APPROACH TO POLY-ARTHRITIS

DR CB NEL

Joints cartilage/synovium

Arthritis

Degenerative

Osteoartritis

InflammatoryRheumatoid arthritis

Seronegative spondiloarthropaties

GoutSeptic

Lower back pain

Diagnostic approach

• Inflammatory vs. Noninflamatory• Acute vs. Chronic• Temporal pattern of joint involvement• Distribution of joint involvement• Age of patient• Sex of patient• Systemic involvement

Inflammatory vs Mechanical

Morning stiffness>1 hrFatigueProfoundActivityImproves symptomsRestWorsens symptomsSystemic involvementYesSwelling, warmth, erythema, tenderness, loss of function

• Morning stiffness– <30 min

• Fatigue– Minimal

• Activity– Worsens symptoms

• Rest– Improves symptoms

• Systemic involvement– No

Acute vs. Chronic

Acute Polyarthritis• Infection

– Gonococcal– Meningococcal– Acute rheumatic fever– Bacterial endocarditis– Viral(esp.. rubella,

hepatitis B, parvovirus, Epstein-Barr, HIV)

• Other inflammatory– Rheumatoid arthritis– Juvenile chronic arthritis– SLE– Reactive arthritis– Psoriatic arthritis– Polyarticular gout– Sarcoid arthritis– Serum sickness

Chronic Polyarthritis (>6 weeks)

• Inflammatory– Rheumatoid arthritis– Polyarticular Juvenile

chronic arthritis– SLE– Progressive systemic

sclerosis– Polymyositis– Reiter’s syndrome

– Psoriatic arthritis– Enteropathic arthritis– Polyarticular gout– Pseudogout (CPPD)– Sarcoid arthritis– Vasculitis– Polymialgia rheumatica

Chronic Polyarthritis (>6 weeks)

• Noninflammatory– Osteoarthritis– Pseudogout (CPPD)– Polyarticular gout– Paget’s disease– Fibromyalgia– Benign hypermobility syndrome– Hemochromatosis

Temporal patterns of joint involvement

• Migratory– Rheumatic fever

– Gonococcal arthritis

• Additive– Nonspecific

• Rheumatoid arthritis

• SLE

• Intermittent– Rheumatoid arthritis

– Psoriatic arthritis

– Reactive Arthritis

• Palandromic– Gout

– Rheumatoid arthritis

Distribution of joint involvement

• Rheumatoid arthritis– Commonly involved

• Wrist, MCP, PIP, elbow, glenohumeral, cervical spine, hip, knee, ankle, tarsal, MTP

– Commonly spared• DIP, thoracolumbar spine

Distribution of joint involvement

• Osteoarthritis– Commonly involved

• First CMC, DIP, PIP, cervical spine, thoracolumbar spine, hip, knee, first MTP, toe IP

– Commonly spared• MCP, wrist, elbow, glenohumeral, ankle, tarsal

Distribution of joint involvement

• Reactive arthrits– Commonly involved

• Knee, ankle, tarsal, MTP, toe IP, elbow, axial• Gonococcal arthritis

– Commonly involved• Knee, wrist, ankle, hand IP

– Commonly spared• Axial

RHEUMATOID ARTHRITIS

CLINICAL FEATURES

• Prolonged morning stiffness • Synovitis of small joints of hands, wrists and feet• Other synovial structures (tenosynovitis, bursae) also

common• Typical hand features:

o Symmetrical swelling of the MCP and PIP jointso Tenderness of involved jointso Swan neck deformitieso Boutonniére deformitieso Z-deformity of the thumbo Dorsal subluxation of the ulna styloido Triggering of the fingers

EXTRA-ARTICULAR MANIFESTATIONS

• Systemic Fever, fatigue, weight loss, increased infection risk

• MSKMuscle-wasting, tenosynovitis, bursitis, osteoporosis

• HaematologicalReactive thrombocytosis, microcytic anaemia, anaemia of chronic disease(normochromic, normocytic)

