Download - Xryas and Arthritis Phenotypes
-
8/15/2019 Xryas and Arthritis Phenotypes
1/88
Leanne Alblas2nd year rheumatology trainee
Western Health 2015
-
8/15/2019 Xryas and Arthritis Phenotypes
2/88
QuestionsReview of Arthritis approachImaging in arthritis
-
8/15/2019 Xryas and Arthritis Phenotypes
3/88
-
8/15/2019 Xryas and Arthritis Phenotypes
4/88
-
8/15/2019 Xryas and Arthritis Phenotypes
5/88
-
8/15/2019 Xryas and Arthritis Phenotypes
6/88
-
8/15/2019 Xryas and Arthritis Phenotypes
7/88
-
8/15/2019 Xryas and Arthritis Phenotypes
8/88
-
8/15/2019 Xryas and Arthritis Phenotypes
9/88
-
8/15/2019 Xryas and Arthritis Phenotypes
10/88
-
8/15/2019 Xryas and Arthritis Phenotypes
11/88
-
8/15/2019 Xryas and Arthritis Phenotypes
12/88
-
8/15/2019 Xryas and Arthritis Phenotypes
13/88
Inflammatoryor Mechanical
Large vs.small joints
Deforming vs. Non
deforming
Mono-,Oligo-
orPolyarthritis
Acute,subacute,
or ChronicSymmetrical vs.
Asymmetrical
-
8/15/2019 Xryas and Arthritis Phenotypes
14/88
65 yo female with an acute non-deforming symmetrical small jointinflammatory polyarthritis
85 yo man with a chronic large jointasymmetrical mechanical oligoarthritis
32 yo woman with a subacuteinflammatory deforming monoarthritis ofher right knee
-
8/15/2019 Xryas and Arthritis Phenotypes
15/88
-
8/15/2019 Xryas and Arthritis Phenotypes
16/88
Inflammatory Mechanical
Early Morning Stiffness >30min
-
8/15/2019 Xryas and Arthritis Phenotypes
17/88
-
8/15/2019 Xryas and Arthritis Phenotypes
18/88
Monoarthritis Oligoarthritis
Polyarthritis
Number 1 2-4 ≥5
Commoncauses OAGoutCPPD
Septic arthritis
PsARA (initially)OA
RASLE
Acute Subacute ChronicWeeks 6
-
8/15/2019 Xryas and Arthritis Phenotypes
19/88
Asymmetrical
OAPsA
Symmetrical
RA
-
8/15/2019 Xryas and Arthritis Phenotypes
20/88
Single jointDDx• Septic arthritis• Traumatic (haemarthrosis, #)• Crystals (gout, pseudogout)• Initial presentation of RA, PsA, Ank Spond
-
8/15/2019 Xryas and Arthritis Phenotypes
21/88
Eye – scleritis/iritis (A.S, RA, reactive)Rash (SLE, Psoriasis)Obesity (psoriasis/gout)ILD• Basal - RA, SLE, Scleroderma,• Apical - Ank spond
Nail changes• Ridging/pitting – Psoriasis• Nailfold (capillaries) – SLE, scleroderma
-
8/15/2019 Xryas and Arthritis Phenotypes
22/88
-
8/15/2019 Xryas and Arthritis Phenotypes
23/88
OsteoarthritisRheumatoid ArthritisPsoriatic Arthritis
Ankylosing spondylitisGoutPseudogout (CPPD)
SLEHaemachromatosis
-
8/15/2019 Xryas and Arthritis Phenotypes
24/88
-
8/15/2019 Xryas and Arthritis Phenotypes
25/88
AsymmetricalOlder populationInvolvesFeatures:• Crepitus• Mechanical (worse post activity)
• Bony joint enlargement• Limited joint mobility
-
8/15/2019 Xryas and Arthritis Phenotypes
26/88
Usually SPARES wrists, elbows, shoulders,ankles, MCP, 2 nd -5 th MTP• If present, consider 2° causes
Group Example
Congenital Congenital Hip Dislocation
Dysplasia Epiphyseal
Mechanical Joint hypermobility, valgus/varus deformity
Trauma ACL tear, meniscectomy/prev. arthroscopyMetabolic HH, Haemaglobinopathy, Crystal deposition
