Approach for Diagnosis of Arthritis

1. Demographic data 2. Articular disease or non-articular disease 3. Clinical data Paijit Asavatanabodee Rheumatic Disease Unit Phramongkutklao Hospital Articular features Extra-articular features

Demographic Characteristics and Diagnosis of Articular Complaints

40 years TK, SLE, SSc

Associated or prior events Triggering events Aggravating factors

> 40 years

RA, OA, GCA

Personal history

Age of onset
40 years RD, AS Family history Drug history > 40 years Gout

Articular diseases or Peri-articular diseases

Symptoms and physical signs Pain / discomfort Stiffness Signs of inflammation Crepitus / locking / stability

Articular Pathology (eg. arthritis, OA)

Peri-articular Pathology (bursitis, tendinitis)

Non-rheumatic Pathology (eg. referred pain) Diffuse, beyond joint boundary without activity relation None None None

Around joint Localized plane boundary, after with use prolonged inactivity Often, > 15 min duration Around joint boundary Often (internal derangement, loose body) All direction, active = passive (with pain) Common if joint destruction, irreducible , brief duration Localized / linear plane Unusual, except rotator cuff tendinitis, FTS Some direction, active < passive (with pain) Uncommon, reducible

Traumatic arthritis

Olecranon bursitis

Cellulitis

Limited ROM

Free ROM without pain None

Deformity
Prepatellar Bursitis Anserinus bursitis Osgood Schlatter disease De Quervain tenosynovitis

Pattern of Joint Involvement and Diagnosis of Articular Complaints

Acute inflammatory MonoInflam Chronic Noninflam Acute migratory Chronic additive Acute Poly(> 4 joints) Chronic Asymmetry Trauma, crystal, bact.infection, tumor Non-bact infection, PVNS, RA, SpA Int.derangement, OA, Osteonecrosis Rheumatic fever, GC arthritis SpA (RD, ReA, PsA), RA Viral arthritis, BE, pseudogout, elderly gout, drug-induced arthritis Destructive Symmetry Non-destructive CNTD, malignancy, Stills, metabolic dis. RA, OA

Acute inflammatory Mono-

Trauma, hemarthrosis, gout, pseudogout, bact. infection, tumor

Acute hemarthrosis

Oligo(2-4 joints)

Traumatic arthritis

SpA (RD, PsA), chronic crystal arthropathy

Acute inflammatory Mono-

Trauma, hemarthrosis, gout, pseudogout, bact. infection, tumor Diagnosis Monitoring

Infection (TB, fungus), Monoarticular RA, SpA, amyloidosis, Chronic inflam.

Pigmented villonodular synovitis

1.

History

2. Physical examination 3. Routine lab 4. Synovial fluid analysis 5. Bone / joint radiograph 6. Serology 7. Histology 8. Special lab tests
Miliary TB Acid fast stain

TB arthritis

Rheumatoid arthritis
Rheumatoid nodule

Infection (TB, fungus), Monoarticular RA, SpA, amyloidosis, Chronic inflam.

Pigmented villonodular synovitis

Monoarticular

Chronic non-inflam.

Osteoarthritis, internal derangement, osteonecrosis

Diagnosis
1. History 2. Physical examination 3. Routine lab 4. Synovial fluid analysis 5. Bone / joint radiograph 6. Serology (RF, HLA B27) 7. Histology 8. Special lab tests (PCR, MRI, arthroscope, special C/S orstaining)

Monitoring

Osteoarthritis

Osteonecrosis
Godfrey's drop back test

Apleys test Lateral instability test

Drawers test

Mc Murrays test

Monoarticular

Chronic non-inflam.

Osteoarthritis, internal derangement, osteonecrosis Diagnosis Monitoring

Acute (migratory) Oligo-

Rheumatic fever, septic arthritis (GC, non-GC), BE

Septic vasculitis

1.

History

2. Extra-articular manifestation 3. Routine lab 4. Synovial fluid analysis 5. Bone / joint radiograph 6. Serology 7. Histology 8. Special lab tests (MRI, arthroscope, etc.)
Asymmetrical arthritis Septic vasculitis
Splinter hge Roth spot

Septic vasculitis

Grams stain

Acute (migratory) Oligo-

Rheumatic fever, septic arthritis (GC, non-GC), BE Diagnosis Monitoring

OligoUrethritis

Subacute-chronic additive
Balanitis

SpA (RD, ReA, PsA) RA

Psoriasis

Keratoderma blennorhagica

1.

