Inflammatory ArthritisMichael Aref, MD, PhDHospitalist, Carle Physician Group

Department of Nuclear, Plasma, and Radiological Engineering, UIUCDepartment of Medicine, UICOM-UC

Objectives

• Review the history and physical examination findings of inflammatory arthritis

• Define and categorize inflammatory arthritis

• Understand the initial laboratory and radiological evaluation of suspected rheumatological disease

• Increase clinical sensitivity and specificity to rheumatological disease

Chest pain rule-out• 45 y/o WM

• Persistent, bilateral shoulder, elbow, and hand pain, worse with activity. Associated fatigue.

• Smoker, mother has history of rheumatoid arthritis.

• VSS, decreased ROM of shoulders, with bilateral finger, elbow, and shoulder synovitis.

• Mild normochromic, normocytic anemia and hypokalemia; EKG and chest x-ray benign.

• What test(s) would you like to order next?

Objectives

• Review the history and physical examination findings of inflammatory arthritis

• Define and categorize inflammatory arthritis

• Understand the initial laboratory and radiological evaluation of suspected rheumatological disease

• Increase clinical sensitivity and specificity to rheumatological disease

HistoryAggravating and alleviating factors

Severity

Character

Location

Associated symptoms

Setting

Timing

• Does activity make your symptoms better or worse?

• Probably pretty bad, or they wouldn’t be in the hospital.

• Are the same joints affected persistently or are different joints affected?

• How many joints are affected? 1 (monoarticular), 2-4 (oligoarticular), or more (polyarticular)?

• Any association with your back, particularly your spine?

• Joint swelling? Low grade temperature? Rash? Fatigue?

• When you wake up in the morning, how long do your symptoms last?

• How long have you been noticing these symptoms?

Physical Examination• Main signs of active inflammation includeErythema (Rubor)Warmth (Calor)Swelling (Tumor)Tenderness (Dolor)Loss of Function

• EnthesopathyPathology or lesions of enthesis (the site where ligament or tendon inserts into bone) Examples include: plantar fasciitis, Achilles tendonitis.

• DislocationArticulating surfaces are displaced and no longer in contact

• SubluxationPartial dislocation

• SynovitisInflammation of the synovial membrane

• ValgusLower limb deformity whereby distal part is directed away from the midline e.g. hallux valgus

• VarusLower limb deformity whereby distal part is directed towards the midline e.g. varus knee with medial compartment OA

GALS Screen Basic Rheumatologic Examination

The Clinical Examination of the Rheumatic Disease Patient

The Clinical Examination of the Rheumatic Disease Patient

Objectives

• Review the history and physical examination findings of inflammatory arthritis

• Define and categorize inflammatory arthritis

• Understand the initial laboratory and radiological evaluation of suspected rheumatological disease

• Increase clinical sensitivity and specificity to rheumatological disease

Inflammatory vs. Non-inflammatory

FeaturesFeatures InflammatoryInflammatory Non-inflammatoryNon-inflammatory

HxMorning stiffness > 1 hourLow-grade temperature

FatigueRash

Morning stiffness < 1 hour

Px Erythema (Rubor) • Warmth (Calor) • Swelling (Tumor) • Tenderness (Dolor) • Loss of Function Bony proliferation in osteoarthritis

Labs(+)ve ESR ± CRP

Anemia of chronic disease(+)ve rheumatoid factor or anti-CCP antibodies

Within normal limits

RadiographsErosionsPeriostitis

Joint-space narrowing

Joint-space narrowingOsteophytes

Subchondral sclerosis

Synovial Fluid

Non-infectious Infectious

Leukocyte count < 2,000/uL< 50% neutrophilsLeukocyte count >

2,000 /uLPredominantly neutrophils

Leukocyte count > 50,000 /uL

MKSAP 15 Rheumatology

Autoimmune

SymmetricSymmetric AsymmetricAsymmetric SpineSpine MonoarticularMonoarticular OligoarthritisOligoarthritis PolyarthritisPolyarthritis MigratoryMigratory

Rheumatoid Arthritis ++++ - Cervical - + ++++

Ankylosing Spondylitis ++++ ++++

Psoriatic Arthritis ++ +++ + ++ +++ ++

Inflammatory Bowel Disease

Associated++ +++ + ++ +++ ++

MKSAP 15 Rheumatology

Infectious

SymmetricSymmetric AsymmetricAsymmetric SpineSpine MonoarticularMonoarticular OligoarthritisOligoarthritis PolyarthritisPolyarthritis MigratoryMigratory

