ARTHRITISAnna JaatinenRotary Doctor Bank Finland, Ilembula Hospital
Today’s topics
Osteoarthritis Rheumatoid arthritis Reactive arthritis Crystal-induced Synovitis Infectious Arthritis HIV-associated arthritis
Rheumatoid arthritis 1
Systemic diseace Unknown etiology
Symmetric inflammatory polyarthritis Extra-articular manifestations
Rheumatoid nodules Pulmonary fibrosis Serositis Vasculitis
Rheumatoid factor up to 80%
Rheumatoid arthritis 2
Clinical Presentation Insidous oncet of the pain, swelling and
morning stiffness in the joints (hands, wrists)Synovitis! Typical places: MCP, PIP, wristRheumatoid nodules on extensor surfacesCourse is often chronic and progressiveErosions!
Rheumatoid arthritis may substatial long-term disability and is associated with increased mortality!
Rheumatoid arthritis 3
American Collece of Rheumatology 1987 Classification Criteria
Morning stiffness (>60 min)Arthritis of three of more jointsArthritis of hand jointsRheumatoid nodulesSerum rheumatoid factorX-ray changes (erosions and decalcification)
4 of the 7 criteria should be met, with criteria 1 to 4 present for more than 6 weeks
Morning stiffness (>60 min)Arthritis of three of more jointsArthritis of hand jointsRheumatoid nodulesSerum rheumatoid factorX-ray changes (erosions and decalcification)
4 of the 7 criteria should be met, with criteria 1 to 4 present for more than 6 weeks
Rheumatoid arthritis 4
TREATMENT NSAID
Ibuprofen 400-800 mg TDS as long as needed
Acetylsalicylic acid Corticosteroids
Prednison 5 to 20 mg OD With long treatments
remember to decrease the dose slowly!
Intra-articulr administration Hydrocortison 25-100
mg i.a.
DMARDs (Diseace-modifying antirheumatic drugs) Methotrexate Hydroxychloroquine Sulfasalazine Leflunomide Biologic DMARDs
Patients with itractable symptoms may require special treatment at spesialist centre!
Patients with itractable symptoms may require special treatment at spesialist centre!
Osteoarthritis 1
= Degenerative joint disease= Arthrosis Most common form of arthritis! Degenerative loss of articular cartilage with
subsequent formation of reactive new bone at the cartilage surface
Most common: PIP, DIP, hips, knees, cervical and lumbar spine
Common in the elderly, but may occur any age especially after joint trauma, chronic inflammatory arthritis or congenital malformation.
Osteoarthritis 2
Clinical PresentationPain!Specific clinical features depend on the
joint involvedKnee: possible hydrops, no signs of infection or
severe inflammationDIP: enlarged joint Bouchard’s nodes
X-ray shows cartilage damage and sometimes even deformity
Osteoarthritis 3
TREATMENT Nonpharmacologic
approaches Prief period of rest Good shoes:
Walkers Crepe bandage or
brace can help Physiotherapy and
exercise to affected joints
Reduction on weight in obese patients
Medications Paracetamol 1 g TID
(QID) NSAID (As low dose
as possible) Ibuprofen 200-600 mg
TID Itra-articular
clucocorticoidShould not be given
more than every 3 to 6 months
Systemic clucocorticoid should be avoided!