History
Conjunctivitis

2. PE (articular & extra-articular) 3. Routine lab 4. Synovial fluid analysis 5. Bone / joint radiograph 6. Serology (ASO titer) 7. Histology 8. Special lab tests

Anterior uveitis

Dactylitis

Psoriatic nail

Guttage psoriasis

Acute OligoSubacute-chronic additive SpA (RD, ReA, PsA) RA Diagnosis Monitoring

1. History 2. PE (articular & extra-articular) 3. Routine lab 4. Synovial fluid analysis (for exclusion of crystal / infection) 5. Bone / joint radiograph 6. Serology (RF, HLA B27) 7. Histology 8. Special lab tests
Slapped cheek in Fifth disease Symmetrical polyarthritis

Poly-

(usually symmetrical)

Viral arthritis (Rubella, parvovirus, HVB, HVC, HIV, CMV, etc), bact. endocarditis Elderly gout, pseudogout (pseudo-RA) Drug-induced arthropathy

Rubella rash

Pseudo-RA in pseudogout Elderly gout in OA hand

Acute Poly-

Viral arthritis (Rubella, mumps, HVB, HVC, HIV, CMV, etc), bact. endocarditis Elderly gout, pseudogout Drug-induced arthropathy Diagnosis Monitoring

PolyChronic

Destructive Symmetry Nondestructive

RA, OA CNTD, vasculitis Stills, malignancy, metabolic dis.

Severe OA

Severe RA

1. History 2. PE (articular & extra-articular) 3. Routine lab 4. Synovial fluid analysis (crystal) 5. Bone / joint radiograph 6. Serology (viral studies) 7. Histology 8. Special lab tests (anti-histone Ab)
Jaccouds arthropathy SLE rash Gottron rash in DM

PolyChronic

Destructive Symmetry Nondestructive Diagnosis

RA, OA CNTD, vasculitis Stills, malignancy, metabolic dis. Monitoring Osteoarthritis

Rheumatoid arthritis
Adult Juvenile

Rheumatoid arthritis Osteoarthritis

Adult Juvenile

1. History 2. PE (articular & extra-articular) 3. Routine lab (CBC, U/A, ESR) 4. Synovial fluid analysis 5. Bone / joint radiograph 6. Serology (ANA, RF) 7. Histology (Tissue biopsy) 8. Special lab tests (TFT, PTH, search for occult malignacy)
Rare in OA: Shoulder, elbow, ulnar side of wrists, ankles, 2nd-5th MCP and 2nd-5th MTP joints Rare in RA: T-L spine

PolyChronic Asymmetry
Psoriasis

RD, PsA, (RA) Chronic gout Pseudogout

Gout

PolyChronic Asymmetry

RD, PsA, (RA) Chronic gout Pseudogout

Diagnosis Monitoring

1. History 2. PE (articular & extra-articular) 3. Routine lab

Arthritis mutilans Tophaceous gout

4. Synovial fluid analysis 5. Bone / joint radiograph 6. Serology (RF) 7. Histology 8. Special lab tests

Psoriatic arthritis
Distinctive clinical features 1. Asymmetrical polyarthritis 2. Predominance of DIP joint involvement 3. Tenosynovitis (sausage digit) 4. Psoriatic skin or nail lesions

Saturnine gout (Ancient Rome)

Saturn was a demonic god who ate his own children. The Romans noticed similarities between symptoms of gout (caused by lead poisoning) and the irritable god, and named the disease after him. Saturnine gout = moonshine gout Gout in chronic lead poisoning : Consumption of moonshine whiskey contaminating lead.

Increased uric acid production

Primary Specific enzyme defects Secondary Specific enzyme defects myelo or lymphoproliferative disorders Infectious mononucleosis Chronic hemoolytic anemia Gaucher's disease Severe proliferative psoriasis

Criterion
Sex Age Acute attacks Number of joint involved

Primary gout
Male much more than female Middle aged Common Mono-

Secondary gout
Male = female Elderly Uncommon PolyEarly Renal impairment, osteoarthritis

Decreased uric acid excretion (90%)

Primary Idiopathic (90%) Familial juvenile gouty nephropathy Secondary Chronic renal disease, kidney injury Volume depletion, Hypertension Sickle cell anemia, Hypothyroidism Down's syndrome Beryllium or lead poisoning Cystinuria Drugs (diuretics, low dose aspirin)

Tophi development Late Obesity, hypertension, Associations hyperlipidaemia, high alcohol intake

Disease causing shoulder pain

Rotator cuff tendinitis Rotator cuff rupture Frozen shoulder (adhesive periarthritis)

Physical Examination
Arthritis of shoulder joint

Calcific tendinitis

Subacromial or subdeltoid bursitis

Arthritis of Sternoclavicular joint

Shoulder arthritis Bicipital tendinitis

Subluxation of acromioclavicular joint

Physical Examination
1 2 3

Physical Examination

5 4
Winging of scapula

6. 1. Subacromial space: Rotator cuff tendinitis / impingement syndrome,

rotator cuff tear, calcific tendinitis, subacromial bursitis) 7 6

Posterior edge of acromion: Rotator cuff tendinitis, rotator cuff tear, calcific tendinitis, subacromial bursitis.

