The story…. (see www.dipex.org/)
• A 53 year old woman, divorced with 2 children born after onset of painful joints, particularly hands and feet
• Symptoms subsided during 1st pregnancy, no remission in 2nd pregnancy
• Diagnosis made 23 years ago after infection with glandular fever.
• Had foot surgery and hand surgery planned
Features of her illness:• Describes intense pain at times- counts the
hours between painkillers• Finds physiotherapy and hydrotherapy helpful in
keeping joints moving• Unhappy with results of foot surgery-still has
pain• Finds complementary therapy too expensive• On Incapacity Benefit- would like to have been
an artist
She comes to see you because:
• She is a concerned as she has recently noticed increasing shortness of breath
• She wants to know if there is any new treatment around which might help her
• If you can help provide any complementary treatments
Polyarthritis: osteoarthritis
• Osteoarthritis- disease of synovial joints; loss of articular cartilage and overgrowth of underlying bone
• Multifactorial causes; usually begins in middle age
• May be triggered by mechanical damage
• May be primary or secondary
Primary osteoarthritis
• Classic: pain and dysfunction of one or two weight bearing joints
• Generalised nodal: affecting finger joints of middle aged women
Secondary osteoarthritis
• Abnormal “wear and tear” following clearly defined insult to joint
• E.g. Charcot joint 2ry to diabetic neuropathy
Polyarthritis: rheumatoid arthritis
• Chronic systemic disease primarily affecting joints
• Inflammatory changes in synovial membranes and articular structures, including ligaments
• Leads to deformity: subluxation, ligament & joint disruption, joint erosion, ankylosis
• Systemic features develop as disease progresses
Rheumatoid arthritis
• 1-3% population
• Women:men 3:1
• Peak incidence 25-55
• Cause unknown ?autoimmunity triggered by viral infection
• Genetic link: HLA DR4 alleles poor prognostic factor
Diagnosis of RA: history
• Bilateral, symmetrical polyarthritis
• Involves proximal joints of hands and feet
• Present at least 6 weeks
• May have subcutaneous rheumatic nodules on hands or elbows
Diagnosis of RA: investigations• Raised ESR and CRP in active disease• +ve Rheumatoid factor in 80% cases• High seropositivity with systemic
complications• Anticitrulline antibody with erosive RA• Blood count: may have anaemia,
hypoalbuminaemia• Proteinuria• radiology
Features of radiology
• Synovitis: soft tissue swelling
• Joint destruction; erosion
• Deformity
• Evidence of previous surgery
Extra-articular manifestations of RA
• respiratory
• haematological
• neurological
• lymphoreticular
• ocular
• cardiac
• systemic
Respiratory complications
• pleurisy
• pleural effusion
• pleural nodules
• pulmonary fibrosis
• Caplan's syndrome
• obliterative bronchiolitis
• cricoarytenoid inflammation
Caplan’s syndrome
• Rheumatoid lung nodules with pneumoconiosis
• May resemble TB on Xray
• Restrictive and obstructive defect
• Airflow limitation and reduced gas transfer
Medical treatment
1. Symptom control:
• NSAIDs, including aspirin
• Selective COX-2 inhibitors
BUT remember NSAIDs may cause gastritis and affect renal function
AND COX-2 inhibitors may increase risk of cardiovascular events
• Use lowest effective dose
Medical treatment:2. Disease-Modifying Anti-Rheumatic Drugs
(DMARDs)• Low-dose weekly methotrexate• Sulfasalazine• Hydroxychloroquine, leflonamide• Azathioprine, penicillamine, gold salts• May use combination in patients at risk of
progressive disease• NEW! Infliximab tissue necrosis factor blocker
(TNF-α)
TNF-α
• Launched for Crohn’s 1999
• Very expensive: national guidelines published by BSR 2001
• Mainly used if patient resistant to standard DMARD therapy
Medical treatment
3. Corticosteroids
• May use with anti-inflammatories and DMARDs
• Helps in acute flare-ups
• Remember side effects: osteporosis, Cushing’s disease, hypertension
Surgical options
• Tendon repair or transfer
• Synovectomy
• Arthrodesis
• Joint replacement
• osteotomy
Role of physio
• Rest inflamed joints
• Use of splints
• Exercise when inflammation subsides to strengthen surrounding muscles and reduce risk of osteporosis
Complementary treatment on NHS:
• Variable between practices
• No evidence for homeopathy
• ?acupuncture
• ?glucosamine
• ?aromatherapy
• ?massage
Other causes of polyarthritis• Seronegative spondyloarthritis• SLE• Polyarteritis nodosa• Wegener’s granulomatosis• Systemic sclerosis• Post-infective: rheumatic fever, Reiter’s
syndrome, enteric infections• Infective: Lyme disease, bacterial
endocarditis, gonococcus• Sarcoidosis
monoarthritis
• Infection
• Haemarthrosis: trauma, esp. haemophilia
• Tumour: osteoma, sarcoma, metastasis
• Rheumatic: RA or OA
• Crystal (gout: urates, pseudogout: calcium pyrophosphate dihydrate))