• LymphaticSplenomegaly, Felty’s syndrome(RA, splenomegaly,

neutropenia)

EXTRA-ARTICULAR MANIFESTATIONS

• OcularEpiscleritis, scleritis, scleromalacia, keratoconjunctivitis sicca

• VasculitisNailfold infarcts, skin ulcers, pyoderma gangrenosum, mononeuritis multiplex, visceral arteritis

• CardiacPericarditis, myocarditis

EXTRA-ARTICULAR MANIFESTATIONS

• NeurologicalAtlantoaxial subluxation, carpal tunnel syndrome,

peripheral neuropathies, mononeuritis multiplex

• Pulmonary Nodules, pleural effusions, pulmonary fibrosis,

bronchiolitis, Caplan’ssyndrome(RA plus pneumoconiosis), bronchiectasis

• Nodules Subcutaneous, lungs, pericardium

• Amyloidosis

Early RA

RA HANDS

Extensor tenosinovitis

Olecranon bursitis and subcutaneous nodules

Baker’s popliteal sist

RA FEET

RA feet

SPECIAL INVESTIGATIONS

• CRP and ESR usually elevated• Rheumatoid factor positive in 70%• Anti-CCP positive in a sub-population• X-rays: periarticular osteopenia and marginal erosion (x-ray changes takes months to develop)

CLASSIFICATION CRITERIA OF RA

NEW CRITERIA HAS BEEN PUBLISHED IN 2010

TREATMENT• A multidisciplinary team approach is followed

PATIENT EDUCATION• The nature of the disease as well as its chronic

course • Disease is characterised by fluctuations • It takes a considerable time before the therapy

starts to show results• Ignorance and especially the fear of becoming

an invalid must be adressed

PHYSIOTHERAPY• Exercise programme

– Maintain muscle strength– Maintain joint mobility as well as prevent

contractures

OCCUPATIONAL THERAPY

• Patient guidance with regard to work activities and joint-saving techniques, as well as the positions of joints during sleep

• Rest and night splints are also important

• Other aids for daily activies are also provided

PHARMACOLOGICAL THERAPY

• Analgesics

• DMARD (changes the course of the disease)

• Corticosteroids

• Immunotherapy

• Other

ANALGESICS• Oral analgesics (Paracetamol, tramadol)• NSAID’s

– gastro-intestinal and renal side-effects – high-risk cases

• Misoprostol (Cytotec) • Proton pump inhibiters • H2 antagonists

• Coxibs

CORTICOSTEROIDS• Low dose oral (chronic as a “DMARD”)• Intra-articular steroids• Pulse high dose treatment

– Flares– Treatment of complications

DMARD’S

• Chloroquine• Sulphasalazine• Methotrexate • Other immunosuppressants• Combination therapy

Biologic agents when patients fail DMARD therapy- TNF alpha inhibiters- B cell inhibiters- Interleukin 6 inhibiters

OTHER• Orthopaedic aids• Orthopaedic surgical treatment• Rx extra-articular complications• Supportive therapy

– education– anxiety– depression

OSTEOARTHRITIS

OSTEOARTHRITIS

• Most common arthritis• Strongly associated with aging• Characterised by focal loss of articular cartilage with new bone

proliferation and remodelling of the joint contour• Inflammation is NOT a prominent feature• Risk factors

– Family history– Caucasians– Women– Trauma– Adverse loading(obesity,sport,profession)

PATHOLOGICAL CHANGES IN OA

SYMPTOMS

• Artralgia and functional restriction• Insidious onset of symptoms• Pain worsened by movement and relieved by rest• Brief (<15min.) morning stiffness and brief “gelling” after rest

PHYSICAL SIGNS

• Bony swelling and deformity around joint margins• Joint-line tenderness• Decreased range of movement• Palpable coarse crepitations • Muscle wasting• Antalgic gait common with involvement of lower limbs