2. Bicipital groove: Bicipital tendinitis, biceps tendon subluxation / tear. 3. Acromioclavicular joint: RA, OA, SpA, septic arthritis. 4. Anterior glenohumeral joint: RA, OA, SpA, pseudogout, septic arthritis,
apatite arthropathy, osteonecrosis, glenoid labrum tear, frozen shoulder.

7.
8

Suprascapular notch: Suprascapular nerve entrapment

5. Sternoclavicular joint: SpA, RA, septic arthritis, OA.

8. Quadrilateral space: Axillary nerve entrapment.

Physical Examination
Trigger points

Painful arc

Shrug sign

Empty cane beer test (Supraspinatus)

Drop arm test

Lift-off test (Subscapularis)

Infraspinatus Teres major

Neer test (Impingement test)

Hawkins test (Impingement test)

Speeds test

Yergasons test

Taut band

Acromioclavicular pathology

Biceps tendinitis

Back pain
1. Non-specific or mechanical type
Injury Degeneration Congenital

Medical back pain

Inflammatory diseases
Infectious Non-infectious

Non-inflammatory diseases
Metabolic bone disease Malignancy Hematologic diseases Psychogenic rheumatism Malingering Referred pain

2. Specific type or medical type

Inflammation (Infectious, non-infectious) Non-inflammation (Fracture, malignancy)

Age range associated with back pain

20 30 40 50 60 Ankylosing spondylitis Inflamm. bowel disease Reiters disease Psoriatic spondylitis
Herniated nucleus pulposus

Red flags in low back pain

(Agency for Health Care Policy and Research, AHCPR guideline) 70 years 1. 2. 3. 4. 5. 6. 7. 8. Acute onset in patients with risk factors for osteoporosis Constant or progressive back pain Nocturnal pain Constitutional symptoms: fever, night sweats and weight loss Morning back stiffness in patients younger than 20 Progressive bilateral or alternating back pain Severe or progressive neurological abnormalities Cauda equina syndrome: saddle anesthesia, bladder dysfunction Vascular claudication or presence of abdominal mass
Lo Ba w c Pain k

Muscle strain Isthmic spondylolisthesis Fibrositis Osteoarthritis Metastases Spinal stenosis Multiple myeloma

9.

10. Unable to lie still due to pain 11. Patients with risk factors: immunosuppressive state, current or recent infection, malignancy or major trauma

Positive Red flag of recent LBP

1. Neurological compromise Saddle anesthesia Sphincter dysfunction Sensory / motor loss of lower limb 2. Fracture Recent trauma Risk factors for osteoporosis Long term use of corticosteroid 3. Infection Fever chill, weight loss. Risk factors: HIV, DM, drugs, etc. Recent surgery, dental work, sources of infection Shock of unknown origin 4. Cancer Young (<20) or elderly (>55) History of cancer, (+) S/S of malignancy Unexplained weight loss & nocturnal pain 5. Inflammatory arthritis Family history Nocturnal pain, AM stiffness, arthritis, enthesitis History of uveitis, psoriasis, IBD, etc.

Investigation & Rx.

Emergency MRI or CT Neurosurgical Evaluation

Erythema nodosum
Non-specific skin sign in autoimmune dis. Septal panniculitis without vasculitis Inflammatory subcutaneous plaques (nodules) on anterior aspect of shins Often accompanied by fever, chills, malaise, leukocytosis and arthritis. Dx: Typical lesion and typical location Prognosis: Spontaneous resolve in 3 - 6 wks without ulcerations or scarring.

