rheumatology panel for primary care dr. vu kiet tran, md
TRANSCRIPT
![Page 1: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/1.jpg)
Rheumatology Panel for Primary Care
Dr. Vu Kiet Tran, MD
![Page 2: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/2.jpg)
Objectives
• Recognize history and physical exam are the cornerstone of diagnosis for most rheumatologic diseases
• Analyze rheumatology panels in conjunction with history and physical exam to derive a diganosis
• Enumerate the limitations of these rheumatology panels
![Page 3: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/3.jpg)
Disclosure
• Medical advisor– Dynacare laboratories
• Medical director– Best Doctors Canada
![Page 4: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/4.jpg)
Case 1
• 56yo female with joint pain in both knees for 3-4 months.
• It is worse after a long day standing at work.• She has a hard time going up and down stairs• It is worsening
She wants testing for Rheumatoid arthritis
![Page 5: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/5.jpg)
Case 2
• 36yo female presents with fatigue and shortness of breath on exertion.
• She is losing hair and has a facial rash that appeared 3 weeks ago.
• She is concerned she has Lupus like her mother.
What will you do and what tests would you order (if any)?
![Page 6: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/6.jpg)
Case 3
• 37yo male sees you because her has been c/o joint pains in the hand for 3-4 weeks
• He feels the joint are stiff in the morning
What other symptoms are you looking for?
![Page 7: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/7.jpg)
Take Home Messages
• History and physical exam are the fundamentals for an accurate diagnosis
• The lab tests are used to confirm or refute your clinical impression
• Lab testing is not always necessary to make a diagnosis– Can sometimes be misleading
• High degree of false positives– Lead to additional and unnecessary testing
![Page 8: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/8.jpg)
Major causes of Inflammatory Polyarthritis
Etiologies
Infectious arthritisBacterial
LymeBacterial endocarditis
ViralReactive ArthritisRheumatic feverReactive arthritisEnteric infection
Rheumatoid Arthritis
Inflammatory Osteoarthritis
Crystal-induced arthritis
Etiologies
Systemic rheumatic illnessesSLE
VasculitisSystemic Sclerosis
Polymyositis/dermatomyositisStill’s disease
Behcet’s diseaseRelapsing polychondritis
Seronegative SpondyloarthritisAnkylosing spondylitis
Psoriatic arthritisIBD
Systemic illnessesSarcoidosis
Palindromic rheumatismFamilial Mediterranean fever
MalignancyHyperlipoproteinemias
![Page 9: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/9.jpg)
History
• Presence of arthritis (synovitis) or not• Mono or polyarthritis• Seek out join emergencies– Fever– Hot and swollen joints– Weight loss/malaise
![Page 10: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/10.jpg)
History
• Joint symptoms– Pain quality– Time of onset– Duration– Exacerbating or relieving factors
![Page 11: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/11.jpg)
Joint symptoms
Inflammatory• Pain is worsened with
immobility• Morning stiffness or
“gelling”• Joint involvement is usually
symmetrical
Non-inflammatory• Pain is worsened by
mobility and weight-bearing• Pain is relieved by rest• Joint involvement in OA is
frequently asymmetrical, especially in the larger joints
![Page 12: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/12.jpg)
Associated symptoms
Non-rheumatic• Weakness (neurologic or
myopathic illnesses)• Fever• Night sweats• Weight loss
Rheumatic• Multi-system involvement
– Fatigue– Rash– Adenopathy– Alopecia– Oral or nasal ulcers– Pleuretic chest pain– Raynaud’s phenomenon– Dry eyes or mouth
![Page 13: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/13.jpg)
History
• Focus on – Usual areas– PMHx– Medication list– Family history– Social history– ROS– History of joint injury– Functional capacity– Psychological state and social support
![Page 14: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/14.jpg)
Physical exam
• Establish the presence of synovitis– Soft tissue swelling– Warmth over the joint– Joint effusion– Loss of motion
