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WARNING SIGNS OF RHEUMATIC DISEASE

Dr. Llamado ACR 1987 Classification Criteria for RA
1. Morning stiffness >30 mins
(Module 4 / Lecture Date: July 17, 2006) 2. arthritis of the 3 or more joints
3. arthritis of hand joints
CASE 1: 4. symmetric arthritis
62 year-old female 5. rheumatoid nodules
BMI = 26 (overweight) - extensor surface of elbow
Hand pain - poor prognosis marker, If present, must be
Knee pain worsens after prolonged standing more aggressive with management
PE: genu varum (bow-legged) 6. Serum rheumatoid factor
- there may be sero (-) Rf but does not ruleout
Dx: OSTEOARTHRITIS RA

Clinical
- a prognostic factor: the ↑  poorer prognosis
7. radiographic changes
 Age > 50 y.o.
 Morning stiffness < 30 mins Note: First 4 criteria must be present for at least 6 weeks
 Crepitus (Rationale: Viral arthritits may mimic RA but resolves within 6
 (-) inflammation weeks)
 Bony enlargement or tenderness
Hand involvement
Laboratory
 ESR < 40 mm/hr  PIP involvement in early stage
 (-) RF  Sparing of DIP especially in early stage
 Synovial fluid non-inflammatory
 Soft tissue swelling  synovitis
Radiography  X-ray: bone erosion
 Osteophytes or new bone formation  Deformities
 Joint space narrowing: asymmetric - Swan neck deformity
- Buotonnier deformity
 Subchondral cyst or sclerosis : signifies new bone - Mallet finger: flexion of DIP
formation; ↑ opacity  Subluxation of phalanges: prominence of the head
 Malalignment of MCPs
 Problem with grip
When looking at x-ray, note for:
 Alignment - straight Knee x-ray of RA

 Bone - radioopaque  Fusion of bones  symmetric narrowing 

ankylosis
 Cartilage
- not seen radiographically, look for joint space
Spine involvement
which will give an idea of the thickness/thinness
 Compare medial vs. lateral compartment
 Upper cervical spine are affected  C1-C2
(atlantoaxial joint)
- fibula (lateral)
- if (+) joint space narrowing, compare:  Look at the distance between 2 bones. If > 5 mm
Assymetrical in OA space of atlantoaxial joint  suggestive of
- if (+) white area in tibial plateau: Unnecessary subluxation; joint instability
pressure/bone-to-bone contact  stimulus for
Criteria for Progression of RA
osteophytes  leading to new bone formation
(subchondral sclerosis)
Stage 1: Early
No destructive changes
Hand involvement in OA
Osteoporosis on x-ray
 Refers to bony new growth or bone enlargement
Stage 2 : Moderate
 DIP = Heberden’s nodes Osteoporosis and slight subchondral bone or
 PIP = Bouchard’s nodes cartilage destruction
 X-ray : (-) joint space, (+) osteophytes No joint deformities
 (-) tissue swelling. Mobility may be limited
 Note: In RA, there is an inflammatory cytokine (esp Adjacent muscle atrophy
Nodules or tenosynovitis may be present
IL-1) reaction  osteoclast stimulation  no new
Stage 3 : Severe
bone formation
Osteoporosis and erosions
Deformity without ankylosis
Spine involvement in OA
Extensive muscle atrophy
 (+) osteophytes Nodules & tenosynovitis
 Asymmetric Stage 4 : Terminal
 Subchondral sclerosis at the edge of the vertebral Fibrous or bony ankylosis (fusion of 2 bones, no
body (radioopacity) flex/ext)
 OBLIQUE VIEW: done to view the IV joint space Features of Stage 3
o (+) Scotty-dog sign
o (+) joint space narrowing
o intact cartilage above but narrowing in lower CASE 3:
43 year-old male
segment
Recurrent monoarthritis
 Commonly affected:
Later on becoming polyarthritis
o Weight-bearing joints (hips and knees)
Chronic alcoholic beverage drinker
o Lower cervical  Usually C6-C7 Occasional chest discomfort
o Hand (bony enlargement) Dx: GOUT

1ST MTP joint : Podagra

CASE 2: Most painful type of arthritis
34 year-old female Any form of stress can cause change in serum uric acid and
Hand joint pain & swelling for 6 months precipitate gout
Muscle aches & pains
Anemia (systemic manifestation) Hyperuricemia : (+) tophi
Tophaceous or urate nephropathy
Dx: RHEUMATOID ARTHRITIS Can be deposited elsewhere (ears, heart, kidney)
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Gouty arthritis generalities:  Thinning and breakdown of trabeculae
 Extremely painful episodes of arthritis
Spinal osteoporosis: Clinical Features
 Intermittent course, usually monoaticular involving
 (-) early warning symptoms
the big toe, ankle, knee
 Height loss
 May later be poly or oligoarticular
 Dorsal kyphosis
 Tendency to abuse NSAIDS (and steroids)  may  Paraspinal muscle pain
cause upper GI bleeding  Restrictive lung disease
 May be precipitated by stress e.g. surgery & blood  Protuberant lower abdomen with early satiety,
transfusion bloating & nausea (increased risk of function at other
areas e.g. hip)