Std.X-raysBone scan CBC, U/A, ESR, CRP, hemo & relevant C/S Bl.chem, Std. X-rays, MRI, bone scintigraphy Routine lab, ESR, CRP, Standard X-rays bone scan, MRI ESR, CRP, X-rays KUB, lumbar spine and heels Rx. NSAIDs DMARDs

Erythema nodosum
Associated conditions Infections Strept.pharyngitis, TB, leprosy, fungus, Lymes disease, leptospirosis, yersinia Drugs Penicillin, sulfonamide, bromides, contraceptive pills Autoimmune diseases: Behcet, SLE Malignancy: RE malignancy Miscellaneous Sarcoidosis, pregnancy, IBD (UC > Crohn) Idiopathic Rx: NSAIDs, steroids, KI

Size of Vessel Involvement in Vasculitis

Cutaneous
Palpable purpura Post-capillary venules LCV, any type of vasculitis of (medium-sized vessels) in medium and small vessel sized vasculitis. dermis. Less commonly capillaries and arterioles. Small arterioles (perpendicular branches in dermis). Medium-sized vessels. PAN, cryoglob, SLE, RA, D/M, APL (Sneddons syndrome), lymphoma, TB, syphilis, drug, PRV, IVDU, hypercalcemia, arteriosclerosis. PAN, TK, WG, RA, SLE, infection, drug, Behcets disease, sarcoid, malignancy, UC PAN, CS, WG. Hypersensitivity vasculitis, PAN, CS, WG, cryoglobulinemia.

LVR

Nodules

Ulcers Gangrene

Arterioles to small arteries. Medium sized vessels to capillaries.

Type of Vessel Involvement in Vasculitis

GI
Abdominal pain or mesenteric ischemia GI bleeding Small to medium sized arteries Capillaries to medium-sized arteries Capillaries Small to medium sized arteries HSP, PAN, CS HSP, PAN, CS

Vasculitis and BV size

Primary vasculitis
TK GCA PAN KW WG, CSS, MPA Cryoglob. HSP, cut. LCV Arterioles, capillaries, venules Small Medium arteries arteries Large arteries

Renal
Glomerulonephritis Ischemic renal failure MPA, WG, CS, Cryoglobulinemia, HSP PAN, TK (common) CS, WG (less common)

Pulmonary
Pulmonary hemorrhage Pulmonary infiltrates or cavities Capillaries; Less commonly small to medium sized arteries Small to medium sized vasculitis MPA, WG CS, MPA

Neurological
Peripheral neuropathies Stroke Small arteries Small, medium or large arteries PAN, CS, WG, cryoglobulinemia GCA, SLE

Clinical Features
Jaw claudication, visual loss, tender temporal A, temporal A pulsation Absent radial pulses Hypertension in young female Mononeuritis multiplex Sinusitis, pulmonary-renal synd. Asthma Testicular tenderness Bloody diarrhea, crampy abdomen

Specific types of primary vasculitis GCA

Drug-induced hyperuricemia
Production / intake Chemothrapeuatic agents Didanosine Ethanol Filgrasim Fructose Glucocorticoids Ribavirin / Interferon Nicotinic acid (>3g/d) Renal excretion ACE inhibitors (except losartan) Cyclosporin / Tacrolimus Diazoxide Diuretics (except triamterene, spinorolactone) Ethambutol / Pyrazinamide Levodopa Probenecid Salicylates (<2g/d) Nicotinic acid (>3g/d)

TK, GCA TK, PAN, WG, MPA PAN, WG, CS WG, MPA CS PAN HSP. IBD

CANT LEAP : Cyclosporin,

Alcohol, Nicotinic acid, Thiazides, Loop diuretics, Ethambutol, Aspirin low dose, Pyrazinamide.

Drug-induced Rheumatic Syndrome

Drug-induced Lupus
Carbamazepine Chlorpromazine Ethosuximide Hydralazine INH Methyldopa
Slow or rapid genotype Inactive metabolites Acetylation Aromatic amine

Drug-induced Rheumatic Syndrome

Drug-induced Anti-phospholipid Syndrome

Minocycline Penicillamine Phenytoin Procainamide Quinidine Sulfasalazine Chlorothiazide Chlorpromazine Ethosuxumide Hydralazine Interferon-gamma Oral contraceptive pills Phenothiazines Procainamide Quinidine Quinine sulphate

Drug-induced SCLE: Terbinafine, CCB, etanercept.

Drug-induced Rheumatic Syndrome

Drug-induced ANCA-associated Vasculitis
Hydralazine Methimazole Minocycline PTU d-Penicillamine

Anti-nuclear antibodies
(Patterns, ANA specificities, Disease association)

Homogenous Rim

Speckled

Nucleolar

Drug-induced Scleroderma
Vinyl chloride Fosinopril Pentazocine Tryptophan Bleomysin Organic solvents

Histone

ds-DNA Sm

U1-RNP

Ro

La Scl-70

+
High titer

Drug-induced Myositis
Statins

DIL

SLE

MCTD

SS

PSS

Drug-induced arthropathy
Fluoroquinolones, retinoids Cyclosporin, PZA, ETB.

