Polyarticular Arthritis Flashcards
What are 5 syndromes with widespread arthralgia that do NOT have direct evidence of joint pathology?
- fibromylagia
- hypothyroidism
- paraneoplastic syndrome
- drug reactions
- psychiatric syndromes
What are the 6 most common presentations of polyarticular arthritis?
- viral arthritis- most common parvoB19
- rheumatoid arthritis
- psoriatic arthritis
- ankylosing spondylitis
- reactive arthritis
- juvenile arthritis
What systemic autoimmune diseases present with polyarthritis?
SLE
scleroderma
polymyositis/dermatomyosis
What is the differential if the polyarthritis came on acutely (days/wks)?
- Infection - parvoB19, gonococcal, meningococcal, Lyme, rheumatic fever, endocarditis
- RA or gout
A patient presents with MCP, PIP and wrist joint involvement but the DIP and thoracolumbar spine are spared. What is the most likely cause?
RA
A patient presents with arthritis in the 1st CMC, DIP, PIP, spine, hip, and 1st MTP but NOT:
- wrist
- MCP
- elbow, shoulder
What is the likely cause?
OA
What 4 types of polyarthritis present with fever?
- infectious
- reactive arthritis
- systemic rheumatic disease
- crystal arthritis
A patient presents with skin rash and polyarticular arthritis. What 5 things should be on the differential?
- psoriatic arthritis
- sarcoidosis
- reactive arthritis
- SLE
- acute rheumatic fever
If a patient has a history of GI/GU infections, what is the likely cause of polyarthritis?
Reactive arthritis
How does initial treatment differ for monoarthritis and polyarthritis?
In mono you are really worried about septic issues so you must obtain synovial fluid before anything else.
In poly it is not necessary to get synovial fluid in ALL cases
What tests should you obtain for all patients with undiagnosed polyarthritis?
- CBC with differential
- urinalysis
- liver enzymes/serum creatinine
- ESR/CRP
What are the 4 most common viral causes of polyarthritis?
- parvovirus B19
- rubella
- hep B and C
- HIV
Describe the clinical features of RA. Acute/chronic? inflammatory/non? mono/polyarticular? symmetric/asymmetric? What are the extra-articular manifestations?
RA is a cell-mediated autoimmune synovitis (inflammation of lining of diarthrodial joints)
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It is a chronic, inflammatory, symmetric, additive polyarthritis.
Rheumatoid nodules, vasculitis, ocular, lung disease
What is the evidence for the autoimmune nature of RA?
HLA-DR1 and HLA-DR4
These bind molecules that have undergone citrullination including:
1. vimentin
2. fibrinogen
3. enolase
Which are postulated to be the self antigens.
What enviromental factors increase the risk for RA?
- smoking
- periodontal disease
(if they have the susceptible HLA genes)
How does the appearance of early RA synovitis differ from late RA synovitis?
Early:
- tissue edema
- hypertrophy of synovial lining layer
- infiltration of CD4 T cells
- formation of new blood vessels
Late:
- lymphoid follicles and plasma cells appear
- synovium hypertrophies to form pannus (covers cartilage and erodes periarticular bone
- joint effusion with 10-50000 WBC and 70% neutrophils
- collagenase/hyaluronadase degrades normal proteins/proteoglycans in synovial fluid decreasing viscosity (joint is not lubricated)
What are the most common joints involved in RA? What is the clinical presentation of the joint?
MCP, PIP, wrist, ankle, elbow, shoulder, knee, hip, C-spine, TMJ, crico-arytenoid
- Joints are tender, swollen, decreased ROM
- morning stiffness that lasts over 60 minutes and improves with hot water or movement
What are the 4 characteristics of chronic RA (specifically seen in the hands)?
- joint capsules of interphalangeal joints loosen leading to ulnar deviation of the wrist
- Boutonniere: flexed PIP, extended DIP
- Swan neck: extended PIP, flexed DIP
- erosion of bone and loosening of tendons
What are the 4 radiographic findings of RA?
- soft tissue swelling
2 periarticular osteopenia - uniform joint narrowing (opposed to OA)
- marginal erosion where joint synovium meets bone that can progress to ankylosis
What are the lab findings of RA?
- RF and antiCCP (more specific)
- ESR, CRP
- anemia, thrombocytosis
- hypergammaglobinemia
What if rheumatoid factor? Who is it present in? What is the titer and affinity?
What happens to the titer with age?
Is it polyclonal or monoclonal?
It is an autoantibody directed against Fc portion of IgG.
It is in EVERYONE with low titer and low affinity.
Titer increases with age.
It is polyclonal in autoimmune disorders and monoclonal in lymphoid malignancies.
What arthritides, viral infections, bacterial infections, parasites, and other conditions would present with elevated RF?
Arthritides:
RA, sjogrens, SLE
Viral: hep C, mono, HIV, influenza
Bacterial: TB, leprosy, syphilis, brucella
Parasites: trypansoma, malaria, schistosomiasis
Sarcoid, IPF, chronic liver disease
An 85 year old man presents with non-inflammatory arthritis of one knee. His RF levels are elevated. What is the most likely cause of disease?
OA.
RF is elevated due to age. If it was polyarticular and inflammatory you might lean toward RA.
Patients with RF values over 400 are likely to present with what features?
- Rheumatoid nodules
2. vasculitis
What is anti-CCP? How does the sensitivity and specificity differ from RA?
It is anti-cyclic citrullinated peptide which is an autoantibody against proteins that have been post-translationally modified by converting arginine to citrulline.