Reactive arhtritis 1
Inflammatory arthritis, which occasionally follows certain GI or genitourinary infectionsReiter sdr = arthritis + conjuctivitis + urethritis
Most common afterChlamydia trachomatis, Shigella flexneri,
Salmonella species, Yersinia enterocolitica, Campylobacter jejuni
Genetic predispositionHLA-27 positive 60-80%
Reactive arthritis 2
Clinical PresentationAsymmetric oligoarthritisUrethritisConjuctivitisSkin and mucous lesionsUsually transient, lastin one to several
monthsSome patients develope chronic arthritis
Reactive arthritis 3
TREATMENT Control of pain and
inflammation! NSAIDs Severe cases short
glucocorticoid therapy
Ophthalmologic referral if you suspect iritis
Remember and search for infection!Clamydia tr
Antibiotic treatment if still neededProlonged
antiobiotic therapy has NOT been showed to be beneficial
Crystal-Induced Arthritis 1
Gout (Urate crystals) Pseudogout (Calcium pyrophosphate dihydrate
crystals) Apatite disease
Gout arthritis developes when urate crystals deposites in the joints Primary: hyperuricemia due to undersecretion of
uric acid Secondary: Renal disease, diuretic therapy, low-
dose aspirin, ethanol, starvation, lactic asidosis, dehydration, pre-eclampsia, diabetic ketoasidosis
Crystal Induced Arthritis 2
Clinical PresentationExcruciating painUsually in single joint in foot or ankle
Occasionally a polyarthritic oncet can mimic rheumatoid arthritis
Joint is swollen, skin erythema, warm/hotChronic gout: With time acute gouty attacs
more often, even chronic joint deformity may appear
Lab: Uric acid levels with 70%, Crystals seen in the joint fluid examined with microscope
Crystal Induced Arthritis 3
TREATMENT Acute gout
NSAID high dose Indomethacin 75 mg start
then 50 mg every 6 hours 24 hrs, 50 mg TDS 24 h, 25 mg TDS 24 h
Diclofenac 75 mg BDS Ibuprofen 400-800 mg TDS
Glucocorticoids (especcially when NSAID is contraindicated) Intra-articular injection Prednison 40 mg OD 3-5
days Colchisine
1 mg stat followed 0,5 mg every 2 hours orally until patient improves or ad 10 mg
Prevention Anti-hyperuricaemic
therapy; Allopurinol Goal serum uric acid
below 8 mg/dl (0.48 mmol/l)
Avoid precipitants (alcohol, small fish, diuretics)
Reduce weight in obese patients
Remember that allopurinol can make acute gout even worse! Start after clinical improvement!
Remember that allopurinol can make acute gout even worse! Start after clinical improvement!
Infectious Arthritis 1
Septic infection! Non-conococcal: Staphylococcus Aureus,
Streptococci Conococcal arthritis Occasionally: M Tuberculosis, Brucella,
Fungi
Non-bacterial infectious arthritisViral infections: Hepatitis B, Rubella, Mumps,
Mononucleosis, parvovirus, enterovirus, adenovirus
Infectious Arthritis 2
Clinical Presentation Non-gonococcal infectious arthritis
FeverAcute monoarticular arthritis
Multiple joint may be affected by hematogenous spread of pathogens
Gonococcal arthritisMigratory or additive polyarthralgias
followed by tenosynovitis or arthritis of wrist, ankle or knee and vesicopustular skin lesions
Infectious Arthritis 3
TREATMENT Immediate antibiotic therapy
Cover S. Aureus, Streptococcus, Neisseria gonorrhoeae
IV-antibiotics are recommended for at least 2 weeks, followed by oral antibiotics 2(-4) weeks
When definite gonococcal arthritis Ceftriaxone i.v. For 3 days followin 7-14 days treatment with cefixime or Amoxicillin/clavulanate
Surgical drainage especcially if there is big joint (shoulder, hip), lobulation of pus, osteomyelitis or delay with response to treatment
Supportive treatment for septic infection! NSAID
HIV-infection and arthritis 1
HIV-associated arthralgiaAny stage of HIV infectionMild to moderate, involves usually large
joints (shoulders, elbows, knees)No synovitis!Treatment: Pain medication, support
HIV-infection and arthritis 2
Reactive arthritis Psoriatic arthritis HIV-assosiated arthritis
Virus is directly involving joint synovium Oligoarticular, occurs predominantly in the lower
extremities Self-limiting course, lasting <6 weeks X-ray: no erosion in the joints
Also HIV-associated polyarthritis is possible, resembles rhematoid arthritis
Synovitis abates when CD4 is declining, but joint destruction continues
Diagnose with intra-articular punctureMain principles Clear synovial fluid: Osteoarthritis,
Rheumatoid arthritisLeukocyte amount
Thick, fuzzy: Crystal-induced ArthritisCrystals seen in microscope
Purulent: Infectious arthritisCulture, Gram stain
Assure that your technique is clean!Assure that your technique is clean!
Take Home Message
Osteoarthritis is the most common reason for joint pain; treat the pain and educate the patient
Treat with antibiotics when… It’s infectious arthritis!Reactive arthritis if there still is infection
If you suspect Rheumatoid arthritis, treat aggressively, consider refferal for specialist
Asante, Thank you!