• Axial involvement– Seronegative spondyloarthritis
![Page 15: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/15.jpg)
![Page 16: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/16.jpg)
Physical exam
• Subcutaneous nodules (rheumatoid nodules vs tophi)
• Skin lesions• Eye manifestations– Keratoconjunctivitis sicca– Uveitis– Conjunctivitis– Episcleritis
![Page 17: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/17.jpg)
![Page 18: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/18.jpg)
![Page 19: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/19.jpg)
![Page 20: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/20.jpg)
Classification Criteria
![Page 21: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/21.jpg)
Adding radiographs
![Page 22: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/22.jpg)
Diagnosis of RA
• Classification criteria is not diagnostic criteria• There is no diagnostic criteria for RA• Classification criteria might be a guide to
“clinical diagnosis”
![Page 23: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/23.jpg)
SLE
• Diagnosis is based on clinical judgment, after excluding other diagnoses
• Heterogeneity (broad range) of clinical presentation is often a challenge
![Page 24: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/24.jpg)
SLE
• Classic triad– Fever– Joint pain– RashIn women of child-bearing age
![Page 25: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/25.jpg)
Symptoms of Lupus
• Constitutional symptoms– Fever– Weight loss– Fatigue– Lymphadenopathy
• Photosensitivity– Malar rash
• Painless oral or nasal ulcer
• Patchy hair loss
• Raynaud’s phenomenon• Migratory/symmetrical
joint swelling• Serositis
– Pleuretic chest pain or dyspnea
• Pericarditis– Pleuretic chest pain
• Leg edema• Seizure/psychosis
![Page 26: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/26.jpg)
![Page 27: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/27.jpg)
Laboratory studies
• Not always necessary to make a diagnosis• Can sometimes be misleading
![Page 28: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/28.jpg)
Laboratory studies
• ESR• CRP• ANA• Rheumatoid factor (RF)• Anti-citrullinated peptides (Anti-CCP)• Uric acid• Antibodies
– Strept A– Hep B– Hep C– Borrelia Burgdorferi (Lyme)
![Page 29: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/29.jpg)
ESR
• Non-specific marker of inflammation• Never diagnostic• May be abnormal in
– Advancing age– Gender– Infectious, malignant, rheumatic diseases– Renal failure– Diabetes– obesity– Occult malignancy
• May be normal in up to 70% of RA patients
![Page 30: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/30.jpg)
CRP
• Synthesized in the liver in response to tissue injury• Levels change more quickly than the ESR
– can increase within 4-6 hours– peak at 24-72 hours– normalize within a week
• Non-specific marker of inflammation• Never diagnostic• It is more stable and less variable than ESR• More reliable for longitudinal
measurement/monitoring disease activity than RF
![Page 31: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/31.jpg)
ANA
• High sensitivity for SLE• Low specificity for SLE• Therefore, a negative test essentially rules-out SLE• High false positives– Up to 30% of healthy people may turn out to have a
positive titer– Even in the presence of a positive ANA, a patient with
few or no clinical features of SLE is unlikely to have SLE
![Page 32: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/32.jpg)
ANA
• The higher the ANA titer, the more likely that the patient has either SLE or another ANA-associated disease
• ANA is positive in all SLE patients at some time in the disease
![Page 33: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/33.jpg)
Diseases associated with positive ANA
![Page 34: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/34.jpg)
Rheumatoid Arthritis Panel
Rheumatoid factor• Commonly used in the diagnosis of
RA• Positivity implies a more severe
course but is not specific• Sensitivity for RA varies (around 50%
– 80%)• Usually lower in early RA and higher
in established clinical disease. • Higher titers are associated with
more severe disease but fare poorly as a longitudinal measure of disease activity.