Sensitivity is the same as RF, but it is 90-95% specific (way more specific than RF)
What are rheumatoid nodules? Where in the body are they found?
They are firm, non-tender subcutaneous nodules in the bursa and along tendon sheaths.
Most common:
achilles tendon
pressure points like extensor tendon of arm
Less common:
lungs, heart, brain
What are the most common extra-articular manifestations of RA?
Who is most likely to have extra-articular symptoms?
- Rheumatoid nodules
- keratoconjuctivitis sicca (dry eyes/mouth)
- Episcleritis/severe scleritis - perforated globe
- vasculitis in small vessels
- interstitial lung disease (fibrosis/nodules)
Most commonly seen in patients with high RF titer and DR4/Dw4 homozygotes
RA guidelines are given for classification, not diagnosis of RA, although it can be helpful for diagnosis. What score makes the person highly likely to have RA?
What gets 5 points? 3 points? 2 points? 1 point?
6/10
5 points if over 10 joints are involved
3 points:
- 4-10 joints involved
- high RF, positive anti-CCP
2 points:
- 1-3 small joints
- low RF, low anti-CCP
1 point:
- 2-10 large joints
- abnormal CRP, ESR
- over 6 week duration
Why does smoking double changes for RA?
It increases citrulline proteins so you have more proteins being attacked by anti-CCP
What are the seronegative spondylarthropathies?
What makes them seronegativE?
- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- enteropathic arthritis (IBD)
None of these have markers like RF or anti-CCP
What are the general features of seronegative spondyloarthropathy? Acute or chronic? Mono, poly? symmetric/asymmetric? Axial/appendicular? genetic associations?
Chronic oligoarticular asymmetric axial skeleton HLA-B27
What does the earliest pathologic lesion of ankylosing spondylitis originate?
What are the most common joints involved?
Earliest lesion is inflammation at the entheses (where ligaments, tendons, fascia, capsule attach to bone).
- SI joint
- intervertebral disks
- apophyseal joints (on vertebral column)
- vertebral ligaments
What are the 3 things you should consider if your patient is presenting with inflammatory back pain?
- ankylosing spondylosis
- mets
- infection
Who is usually affected by ankylosing spondylosis? Men or women? Young or old? What is the common first symptom? Is it acute/chronic? What is the duration?
It usually affects men under the age of 40. Back pain is the usual first symptom -insidious onset (chronic) - lasts over 3 months - morning stiffness
What are the 4 most prominent articular manifestations of Ank. Spond?
- axial arthritis
- enthesitis- pain/inflammation where tendon attaches to bone (achilles, plantar fasciitis)
- arthritis of hip/shoulder
- peripheral
What test is most useful for testing spinal mobility in someone with ank spond?
Shober test- mark their back at the level of the 5th lumbar vertebrae and 10 cm above that.
As the patient bends forward, the distance between the lines SHOULD increase by 5cm. If it doesnt, it could be a sign the spine is fusing (ank spond)
What are the extra-articular manifestations of Ank Spond?
- anterior uveitis
- tearing, pain, blurry vision unilaterally (but can alternate)
- corneal inflammation/edema - Aortitis, aortic insufficiency, heart block
- spinal cord damage
- fracture
- cauda equina syndrome
What are the radiographic findings of Ank. Spond?
- erosion, sclerosis, fusion of SI joint
- erosion at tendon attachment sites
- bamboo spine - ossification of annulus fibrosis, apophyseal joints, intervertebral ligaments
- bone spurs
Arthritis affects _______% of people with psoriasis.
Does it affect men or women more?
When does the arthritis usually occur in comparison to the skin disease?
5-7%
It affects men and women equally although women have more peripheral arthritis.
It usually comes on decades after the skin disease, but it CAN occur at the same time
What are the 4 major forms of psoriatic arthritis?
What is the most common?
- mono or oligoarticular arthritis with large joints of lower extremities and interphalageal joints (2/3)
- RA-like (but with more DIP)
- arthritis mutilans (all bones in the hands)
- axial skeletal (SI/spine) like ank spond.
What are extra-articular signs of psoriatic arthritis?
- scaly, erythematous plaques on skin
2. nail pitting, oncholysis, ridging of nails
What are the X-ray findings of psoriatic arthritis?
- sausage digits (soft-tissue swelling of hands/feet)
- joint space loss
- bony overgrowth at the distal side of the joint (bone in cup)
What is the triad associated with reactive arthritis?
- arthritis
- urethritis
- conjuctivitis
Eyes, GU, Joints
Reactive arthritis can follow GI or GU infections by what organisms?
What organism can be a co-existent infection, but is more associated with acute septic arthritis than chronic reactive arthritis?
Shigella, salmonella, campylobacter, yersinia
Chlamydia
Gonorrhea = acute septic
How soon after the infectious disease will reactive arthritis present?
What are signs of the infection that precede articular involvement?
2-4 wks
GU- ongoing with discharge, pus, dysuria, prostatitis
GI- transient diarrhea
Is reactive arthritis monoarticular or polyarticular? symmetric or asymmetric?
Migratory or additive?
Oligoarticular, asymmetric and additive
What joints are most frequently affected in reactive arthritis?
knees, ankles, feet
60% have lower and upper joints
40% just lower joint involvement
What is the presentation of reactive arthritis on the hands and feet of the patients?
Dactylitis- entire digits are diffusely swollen
Enthesitis- achilles tendon/plantar fasciitis
What are the extra-articular signs of reactive arthritis?
- keratoderma blenorrhagicum- psoriasis on palms/soles
- circinate balantis
- oral ulcers
- anterior uveitis
- aortitis
- nail dystophy but NO PITTING