Non-gonococcal - ++++ ++ ++++ +++ + -

Disseminated gonococcal ++++ ++++ ++++

Late Lyme Disease ++++ ++++ ++++

MKSAP 15 Rheumatology

Post-Infectious

SymmetricSymmetric AsymmetricAsymmetric SpineSpine MonoarticularMonoarticular OligoarthritisOligoarthritis PolyarthritisPolyarthritis MigratoryMigratory

Reactive Arthritis ++++ ++ ++++ ++

Acute Rheumatic

Fever++++ ++ +++ ++++

Up-To-Date and MKSAP 15 Rheumatology

Crystalline Arthropathies

SymmetricSymmetric AsymmetricAsymmetric SpineSpine MonoarticularMonoarticular OligoarthritisOligoarthritis PolyarthritisPolyarthritis MigratoryMigratory

Gout + ++++ + +++ +++ + +

Pseudogout ++ +++ - +++ ++ ++

MKSAP 15 Rheumatology

Objectives

• Review the history and physical examination findings of inflammatory arthritis

• Define and categorize inflammatory arthritis

• Understand the initial laboratory and radiological evaluation of suspected rheumatological disease

• Increase clinical sensitivity and specificity to rheumatological disease

Erythrocyte Sedimentation Rate (ESR)

• Conditions with increased immunoglobulins

• Age

• Normal males = age/2

• Normal females = (age + 10)/2

• Myeloma, Waldenström’s, 1° amyloid

• SLE, Sjogren’s

• Chronic liver disease/cirrhosis

Miller ML, The Little Black Book of Rheumatology

“C-Reactive Protein”Cytokine Response Protein (CRP)Cytokine Response Protein (CRP)

• ESR and CRP both elevated:

• Infection

• Inflammatory States

• Trauma

• Cancer

Miller ML, The Little Black Book of Rheumatology

Serology

• Rheumatoid Factor (RF)

• Titer of IgM against IgG

• Present in 80% of rheumatoid arthritis

• Sensitivity 69% / Specificity 85%

• Anti-citrulline-containing peptide antibody (Anti-CCP Ab)

• Associated the development of erosive disease

• Sensitivity 67% / Specificity 95%

Miller ML, The Little Black Book of RheumatologyAnn Int Med, 2007; 146:797

Synovial Fluid

Up-To-Date

Objectives

• Review the history and physical examination findings of inflammatory arthritis

• Define and categorize inflammatory arthritis

• Understand the initial laboratory and radiological evaluation of suspected rheumatological disease

• Increase clinical sensitivity and specificity to rheumatological disease

Rheumatoid Arthritis

2010 Rheumatoid Arthritis Classification Criteria, Arthritis & Rheumatism, Sep 2010, 62(9):2569–2581

Rheumatoid Arthritis

Ankylosing Spondylitis

Modified New York Criteria (1984)

• Definite ankylosing spondylitis is present if

• Radiologic criterion is present in addition to at least one clinical criterion.

• Probable ankylosing spondylitis is present if

• Three clinical criterion are present alone or if

• The radiologic criterion is present but no clinical criteria are present.

Clinical criteria

• Low back pain: present for more than 3 months, improved by exercise but not relieved by rest.

• Limitation of lumbar spine motion in sagittal and frontal planes.

• Limitation of chest expansion relative to normal values for age and sex.

Radiologic criterion

• Sacroiliitis on radiographs

http://emedicine.medscape.com/article/386639-overview

Ankylosing Spondylitis

The Clinical Examination of the Rheumatic Disease Patient

Genetic Predisposition for Development of Ankylosing Spondylitis (AS)

HLA-B27 positive

AS and HLA-B27 positive

Western European Whites 8% 90%

African Americans 2% to 4% 48%

Guidelines in Rheumatology: Ankylosing Spondylitis

Ankylosing Spondylitis

http://basicxray.blogspot.com/2009/08/normal-pelvic-anatomy.html

Ankylosing Spondylitis

Psoriatic Arthritis

• Asymmetric oligoarthritis (43%)

• Symmetric polyarthritis (33%)

• Sacroilitis (14%)

• Predominant spondylitis (4%)

• Synovitis-acne-pustulosis-hyperostosis-osteomyelitis (SAPHO) syndrome (2%)

Br J Rheumatol. 1994 Feb;33(2):133-8

Psoriatic Arthritis

Pencil-in-cup Deformity

Infectious Arthritis• Septic arthritis is the presumed diagnosis in any

patient with acute monoarthritis and fever.