Endocrine Acromegaly, Thyroid
Neuropathy DM, Syphilis
Other End result of inflammatory/infective arthritis
-
8/15/2019 Xryas and Arthritis Phenotypes
27/88
Joint Space NarrowingOsteophytes ‘spurs’ Subchondral cysts ‘geodes’ Sclerosis
-
8/15/2019 Xryas and Arthritis Phenotypes
28/88
-
8/15/2019 Xryas and Arthritis Phenotypes
29/88
• Hard bony enlargements
• Bouchard’s nodes
atthe PIP joints
• Heberden’s nodes atthe DIP joints
• Often have “squared” firstCMC joint due toosteophytes at that joint
-
8/15/2019 Xryas and Arthritis Phenotypes
30/88
Change
pic tonon-erosive
-
8/15/2019 Xryas and Arthritis Phenotypes
31/88
Heberden’s nodes - DIP
-
8/15/2019 Xryas and Arthritis Phenotypes
32/88
Bouchard’s nodes - PIP
-
8/15/2019 Xryas and Arthritis Phenotypes
33/88
-
8/15/2019 Xryas and Arthritis Phenotypes
34/88
-
8/15/2019 Xryas and Arthritis Phenotypes
35/88
• JSN (usually medial >lateral)
• Osteophytes• Subchondral sclerosis
-
8/15/2019 Xryas and Arthritis Phenotypes
36/88
• JSN (usually medial >lateral)
• Osteophytes• Subchondral sclerosis
•
Subchondralcysts
-
8/15/2019 Xryas and Arthritis Phenotypes
37/88
Component ofinflammation
Affect:• 5-10% of OA patients• Typically women in 40s
Joints involved:• DIP, PIP, 1 st CMC
• BilateralInvestigations• Normal ESR/CRP• Neg RF, ANA
‘Gull wing’ sign
-
8/15/2019 Xryas and Arthritis Phenotypes
38/88
Component ofinflammation
Affect:• 5-10% of OA patients• Typically women in 40s
Joints involved:• DIP, PIP, 1 st CMC
• BilateralInvestigations• Normal ESR/CRP• Neg RF, ANA
‘Gull wing’ sign
-
8/15/2019 Xryas and Arthritis Phenotypes
39/88
Do weight bearing views for large jointsSynovial fluid analysis• WCC
-
8/15/2019 Xryas and Arthritis Phenotypes
40/88
-
8/15/2019 Xryas and Arthritis Phenotypes
41/88
Symmetrical inflammatory small jointpolyarthritis
Affects F>MInvolves• PIP, wrist, elbow, shoulder, Cervical spine, knees,
ankles, MTPs
SPARES• DIPs, hips, thoraco-lumbar spine
-
8/15/2019 Xryas and Arthritis Phenotypes
42/88
Uniform JSN (Joint Space Narrowing)Generalised osteoporosisMarginal erosions (of ‘bare areas’) Peri-articular soft tissue swellingSubluxation
-
8/15/2019 Xryas and Arthritis Phenotypes
43/88
Boutonniere deformingSoft tissue swelling/bogginessUlnar deviation at level of MCPs
Delete
this
-
8/15/2019 Xryas and Arthritis Phenotypes
44/88
Subluxation and ulnardeviation of proximalphalanx with respect toMCPs
Generalisedosteoporosis
Erosions
-
8/15/2019 Xryas and Arthritis Phenotypes
45/88
-
8/15/2019 Xryas and Arthritis Phenotypes
46/88
Asymmetrical inflammatory arthritisinvolving• Hands (esp. DIP)• Feet• Sacro-iliac joint (SIJ)• Spine
Peripheral
Axial
-
8/15/2019 Xryas and Arthritis Phenotypes
47/88
Asymmetrical inflammatory arthritisinvolving• Hands (esp. DIP)
• Feet• Sacro-iliac joint (SIJ)• Spine
May precede or follow psoriasis
Peripheral
Axial
-
8/15/2019 Xryas and Arthritis Phenotypes
48/88
Dactylitis
DIP involvement
Nail changes• Onycholysis
• Pitting• Ridging
-