Overlap syndrome or mixed CNT disease Use immunofluorescent assay for staining pattern Use ELISA or immunodiffusion technique for specific Ab test

Mixed Connective Tissue Disease

Clinical combination

Pseudogout (CPPD arthropathy)

PSS

Hand edema Raynauds Sclerodactyly Esophageal dysmotility PHT, IPD High titer of Anti-U1-RNP Ab No other autoAbs Anti-Sm Anti-DNA Anti-Ro Anti-La

SLE Arthragia or non-deforming arthritis Serositis RA PM Chronic non-infectious destructive inflammatory arthropathy Myositis

Licked candy

Overhanging

Gull wing

Spondyloarthropathies
Pertinent findings (asymmetrical involvement) Juxta-articular osteopenia (less severe) Diffuse joint space narrowing Bone erosions / osteolysis (marginal / subchondral bones) New bone formation Subchondral bone sclerosis Peri-articular or marginal bone proliferation Joint ankylosis (early) Predominance of DIP joint involvement (Psoriatic arthritis, undiff. SNSA)

Erlenmeyer flask

Pencil in cup (Pestle in mortar)

Secondary AS

Diffuse Idiopathic Skeletal Hyperostosis

DISH

Diffuse Idiopathic Skeletal Hyperostosis (DISH) Pertinent positive finding Flowing of at least 4 contiguous large paravertebral bony outgrowths (mug handle-like) Peri-articular calcifications Negative findings (DDx. OA, SNSA) Normal disc space and endplate Normal SI and hip joints No vertebral endplate / subchondral bone changes

Bony Proliferation of Spine

10 AS

20 AS

DISH

OA

Bilateral Sacroiliitis

Unilateral Sacroiliitis

No SI joint Involvement

SI ankylosis may occur

Vertebral Osteomyelitis
Loss of disc space Destruction of adjacent vertebral endplates No vertebral sclerosis No soft tissue masses Staph. aureus is the most common causative organism

Metastatic malignancy

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Metastatic spinal fracture

Pertinent findings Soft tissue mass (tumor extension) Normal (or widening) disc space until late Localized (diffuse) osteopenia or osteosclerosis or mixed bone density Stepping and destruction of vertebral endplate Asymmetric collapse of vertebral body Non-homogeneous bone density of collapsed vertebra Loss of pedicle or posterior element destruction

Osteoporotic Fracture of Spine

Osteoporotic spinal fracture

Pertinent findings
Generalized osteopenia Widening (or relatively normal) disc space Stepping (irregular surface) of well-defined vertebral endplate Collapse of vertebral body Homogeneous bone density and increased vertical radiodense striations of collapsed vertebra Increased bone density (compact bone + callus) Normal

Bone / Disc Destruction of Spine Bacterial Spdiscitis Potts disaease Spinal Osteoporotic metastasis fracture

Wedged

Codfish
1. 2. 3. Soft tissue shadow Intervertebral disc space Vertebral endplate 4. Bone texture of vertebral body 5. Pedicle

Pancake

Acute Gout Treatment Acute gouty attack

Single joint Intra-articular steroid injection or NSAIDs or colchicine Oligo-polyarticular joint
Normal renal and liver functions Taking oral medications High risks for cardiac or GI toxicity Renal or hepatic disease Unable to take oral medications

New drugs and sites of action

Allopurinol Uricase (uric oxidase)
Xanthine oxidase

Oxypurinol Febuxostat

Low risks for cardiac or GI toxicity

Solumedral IM,IV
100-150 mg/d x 1-2 days

NSAIDs

Colchicine
0.6 mg x 3

ACTH SC, IM, IV 30-60 mg /day then taper off in 2 wks 25-40 IU q 12 hrs for 1-3 days

Prednisoone

or

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Rheumatologys Ten Golden Rules

1. Good history and physical examination with knowledge of musculoskeletal anatomy. 2. Most shoulder pain is per-articular. Most low back pain is non-surgical. 3. Patients with acute monarthritis need a synovial analysis for diagnosis. 4. Most patients with chronic monarthritis need a synovial biopsy for diagnosis. 5. Gout rarely occurs in pre-menopausal women or affects spine and joints nearby spine.

Rheumatologys Ten Golden Rules

6. Patients with uncommon sites of primary OA need to be evaluated for secondary OA. 7. Primary fibromyalgia rarely initially presents after age of 55 or presents with abnormal lab values. 8. Fever and multi-organ complaints in pts with known systemic rheumatic diseases need to be excluded infection and possibly other causes. 9. Why order a lab test? What to do if it comes back abnormal? 10. Most of asymptomatic persons having positive RF or ANA have neither RA or SLE.

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