• Synovial fluid analysis is the diagnostic test

• White cell count with differential

• Gram stain (sensitivity 29-50%)

• Crystal search using polarized light microscopy

• Culture (positive in the majority of patients with nongonococcal bacterial arthritis)

Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum 1996; 39:1

Infectious Arthritis

Disseminated Gonococcal Arthritis

Disseminated Gonococcal Arthritis

Lyme Arthritis

Characterized by intermittent or persistent arthritis. Monoarthritis of the knee is most common, but can also present as asymmetric oligoarthritis, usually including the knee.

•Knee > shoulder > ankle > elbow > temporomandibular joint > wrist

•≤ 5 joints, large joints > small joints

•Abrupt presentation, lasts from several weeks to months

•Large joint effusions are common in the knees and elsewhere and often recur after aspiration

•Affected joints are usually very swollen and warm

Ann Intern Med 1987 Nov;107(5):725-31

Lyme Arthritis

Reactive Arthritis

Willkens RF et al. Arthritis Rheum 1981;24:844-9

SensitivitySensitivity SpecificitySpecificity

Episode of arthritis of more than 1 month with urethritis and/or cervicitis 84.3%(70/83) 98.2%(163/166)

Episode of arthritis of more than 1 month and either urethritis or cervicitis, or bilateral conjunctivitis85.5%(71/83) 96.4%(160/166)

Episode of arthritis, conjunctivitis, and urethritis 50.6%(42/83) 98.8%(164/166)

Episode of arthritis of more than 1 month, conjunctivitis, and urethritis 48.2%(40/83) 98.8%(164/166)

Reactive Arthritis• Preceding enteric infection (i.e. diarrhea)

• Salmonella of various serovars

• Shigella, especially Shigella flexneri, but also Shigella dysenteriae and sonnei

• Yersinia including Yersinia enterocolitica 0:3 and 0:9 and Yersinia pseudotuberculosis

• Campylobacter especially Campylobacter jejuni

• Clostridium difficile

• Preceding genitourinary infection (i.e. urethritis)

• Chlamydia trachomatis

Up-To-Date

Reactive Arthritis

Gout1977 American College of 1977 American College of

Rheumatology CriteriaRheumatology Criteria New York CriteriaNew York Criteria Rome CriteriaRome Criteria

Monosodium urate monohydrate microcrystals in joint

fluid during attack or ≥ 6 of the following

MSU microcrystals in joint fluid or tissue or tophus or

≥ 2 of the following≥ 2 of the following

> 1 attack of acute arthritis 2 attacks of painful limb joint swelling

Maximum inflammation developed within 1 day Abrupt onset and remission in 1-2 weeks initially Abrupt, painful joint swelling, clearing in 1-2 weeks initially

Monoarthritis attack

Redness observed over joints

First metatarsophalangeal joint painful or swollen First metatarsophalangeal joint attack

Unilateral first metatarsophalangeal joint attack

Unilateral tarsal joint attack

Tophus (proven or suspected) Presence of a tophus Presence of tophi

Hyperuricemia Serum uric acid > 7 in males and > 6 in females

Asymmetric swelling within a joint on x-ray

Subcortical cysts without erosions on x-ray

Joint fluid culture negative for organisms during attackResponse to colchicine—major reduction in

inflammation within 48 hours MSU microcrystals in joint fluid or tissueWallace SL, et al. Arthritis Rheum 1977;20:895-900 and J Clin Rheumatol. 2009 Feb;15(1):22-4

Pseudogout

Definite diagnosis of pseudogout requires either:

• The demonstration of CPPD crystals in tissue or synovial fluid by definitive means (eg, x-ray diffraction, etc) or

• The presence of both positively (but weakly) birefringent crystals by compensated polarized light microscopy and typical cartilage or joint capsule calcification on x-ray examination

Probable diagnosis of pseudogout occurs with either:

• The identification of positively (but weakly) birefringent crystals by compensated polarized light microscopy or

• The presence of typical cartilage or joint capsule calcification on radiographic examination.

Up-To-Date

Pseudogout

CODE SPEED

• 75 y/o WM

• Admitted for fever and malaise, back pain noted on ROS

• Obesity, HTN, HCL, DM, CAD, and CKD III

• “Social” drinker, family history noncontributory.

• Febrile, tachycardic, hypotensive, diaphoretic, examination otherwise noncontributory

• Mild leukocytosis otherwise CBC and CMP benign, negative blood and urine cultures, chest x-ray negative

• Patient intubated and started on vasopressors for shock

• What’s the differential diagnosis?