8/15/2019 Xryas and Arthritis Phenotypes
49/88
Fusiform soft tissue swellingBony proliferation “ periostitis ”
Joint space loss‘pencil in cup’ Normal bone mineralisation
-
8/15/2019 Xryas and Arthritis Phenotypes
50/88
-
8/15/2019 Xryas and Arthritis Phenotypes
51/88
Sausage likeswelling of whole digits
“dactylitis ”
-
8/15/2019 Xryas and Arthritis Phenotypes
52/88
Sausage likeswelling of whole digits
“dactylitis ”
severe erosive ∆ of 2 nd & 3 rd DIPs
-
8/15/2019 Xryas and Arthritis Phenotypes
53/88
Sausage likeswelling of whole digits
“dactylitis ”
severe erosive ∆ of 2 nd & 3 rd DIPs
solid periosteal new bone
-
8/15/2019 Xryas and Arthritis Phenotypes
54/88
Pencil in cup
-
8/15/2019 Xryas and Arthritis Phenotypes
55/88
Pencil in cup
Ankylosis
-
8/15/2019 Xryas and Arthritis Phenotypes
56/88
Pencil in cup
Ankylosis
Periostitis
-
8/15/2019 Xryas and Arthritis Phenotypes
57/88
Cf. to Ankylosing spondylitis• Unilateral or asymmetrical bulky bony
outgrowths of paraverterbral spine
-
8/15/2019 Xryas and Arthritis Phenotypes
58/88
-
8/15/2019 Xryas and Arthritis Phenotypes
59/88
Enthesitis is a distinguishing feature
Axial• Insidious onset inflammatory back pain
Peripheral
• Mono/ oligo-arthritis, usually lower limb
HLAB27
-
8/15/2019 Xryas and Arthritis Phenotypes
60/88
Definite sacroiliitis (on xray)• ≥grade II bilaterally or • Grade III/IV unilaterally
SI changes are usually bilateral &symmetric
Initially involve the synovial lined lower2/3 rd of SI joint
-
8/15/2019 Xryas and Arthritis Phenotypes
61/88
-
8/15/2019 Xryas and Arthritis Phenotypes
62/88
Grade I Grade II
Suspicious changeIrregular joint space w/o sclerosis or
well defined erosions
-
8/15/2019 Xryas and Arthritis Phenotypes
63/88
Grade I Grade II
Suspicious changeIrregular joint space w/o sclerosis or
well defined erosions
Min Abnormalitiessmall localised erosions/sclerosis butNormal joint width
-
8/15/2019 Xryas and Arthritis Phenotypes
64/88
Grade III Grade IV
Unequivocal Abnormal – mod-advanced sacroiliitis & ≥1 of: erosions, sclerosis, widening,narrowing or partial ankylosis
-
8/15/2019 Xryas and Arthritis Phenotypes
65/88
Grade III Grade IV
Unequivocal Abnormal – mod-advanced sacroiliitis & ≥1 of: erosions, sclerosis, widening,narrowing or partial ankylosis
Completely ankylosed (fused)
-
8/15/2019 Xryas and Arthritis Phenotypes
66/88
-
8/15/2019 Xryas and Arthritis Phenotypes
67/88
Syndesmophytes
-
8/15/2019 Xryas and Arthritis Phenotypes
68/88
Diffuse Idiopathic Skeletal HyperostosisNot an arthropathy but a bone formingcondition• Normal cartilage, bony margins & synovium
Affects older patientsEsp. thoracic spine
Assoc. with stiffness/ ROM
-
8/15/2019 Xryas and Arthritis Phenotypes
69/88
Flowing ossification ofparaspinal phytes – anterior to vertebral
bodies
NOTE• Normal disc spaces• Need ≥4 contiguous
vertrebral bodies withossification
Get AP
view ofDISH
-
8/15/2019 Xryas and Arthritis Phenotypes
70/88
Ossification oflongitudinal ligament
(ant. To vertebralbodies)
Can cause dysphagia!
