APPROACH TO THE PATİENTS WİTH CHRONIC ARTHRITIS

Dr. MÜGE BIÇAKÇIGİL KALAYCI

CHRONIC MONOARTHRITIS

• ESSENTIAL FEATURES• Chronic inflammatory monoarthritis

– infection, crystal-induced arthritis, sarcoidosis, or monoarticular presentation of oligoarthritis or polyarthritis

• Chronic noninflammatory monoarthritis – osteoarthritis, mechanical , Chondromalacia

patellae, and osteonecrosis.

• Arthrocentesis and imaging studies are important dignostic tests

CHRONIC MONOARTHRITIS• INITIAL CLINICAL EVALUATION• Infections, particularly indolent infections, are

a concern with inflammatory monoarthritis that lasts from weeks to months.

• The particular joint involved influences the differential diagnosis.

CHRONIC MONOARTHRITIS

• LABORATORY EVALUATION• A critical step is to determine whether the

monoarthritis is inflammatory, preferably by analyzing synovial fluid.

• Synovial fluid should be sent for culture (bacterial, mycobacterial, and fungal), WBC count, and gram stain and examined for crystals by polarized light microscopy.

CHRONIC MONOARTHRITIS

• Routine laboratory studies (eg, complate blood cell count, creatinine, and urine analysis) and determination of the ESR or CRP and uric acid level can provide helpful information.

• Patients with inflammatory monoarthritis and negative bacterial cultures shoud be tested for reactivity to purified protein derivative (PPD)

CHRONIC MONOARTHRITIS

• IMAGING STUDIES• Unlike in acute monoarthritis , radiographs

can be helpful in evaluating chronic monoarthritis and can point to correct diagnosis in cases of infection, osteoarthritis, and osteonecrosis.

Differential diagnosis of chronic

inflammatory monoarthritisInfection Nongonococcal septic arthritis Gonococcal Mycobacterial Fungal ViralCrystal-induced aarthritisGout Pseudogut

Monoarticular presentation of oligoarthritis or polyarthritis

SpondyloarthropathiesRheumatoid arthritisLupus and other systemic autoimmune diseases.

Sarcoidosis

Uncommon or rareFMFAmyloidosisPigmented villonodular synovitis

Non-inflammatory

OsteoarthritisInternal derangements (eg,torn,meniscus)Chondromalacia patellaOsteonecrosisNeıropathic (charcot) arthropathy

CHRONIC MONOARTHRITIS

• Tuberculous infection of a joint can present after days, weeks or months of symptoms.

• Smears for acid fast bacilli are positive only 20% of cases,

• Cultures for mycobacteria are positive in 80 %, but test results take weeks.

• Synovial biopsy can expedite the diagnosis of tuberculous arthritis , and is also indicated in suspected cases of fungal arthritis.

CHRONIC OLIGOARTHRITIS

• ESSENTIAL FEATURES• Careful description of arthritis and detection

of extraarticular disease facilitate accurate diagnosis.

• Radiographs are often of diagnostic value.

CHRONIC OLIGOARTHRITISCommon inflammatory causesSpondyloartropatiesReactive arthritisAnkylosing spondylitisPsoriatic arthritisInflammatory bowel disease

Uncommon-rare inflammatory arthritis

Subacute bacterial endocarditisSarcoidosisBehçet diseaseCeliac disease

Common non-inflammatory causesOsteoarthritisUncommon-rare non inflammatoryHypotyroidismamyloidosis

CHRONIC OLIGOARTHRITIS

• Spondyloartropathies are the most common cause of chr. Oligoarthritis

• Early onset rheumatoid arthritis must be distinquished.

• Osteoarthritis presents as oligoarthritis of the hips or knees

CHRONIC OLIGOARTHRITIS

• Laboratory evaluation• Synovial fluid analysis- culture- crystals

• RF-dd(x) of RA

• HLA B 27- limited value

CHRONIC OLIGOARTHRITIS

• Radiographs and Imaging studies-considerable value

• Evidence of sacroitis indicates a spondyloarthropaty and narrow dd(x)

• Erosions of RA and Gout

CHRONIC OLIGOARTHRITIS

• Spondyloartropaties- asymmetric oligoarthritis

• RA- symmetric poliarthritis• İn early RA- oligoartitis

• Stiffness and pain in low back- Spa• RA- only cervical spine

CHRONIC OLIGOARTHRITIS

• Dactylitis(sausage digits)- sPA, gout, sarcoidosis• Extraarticular manifestations that point to

correct diagnosis

• Psoriasis –umblicus, external auditory canal, scalp and anal creft

• Diarrea- inflammatory bowel disease.• Anterior uveitis

CHRONIC POLYARTHRITIS

• ESSENTIAL FEATURES• Rheumatoid arthritis and Osteoarthritis are

leading causes.• Careful delineation of the joints involved,

particularly in the hands, can help to the correct d(x)

