Diagnosing inflammatory arthritis

Dr Jane Bleasel

RPAH

What is inflammatory arthritis?

• Inflammation in joints• Inflammation in synovium (lining of joints)

= synovitis Joint effusions

• Inflammation in tendon sheaths= tenosynovitis

• +/- Systemic features of inflammationfever, fatigue, weight loss

Pathology of synovitis

Inflammatory arthritisHISTORY IS KEY

• Symptoms– STIFFNESS IN JOINTS, esp early morning aftr

inactivity, > 30 minutes, may be many hours

– Stiffness improved with activity, hot shower

– Swelling

– Pain (not specific to inflammatory arthritis)

– Limitation of movement (not specific)

– +/- constitutional symptoms: fever, weight loss, fatigue, anorexia

Inflammatory arthritis- signs

• Signs of inflammation– Warmth– Redness (not always present)– Tenderness– Swelling, soft tissue, boggy sensation +/-

effusions

History is the key• Pattern of joint involvement

– Symmetrical or asymetrical, peripheral joints or spinal joints

• Nature of onset– Acute, subacute or chronic

• Is there evidence of a systemic process?

• Are there extra-articular features?

History is the key

• Pattern of joint involvement– Symmetrical or asymetrical, peripheral

joints or spinal joints

• Nature of onset– Acute, subacute or chronic

• Is there evidence of a systemic process?

• Are there extra-articular features?

Case history 1• 45 year old women, gradual development of

pain, swelling & stiffness small joints of hands and wrists. Also noticed pain and stiffness under balls of feet and knees. Joints stiff in mornings for around 2 hours, improved with movement. Feeling fatigued.

• Physical examination: symmetrical swelling over MCPs, PIPs, wrists, soft tissue swelling, reduced grip strength.

Clinical photo

Investigations

• Hb 105, MCV 85, plts 500, WCC 8.7

• ESR 65, CRP 30

• UEC, LFT normal

• What other investigations?

What other investigations?

• RF

• ANA

• if ANA +, dsDNA, ENA– SLE inflammatory arthritis looks the same as

RA– Early scleroderma has diffusely “puffy” hands

• Xray hands and feet for erosions

Xray of hand

Soft tissue swellingPara-articular osteoporosis

Investigations Case 1

• RF + 320 IU/ml

• ANA + 1:80

• dsDNA negative, ENA negative

• Xrays: soft tissue swelling, para-articular ostoporosis

• Diagnosis: rheumatoid arthritis

“Rheumatoid-like” arthritis

• If fever, rash, marked systemic features think of viral arthritides:

• Viral causes– Ross River virus

– Barmah Forest

– Hepatitis B (arthritis precedes jaundice)

– Rubella

– Parvo B19 virus

– EBV