-
8/15/2019 Xryas and Arthritis Phenotypes
71/88
-
8/15/2019 Xryas and Arthritis Phenotypes
72/88
Rapid onset painful erythematous jointpain, swelling and erythema• Initially monoarticular (eg Podagra)
• Later polyarticular
Asymmetrical
Monosodium urate crystals – negativelybifringent
-
8/15/2019 Xryas and Arthritis Phenotypes
73/88
Commonly affectsFeet>Ankles>Knees> Hands >Elbows
Increasingly recognised in axialspineOften involves periarticularstructures
With chronicity may developtophi
-
8/15/2019 Xryas and Arthritis Phenotypes
74/88
TophiPunched out lesions with scleroticbordersOverhanging edge of cortexNormal joint space & mineralisation
-
8/15/2019 Xryas and Arthritis Phenotypes
75/88
Tophi in 1 st – 3 rd MTP& 1st IP with assoc.
erosion
Normalmineralisation
-
8/15/2019 Xryas and Arthritis Phenotypes
76/88
-
8/15/2019 Xryas and Arthritis Phenotypes
77/88
-
8/15/2019 Xryas and Arthritis Phenotypes
78/88
3 rd most common inflammatory arthritis• 3.4% adults
Characterised by calcium pyrophosphatedeposition in cartilageRisk factors• Age• OA
Presentation very variable:• Acute or chronic• Mono- oligo-, poly- arthritis• Inflammatory or non-inflammatory
-
8/15/2019 Xryas and Arthritis Phenotypes
79/88
Most common joints involved• Wrist• Knee
If presents
-
8/15/2019 Xryas and Arthritis Phenotypes
80/88
Chondrocalcinosis
Note:• Underlying OA• Should find bilateral
changes on xray• Also xray wrists
-
8/15/2019 Xryas and Arthritis Phenotypes
81/88
Calcification oftrianglular
fibrocartilage
-
8/15/2019 Xryas and Arthritis Phenotypes
82/88
-
8/15/2019 Xryas and Arthritis Phenotypes
83/88
Typically inflammatory small jointpolyarthritis – similar to RA• However it is rarely erosive/destructive
Can also have “ Rhupus ” • Arthritis strongly resembling RA with erosions &
positive RF• Fixed derformities
-
8/15/2019 Xryas and Arthritis Phenotypes
84/88
Jaccoud arthritis – non-erosivearthropathy
Occurs in 10-35%
Swan neck (lax joint capsule, tendons, ligaments)MCP subluxationUlnar deviation
-
8/15/2019 Xryas and Arthritis Phenotypes
85/88
Jaccoud arthritis – non-erosivearthropathy
Occurs in 10-35%
Swan neck (lax joint capsule, tendons, ligaments)MCP subluxationUlnar deviation
-
8/15/2019 Xryas and Arthritis Phenotypes
86/88
-
8/15/2019 Xryas and Arthritis Phenotypes
87/88
Hook like osteophytes atMCPs esp. 2 nd & 3rd
-
8/15/2019 Xryas and Arthritis Phenotypes
88/88
Can involve any joint!Commonly• 2nd & 3 rd MCPs with associated pain and stiffness
• PIPs, radiocarpal, knees, hips, ankles, shouldersCan have CPPD causing flares• Chondrocalcinosis found in 30-60%
Synovial fluid is non-inflammatory