• The distinction between inflammatory non inflammatory is critical

CHRONIC POLYARTHRITISInflammatory –Common

Rheumatoid arthritisSLEspondyloartropaties (especiaally Psoriatic art)GoutChronic hepatitis C infectionDrug induced lupus syndrome

Inflammatory-Uncommon

Paraneoplastic polyarthritisRemitting seronegative symmetric polyarthritis with pitting edema (RS3PE)Adult onset still disease

Inflammatory- uncommon

VasculitiitisSjögren’s syndromeViral infections other than hepatitis C

Non inflammatory

OsteoarthritisHemachromatosis

CHRONIC POLYARTHRITIS

• Laboratory evaluatıon• If arthrosentesis is feasible- joint aspiration-

cell count and crystals• CBC• RFT• Urine analysis• ESR_CRP• RF-ANA- hepatitis B and C serology

CHRONIC POLYARTHRITIS

• Radiographs are indicated in most cases of chronic polyarthritis

• Erosion-RA-OA-hemachromatosis-gout- SPA

• Non-erosive- SLE-drug induced SLE-chronic hepatitis C.

DD(x) of chronic polyarthritis

• Osteoarthritis and Rheumatoid arthritis have different patterns of joint involvement in the hand.

• OA- involves DIP, PIP and first MCP joints.

• RA- PIP- MCP and wrist

• Osteoarthritis and Rheumatoid arthritis spare certain joints

• OA- does not involve MCP, wrist, elbow, ankles• • RA- spare DIP, thoracic and lumbosacral spine

and sacroiic joints• Psoriatic arthritis- DIP joints

ASSOCIATED HISTORY

• •Predisposing factors• •Medication• •Bowels• •Urinary• •Rashes• •Eyes• •Raynaud’s• •Sicca• •Family History

EXAMINATION

•Multi-system•Disability•Range of movement•Signs of inflammation

INVESTIGATIONS

• •FBE/E/LFT• •ESR/CRP• •Iron studies• •Uric Acid• •Auto antibodies• •HLA-B27• •Viral serology• •Joint fluid• •Imaging

Skin and nail findings and arthritis

Skin rashes

• Diffuse eruption with fever and systemic findings

• Generally viral or due to primary immunological disease

• Must be differentiated from bacterial diseases

• SLE, DM

• Rheumatic fever

• Still disease

• Kawasaki disease

Adult still disease

Papulosquamaus lesions

• Psoriatic arthritis

• Reiter Syndrome

• SLE

SLE

Annular lesions

• Rheumatic fever

• Subcutaneous Lupus

Facial lesions

• Malar and discoid rash

• Lupus pernio: Sarcoidosis

• Dermatomyositis-gottron papules-heliotrope rash

• Lupus vulgaris: cutanous tuberculosis

Nodular lesions

• RA, ARA, crystal artropathies

• Erythema nodosum: Behçet’s disease,Sarcoidosis, spondyloartropathies, tbc

Erysipel like rash (FMF)

Acneiform lesions( behçet’s disease)

Purpura

• purpura:vasculitis

Skin thickening

• Scleroderma

• Eosinophilic fasitis and eosinophilic myalgia

syndrome.

Photosensitive skin eruption

• Connective tissue diseases, SLE, DLE,

DM...

• Phototoxic drug allergies (sulfa,

thiazid..)

Oral ulcers

• Behçet ‘s disase

• Crohn disease

• Spondyloarthropathies

• SLE

Genital ulcers

Behçets disease

Reactive arthritis

Sousage digits/Enthesopathy

• Reactive arthritis

• Psoriatic arthritis

Sousoge digits

Achille tendinitis

Raynaud

• Primary or secondary

• Primary- female- %5-8

• Secondary – connective tissue disorders

• Scleroderma, SLE, SS, RA, DM/PM...

Fever, weight loss, malaise and arthritis

Fever and rheumatological diseases

• ARA

• FMF

• JRA/JİA

• Adult onset Still disease

SLE

Vasculitis

Behcet ‘s disease

Scleroderma

DM/PM

Sarcoidosis

Eye and arthritis

Eye and rheumatological diseases

Uveitis

• Anterior uveitis: BH, Spondyloarthropathies,

Sarkoidosis, JRA..

• Posterior Uveitis: BH, SLE, Sarkoidosis...

Cornea Involvement

• Marginal erosion: RA

• Skleritis/episkleritis: RA

Keratoconjonktivitis sicca

• Primary or secondary Sjögren syndrome

Anterior uveitis an hypopyon

Dry eye and sclera erosions

Abdominal symptoms and arthritis

Abdominal symptoms and arthritis

• Diarrea

• Abdominal pain

• Intestinal bleeding

• Enteropahtic arthritis

• Reactive arthritis

• Behcet disease

• FMF

• Vasculitis

• Connective tissue

diseases

Mono-oligoarthritis

Poliarthritis

Axial involvement