• Measurement of RF isotypes have been found to be clinically useful– IgA RF isotype has been linked to erosive
disease
Anti-CCP (anti-cyclic citrullinated peptide)• Sensitivity to RA is similar to that of RF
(50-85%)• More specific (90-95%)• Most useful in the setting of seronegative
subjects suspected of having RA• Detected in early RA & may even
antedate onset of inflammatory synovitis• Better predictor of erosive disease than RF• Does not correlate with extra-articular
disease• Positive anti-CCP + RF (IgM) correlates
strongly with radiographic progression• Not useful in longitudinal monitoring of
RA disease activity
![Page 35: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/35.jpg)
![Page 36: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/36.jpg)
SLE specific antibodies• Anti-DsDNA
– high specificity for SLE– Often correlates with more active/severe disease– Positivity in SLE is also associated with renal disease or involvement– Tends to decrease or become undetectable in quiescent disease
• Anti-Sm– Autoantibody with high specificity for SLE– But only seen in 25-30% of SLE patients– Unlike anti-ds DNA, it remains elevated even in quiescent disease
• Anticardiolipin antibodies– Associated with an increased risk of vascular thrombosis, thrombocytopenia and
recurrent fetal loss in patients with SLE– Also seen in Anti-Phospholipid Syndrome
• Lupus anticoagulant– Immunoglobulin that binds with phospholipids that line cell membranes and which
usually prevents clotting in a test tube (in vitro)
![Page 37: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/37.jpg)
SLE specific antibodies• Anti-SSA (Ro)• Anti-histone• VDRL• C3, C4, CH50 complements• ENA (Extracted Nuclear Antigen) antibodies
– Anti-RNP– Anti-Sm– Anti-SSA (Ro)– Anti-SSB (La)– Scl-70– Anti-Jo-1
• Urine protein-to-creat ratio
![Page 38: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/38.jpg)
Systemic Scleroderma panel• Scl-70
– Positive in 20-60% of patients with diffuse Systemic Sclerosis– Specificity is almost 100%– Sensitivity is low– When present, diagnosis of Scleroderma is almost certain– Positivity is associated with an increased risk of radiographic pulmonary
fibrosis• Anti-centromere
– Almost certainly rules in limited cutaneous Systemic Sclerosis/ CREST– Indicates a high rate of pulmonary hypertension and primary biliary
sclerosis• Anti-U3 RNP
– Its presence is associated with muscle, small bowel, renal and cardiac involvement as well as pulmonary hypertension
![Page 39: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/39.jpg)
Sjogren’s Syndrome panel
• Anti-SSA (Ro)– Associated mainly with Sjogren’s Syndrome– Found in 75% of patients with primary Sjogren’s– Found in 10-15% of patients with secondary Sjogren’s– Found in 50% of patients with SLE (Subacute Cutaneous Lupus),
Cutaneous Vasculitis, Interstitial Lung Disease– Also associated with other conditions such as Neonatal Lupus
Syndrome and congenital heart block• Anti-SSB (La)
– Found in 40-60% of those with Sjogren’s Syndrome– Rarely present without Anti-SSA (La)– May also be positive in SLE (associated with ANA-negative Lupus) and
Scleroderma
![Page 40: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/40.jpg)
Polymyositis/dermatomyositis panel
• Anti-jo-1– Associated with Polymyositis/ Dermatomyositis and Interstitial
Lung Disease– Presence typically implies severe muscle involvement and
resistance to treatment• Anti-SRP
– Presence indicate patients who have • severe, refractory disease• those who may have cardiac involvement or cardiomyopathy
• CK• Aldolase• Anti-Mi2
![Page 41: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/41.jpg)
Mixed Connective Tissue Disease Panel
• Anti-U1 RNP– Highly associated with MCTD– Positive in 95-100% of MCTD patients– May also be positive in SLE and Scleroderma
![Page 42: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/42.jpg)
Vasculitis Panel• ANCA• Used in the evaluation of vasculitis (i.e. Wegener’s granulomatosis,
microscopic polyarteritis, Churg-Strauss syndrome)• Two target antigens are PR3 (proteinase-3) and MPO (myeloperoxidase)• Two basic staining patterns are cytoplasmic (c-ANCA) and perinuclear (p-
ANCA)– some diseases have a predilection for one pattern.
• c-ANCA pattern is highly sensitive and is seen in more than 90% of active Wegener’s granulomatosis wherein PR3 is the antigen involved
• p-ANCA pattern is commonly associated with microscopic polyarteritis and is directed against MPO
– The more active and extensive the vasculitis, the more likely are ANCA assays to be positive
![Page 43: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/43.jpg)
![Page 44: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/44.jpg)
![Page 45: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/45.jpg)
Imaging
Plain radiographs• RA– Erosion at wrist, hand, foot
• Ankylosing Spondylitis• Calcium pyrophosphate crystal deposition
disease (CPPD)– chondrocalcinosis
![Page 46: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/46.jpg)
Imaging
Ultrasound• Tendonitis• Bursitis
![Page 47: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/47.jpg)
Joint aspiration
![Page 48: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/48.jpg)
SUMMARY
![Page 49: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/49.jpg)
![Page 50: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/50.jpg)
![Page 51: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/51.jpg)
Take Home Messages
• History and physical exam are the fundamentals for an accurate diagnosis
• The lab tests are used to confirm or refute your clinical impression
• Lab testing is not always necessary to make a diagnosis– Can sometimes be misleading
• High degree of false positives– Lead to additional and unnecessary testing
![Page 52: Rheumatology Panel for Primary Care Dr. Vu Kiet Tran, MD](https://reader035.vdocuments.site/reader035/viewer/2022081513/5697bfc61a28abf838ca723a/html5/thumbnails/52.jpg)
THANK [email protected]