Vertebral fracture associated with other fractures as well

Acute attack of gout
 Associated with change in serum uric acid level
(either increase or decrease)
 Taking of Allopurinol within 24-48 hours of attack of
gout to decrease hyperuricemia may prolong attacks
due to the sudden drop. Initiate Allopurinol only
when the attack of gout has subsided
 If the patient is not on allopurinol, do not introduce; If
the patient is already on allopurinol, don’t stop
immediately
X-ray:
 (+) tophaceous erosion: far from joint, can deposit
into the bone, as compared to RA where erosions
are near the junction areas
CASE 4:
43 year-old male
Back pain, > 4 months
Morning stiffness
PE: (-) lumbar lordosis
DX: ANKYLOSING SPONDYLITIS
 Bridging syndesmophytes (ossification)
 Early changes: squaring of the vertebral body
 X-ray: Bamboo spine deformity
 Mgt: Infliximab earliler prevention of LOM better
Hip Fracture
 16%: die within 1-2 years due to fracture, embolism,
surgical complications
 80%: loss of independence permanently
Far Eastern Osteoporosis Study, 1996
 Total interviews: 2412 females (Phils 600)
 Awareness of osteoporosis: considerably lower
among Asian women than among women in Europe
 Only about 66% of Asian women surveyed are
aware of the disease compared to 90% of European
women
 Asian women regard it mainly as a function of aging
and not a disease
 Repeat study: no change in awareness level
 Peak bone mass: achieved by 35 years old, after 35 yo,
physiologic bone loss
Vertebral fracture
Assess the following
 Vertebral height
 Anterior, mid-
 Posterior
• Reduction in at least >20% considered as
vertebral compression fracture

Characteristics of Back Pain Deformities

 Onset before 40 years 1. Normal
 Onset is insidious 2. Concave: decrease in midvertebral height

 Duration > 3 months 3. Wedge: anterior part

 Associated with morning stiffness 4. Crush: all (ant-post-mid) parts of the vertebra
 Decreased stiffness with exercise  impt treatment
Bone densitometry
modality = assesses bone mineral density

T-score: Px score vs. normal young sex-matched

CASE 5 : assesses how much bone was lost from the time
53 year-old male px had his or her peak-bone mass
asymmetric arthritis
“Dandruff” Z-score: Px score vs. normal age-matched & sex matched
nail changes : if < -2 = maybe secondary bone loss

Dx: PSORIATIC ARTHRITIS WHO Criteria (Vertebrae and hip)

 Mgt: aggressive due to destructive course T-score
 Nail-pitting changes  early changes  check for > -1 : Normal
-1 to -2.5 : Osteopenia
scalp (dandruff along the hair line)
-2.5 and below : Osteoporosis
 Scalp changes follow hairline
< -2.5 + fracture : Severe osteoporosis
Hand deformity
Warning signs of Serious Rheumatic Disease
 X-ray of DIP : fusion of bone
 Persistent or worsening pains
 Pencil-in-cup deformity
 Telescoping digit  redundant skin, retractable
 Pains unrelieved by regular intake of NSAIDs or
other potent analgesics
 “Nerve pain” (tingling, burning, electric current-like
CASE 6 sensation), vascular pain (claudications), bone pains
68 year-old female  Accompanied by fever, weight loss, pallor, etc.
Chronic back pain
Loss of height
 Elderly patients
PE: Dowager’s hump (C4 compression)
Examples: Infection, Malignancy, Vasculitis (impaired vascular
supply)
Dx: OSTEOPOROSIS

 Silent disease
CASE 7
 Often asymptomatic until fractures occurs 25 year-old male
 Early diagnosis & treatment are essential Chronic fever, cough, back pains
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ESR 120 mm/ 1st hour
Draining sinuses (usually due to TB) Treatment of Septic Arthritis
Recent paraparesis
 Appropriate antibiotics
Dx: POTT’S DISEASE  Draining of fluid
 Joint immobilization (during acute phase only)
 Anterior wedging of the spine
 Abscesses (usually continuous; rare presentations:
skip lesions  problem for surgery) CASE 9
60 year-old male
Heavy smoker
Progressive peripheral swelling of right shoulder
CASE 8
Not relieved by NSAIDs and potent analgesics
40 year-old male
X-ray: Lytic lesions, destroyed humoral head
Alcoholic DM Type 2
Recent arthrotomy for TB arthritis
Dx: PULMONARY MALIGNANCY with BONE METASTASIS
2 weeks post-op developed non-healing
wound or persistent effusion

TB and Bacterial type of arthritis CASE 10

73 year-old male
Dx: SEPTIC ARTHRITIS Bone pains and weight-loss
Elevated acid phosphatase

 Direct invasion of joint space by a variety of Dx: PROSTATIC MALIGNANCY with BLASTIC and LYTIC
microorganism such as bacteria, mycobacteria and LESION
fungi