OA HANDS

SPECIAL INVESTIGATIONS

• NO impact on inflammatory markers(CRP, ESR)• X-ray changes

– Joint space narrowing– Subchondral sclerosis– Osteophytes– Bone cysts

• Correlation between x-ray changes and the level of pain and disability is variable

TREATMENT OF OA

• Exercise• Lose weight• Heat or cold• Analgesia

– Paracetamol– Topical NSAID– Oral NSAID– Opioids

• Intra-articular steroids can give temporary relief• Surgery

– For uncontrolled pain– Progressive functional impairment

Seronegative spondilo-arthropathies

CLINICAL FEATURES OF THE SERONEGATIVE SPONDARTHRITIS

• Asymmetrical inflammatory oligoarthritis (lower>upper limb)• Sacroiliitis and inflammatory spondylitis• Inflammatory enthesitis• Tendency for familial aggregation• NO association with positve Rheumatoid factor• Absence of nodules and other extra-articular features of RA• Strong association with HLA-B27

ENTHESITIS: Inflammation of the attachment of tendons or ligaments to bone (hallmark feature of the seronegative spondarthritis)

LOWER BACKPAIN

Inflammatory

Mechanical

Age < 40 years Any age

Progression Slowly/Chronic Acute

Duration of symptoms

> 3 months < 4 weeks

Morning stiffness

> 60 min. < 3o min.

Night pain(vertebral)

Common Absent

Exercise Improve Worsens

SI-joint tenderness

Common Absent

Vertebral mobility

↓ all directions ↓ flection

Chest expansion Decreased Normal

ANKYLOSING SPONDYLITIS

• Predilection for the sacroiliac joints and spine

• Male : female ratio of 3:1

• Progressive stiffening and fusion of axial skeleton

SPINAL FEATURES

• Insidious onset over months to years• Restriction of lumbar movements• Possible involvement of the entire spine as disease progress• Progressive spinal fusion

o Loss of lumbar lordosiso Marked thoracic kyphosis o Reduced chest expansion

EXTRASPINAL FEATURES

• Plantar fasciitis and Achilles tendinitis• Asymmetrical peripheral arthritis: shoulders, hips, knees and

ankles• Anterior uveitis• Aortic incompetence• Cardiac conduction defects• UPPER lobe pulmonary fibrosis• Osteoporosis

PLANTAR FASCIITIS

ACHILLES TENDON ENTHESITIS

TREATMENT

• Physiotherapy• Regular NSAID’s• Sulfasalazine for peripheral arthritis• Tumour necrosis factor(TNF)-Alpha inhibiters

REACTIVE ARTHRITIS

• Classically young men• Acute onset inflammatory oligoarthritis 1-3 weeks afer an infection

affecting the small and large joints of the lower limbs• Infective “trigger”

– Bacterial dysentery (due to Salmonella, Campylobacter, Shigella, Yersinia)

– Non-spes. urethritis (due to Clamydia)• First attack usually self-limiting with spontaneous remission within 4-6

months• Treatment:

– Mostly symptomatic with NSAID’S– DMARD’s in worse cases

PSORIATIC ARTHROPATHY

• Five major articular presentations:– Asymmetrical inflammatory oligoarthritis– Symmetrical polyarthritis (Strongly resemble RA)– Predominantly distal interphalangeal joint arthritis – Psoriatic spondylitis (strongly resemle Ankylosing spondylitis)– Arthritis mutilans

• Skin lesions• Nail changes: pitting, onycholysis, subungual hyperkeratosis• Treatment similar to Ankylosing spondulitis (methotrexate will also help for peripheral arthritis)

Symmetric psoriatic polyarthritis resembling RA

Distal interphalangeal joint involvement

Psoriatic Arthritis

Nail pittingSkin

EnthesophathyDactilitis

ARTHRITIS ASSOCIATED WITH INFLAMMATORY BOWEL DISEASE

• Two patterns of articular involvement:– Acute oligoarthritis with a predilection for the lower limb

joints.– Sacroiliitis and ankylosing spondylitis

QUESTIONS?