some common differences between inflammatory and non-inflammatory complaints?
Inflammatory: stiffness > 1hr, R/C/D/T, pain at rest, improves with exercise, constitutional complaints
Non-inflammatory: stiffness < 30 min, no signs of inflammation, better with rest, worse with exercise, no constitutional complaints
What are the different kinds of distribution we may see?
Monoarthritis (ANA and RF are not helpful)
Polyarthritis
Oligoarthritis (seen below)
What are the three patterns we may see?
Additive (most common, least specific)
Migratory
Intermittent
What are some examples of additive conditions?
Examples: RA, Connective Tissue disease (SLE, systemic sclerosis, idiopathic inflammatory myopathies), Spondyloarthritis (psoriatic and reactive)
What are some examples of migratory conditions?
Gonococcal (neisseria infections), Rheumatic Fever, Lyme, Childhood Leukemia
What are some examples of intermittent disorders?
Crystalline
Gout and Pseudogout
Palindromic rheumatism, periodic fever syndromes
Whipple’s disease
Systemic inflammatory arthritis early in the course of the disease
What does symmetry suggest to us in arthritis cases?
Symmetry suggests RHEUMATOID ARTHRITIS (or other systemic inflammatory connective tissue disease)
Especially in the Wrist, MCP, and PIP
What kind of demographics help us in arthritis cases, and what do we expect to see in each group?
- Children
- JIA, Infection
- Young adults
- Septic, Gonococcal, Spondyloarthritis, RA, Internal derangement
- Older adults
- Crystal, OA, AVN, Systemic disease, Internal derangement
- Gender
- Men
- Gout, Spondyloarthritis
- Women
- RA, SLE
- Men
- Lifestyle
- Bacteria, Gout (alcohol), Endocarditis (IV drugs), Disseminated gonorrhea, Lyme, Avascular necrosis (alcohol)
What do we expect if the first joint involved is:
First CMC, or
IP joint of hand
Wrist
First MTP
Knee
Ankle
- First CMC
- OA
- IP joint of hand
- OA, PSA, RA
- Wrist
- CPPD, Gonococcal, Early RA (both wrists)
- First MTP
- Gout, OA
- Knee
- Bacteria, JIA, OA, Crystal, Internal derangement
- Ankle
- Sarcoid, Reiter’s
What is the single most important test in the evaluation of a monoarthritis?
Aspiration of the joint
Why do we aspirate the joint?
Rule out infection (gram stain/culture)
What kind of cell counts should we see in joint aspirate, and what does each number range mean?
<200 = normal
200-2,000 = Non-inflammatory
2,000-50,000 = Inflammatory
If you look at the test tube, even before you send it to the labs, and can’t see through it then it is probably >2,000 and you should prepare for lots of additional testing
>80,000 = purulent