VS. Reactive arthritis: occurs after an infection outside the  Blastic  new bone formation
joint; thus sterile arthritis  Spine lesions  blastic, lytic lesions  prostatic
metastasis
Organisms
 Staphylococcus aureus
- most common; adult & children > 2 years of
age
 Neisseria gonorrhea:
- the most frequent pathogen (75%) of cases
among young sexually active individuals CASE 11
 Streptococcus spp. : 20% 63 year-old female
50 pack-year smoking history
 Aerobic gram (-) : 20% Distal clubbing
- in immunocompromised 20-25%
Dx: HYPERTROPHIC OSTEOARTHROPATHY
Affected Joint Distribution in Adults and Children with
Non-Gonococcal Bacterial Arthritis
% Cases
 Clubbing of digits
Adult Children
Hypertrophic Osteoarthropathy
Knee 55 40
Hip 11 >8  characterized by clubbing, excessive proliferation of
Ankle 8 14 the skin, joint effusion and periosteal bone elevation
Shoulder 8 4 in the distal extremities (pachydermoperiostosis)
Wrist 7 3  9times more common in men
Elbow 6 11  pain, when present, is deep-seated; may range from
Others 5 3 burning pain in fingertips to an incapacitating bone
pain more prominent in LE and aggravated by
dependency of the limbs
Synovial fluid examination o Due to periostitis (new bone formation)
 (N): < 180/uL cells (predominance of mononuclear
cells) X-ray: periostitis
 Acute bacterial (+) pulmonary malignancy
o 100,000 cells/uL
o (25,000-250,000 with 90% neutrophils)
 Crystal-induced, rheumatoid, noninfectious CASE 12
54 year-old female
inflammatory arthritis:
Bone pains
o 30,000-50,000 cells/uL
Back pain
 Mycobacterial or Fungal infection Anemia, azotemia
o 10,000 – 30,000 cells/uL Weight loss
o with 50-70% neutrophils Skull x-ray: well-circumscribed lytic lesions
Bone obscureness (cannot see outline)
Mycobacterial Arthritis
 1% of all cases of TB and 10% extrapulmonary Dx: MULTIPLE MYELOMA
manifestation
Low Back Pain
 Most common presentation: chronic granulomatous
 More common in Female > male
monoarthritis
 PONCET DISEASE  Increasing frequency with increasing age
o reactive symmetric form of arthritis that affects  Some statistics:
patients with visceral or disseminated TB o Most episodes are not incapacitating
o > 50% improve after a week
 involves hip, knee and ankle o >90% are better after 8 weeks
 X-ray: PHEMISTER TRIAD o 7-10% continue to experience symptoms for
longer than 6 months
o Peripheral erosion at points of synovial
attachment, periarticular component, Etiology
Periarticular osteopenia, Joint space narrowing
 Treatment is the same for TB pulmonary disease (6-  Mechanical in 90% i.e. Overuse of normal anatomic
9 months) structures e.g. trauma, Deformity (Scoliosis)
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 10% Manifestation of Systemic Illness

Clinical Evaluation
 most source of LBP are disorders of muscles, fascia
and ligaments which cannot be (nor need be)
specifically identified
 however, the clinician must be alert to the red flags
of LBP which portend a more serious underlying
cause which requires early diagnosis and treatment

Red Flags of LBP

 Persistent progressive pain especially on
recumbency
 Saddle anesthesia with or without bladder and bowel
symptoms
 Accompanying fever, weight loss, anemia
 Bone and nerve pains (signs of neuropathy)

Classification
 Mechanical
 Medical
o Infection
- Bacterial – acute
- Tuberculosis and fungal – indolent
- Fever, weight loss, pain is persistent,
present at rest, exacerbated by motion
o Tumor or malignancy
- Fever, weight loss, pallor
- Pain with recumbency or at night &
disturbs sleep
- Pain has gradual onset but persistent in
character and increasing in intensity
- Pain not relieved with rest or application of
heat, localized tenderness
- Signs of hypercalcemia

Cancer Pain: NEUROPATHIC PAIN:

 during the day, the stimulus is masked by other sensation;
during nighttime, this is the only stimulus present thus
“exacerbation”

Assessment of cancer pain

 Assessment: vital first step in cancer pain
management
 Pain: always subjective; patient self-report of pain is
the gold standard for assessment

Some Pittfalls in Rheumatology

 Present polyarthritis may have started as intermittent
monoarthritis of gout
 (referred pain) Knee pain in a perfectly-looking knee
may be coming from hip (referred pain)
 A rash is not a rash if you do not look for it

SUMMARY
 Most rheumatic diseases are diagnosed by history
and PE, occasionally with the use of basic laboratory
tests
 Analgesics and anti-inflammatory drugs are a
mainstay of therapy in most rheumatic diseases
 Therapy is highly individualized even in patients with
the same rheumatic disease
 Recognition of a serious rheumatic disorder may be
more important than making an actual diagnosis

Jobern Hipol/Faye delos Santos/Trina FC

USTMedB’08