rheum a to logy tutorial handout

8/6/2019 Rheum a to Logy Tutorial Handout

1/12

1

Paijit Asavatanabodee

Rheumatic Disease Unit

Phramongkutklao Hospital

Approach for Diagnosis of Arthritis

1. Demographic data

2. Articular disease or

non-articular disease

3. Clinical data

Articular features

Extra-articular features

Demographic Characteristics

and Diagnosis of Articular Complaints

Age of onset

40 years

> 40 years

TK, SLE, SSc

RA, OA, GCA

40 years

> 40 years

RD, AS

Gout

Associated or prior events

Triggering events

Aggravating factors

Personal history

Family history

Drug history

Traumaticarthritis

PrepatellarBursitis

Anserinusbursitis

Olecranonbursitis

Cellulitis

Osgood Schlatterdisease

De Quervaintenosynovitis

Articular diseases or Peri-articular diseases

Uncommon,

reducible

Some direction,

active < passive(with pain)

Unusual, except

rotator cuff

tendinitis, FTS

Localized / linear

plane

, brief duration

Localized plane

with use

Peri-articularPathology

(bursitis, tendinitis)

None

Free ROM

without pain

None

None

None

Diffuse, beyond joint

boundary without

activity relation

Non-rheumaticPathology

(eg. referred pain)

Common if joint

destruction,

irreducible

Deformity

All direction,

active = passive(with pain)

Limited ROM

Often (internal

derangement,

loose body)

Crepitus /locking /stability

Around joint

boundary

Signs ofinflammation

Often, > 15 min

duration

Stiffness

Around joint

boundary, after

prolonged inactivity

Pain /discomfort

Articular

Pathology

(eg. arthritis, OA)

Symptomsand

physical signs


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Pattern of Joint Involvement

and Diagnosis of Articular Complaints

Mono-

Acute inflammatory

Chronic

Oligo-(2-4joints)

Acute migratory

Chronic additive

Poly-(> 4joints)

CNTD, malignancy,Stills, metabolic dis.

Acute

Chronic

Viral arthritis, BE, pseudogout,

elderly gout, drug-induced arthritis

SpA (RD, PsA),chronic crystal arthropathy

Destructive

Trauma, crystal, bact.infection, tumor

Non-bact infection, PVNS, RA, SpA

Rheumatic fever, GC arthritis

SpA (RD, ReA, PsA), RA

Symmetry

Asymmetry

RA, OA

Non-destructive

Inflam

Noninflam Int.derangement, OA, Osteonecrosis

Mono-Acute inflammatory

Trauma, hemarthrosis,

gout, pseudogout,

bact. infection, tumor

Traumaticarthritis

Acute

hemarthrosis

Mono-Acute inflammatory

Trauma, hemarthrosis,

gout, pseudogout,

bact. infection, tumor

MonitoringDiagnosis

7. Histology

1. History

2. Physical examination

3. Routine lab

8. Special lab tests

6. Serology

5. Bone / joint radiograph

4. Synovial fluid analysis

Mono-articular

Infection (TB, fungus),

RA, SpA, amyloidosis,

Pigmented villonodular synovitisChronic inflam.

TB arthritis Rheumatoid arthritis

Rheumatoid nodule

Acid fast stainMiliaryTB

Mono-articular

Infection (TB, fungus),

RA, SpA, amyloidosis,Pigmented villonodular synovitis

MonitoringDiagnosis

7. Histology

1. History

2. Physical examination

3. Routine lab

8. Special lab tests (PCR, MRI,

arthroscope, special C/S orstaining)

6. Serology (RF, HLA B27)



Chronic inflam.

Mono-

articular Chronic non-inflam.

Osteoarthritis,

internal derangement,

osteonecrosis

Drawers testMc Murrays test

Apleys test

Godfrey's dropback test

Lateral instability test

Osteoarthritis Osteonecrosis


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Mono-articular

MonitoringDiagnosis

7. Histology

1. History

2. Extra-articular manifestation

3. Routine lab

8. Special lab tests (MRI,

arthroscope, etc.)

6. Serology



Chronic non-inflam.

Osteoarthritis,

internal derangement,

osteonecrosis

Oligo-Acute (migratory) Rheumatic fever,

septic arthritis

(GC, non-GC), BE

Grams stainSeptic vasculitis

Septic vasculitis

Septic vasculitis

Roth spotSplinter hge

Asymmetrical arthritis

Oligo-Acute (migratory) Rheumatic fever,

septic arthritis

(GC, non-GC), BE

MonitoringDiagnosis

7. Histology

1. History

2. PE (articular & extra-articular)

3. Routine lab


6. Serology (ASO titer)



Oligo- Subacute-chronicadditive

SpA (RD, ReA, PsA)RA

Psoriasis

Guttagepsoriasis

Keratodermablennorhagica

Psoriatic nailDactylitis

Conjunctivitis

BalanitisUrethritis

Anterior uveitis

Oligo- Subacute-chronicadditive

SpA (RD, ReA, PsA)RA

MonitoringDiagnosis

7. Histology

1. History


3. Routine lab


6. Serology (RF, HLA B27)



(for exclusion of crystal / infection)

Poly-

Acute(usually

symmetrical)

Viral arthritis (Rubella, parvovirus, HVB,

HVC, HIV, CMV, etc), bact. endocarditis

Elderly gout, pseudogout (pseudo-RA) Drug-induced arthropathy

Slapped cheek in Fifth disease Rubella rash

Symmetrical polyarthritis

Pseudo-RA in pseudogout

Elderly gout inOA hand


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Poly-

Acute Viral arthritis (Rubella, mumps, HVB,HVC, HIV, CMV, etc), bact. endocarditis

Elderly gout, pseudogout

Drug-induced arthropathy

MonitoringDiagnosis

7. Histology

1. History


3. Routine lab

8. Special lab tests (anti-histone Ab)

6. Serology (viral studies)


4. Synovial fluid analysis (crystal)

Poly-CNTD, vasculitis

Stills, malignancy,metabolic dis.

Chronic

Destructive

Symmetry

RA, OA

Non-destructive

Severe RA Severe OA

Jaccoudsarthropathy

SLE rash Gottron rash in DM

Poly-CNTD, vasculitisStills, malignancy,

metabolic dis.

Chronic

Destructive

Symmetry

RA, OA

Non-destructive

MonitoringDiagnosis

7. Histology (Tissue biopsy)

1. History


3. Routine lab (CBC, U/A, ESR)

8. Special lab tests (TFT, PTH,

search for occult malignacy)

6. Serology (ANA, RF)



Osteoarthritis

Rheumatoidarthritis

Osteoarthritis

Rheumatoidarthritis

Adult Juvenile Adult Juvenile

Rare in OA: Shoulder, elbow, ulnar

side of wrists, ankles, 2nd-5th MCP

and 2nd-5th MTP joints

Rare in RA: T-L spine

Poly-Chronic

RD, PsA, (RA)

Chronic gout

PseudogoutAsymmetry

Psoriasis

Arthritis mutilans

Gout

Tophaceous gout

Poly-

Chronic

RD, PsA, (RA)

Chronic gout

PseudogoutAsymmetry

MonitoringDiagnosis

7. Histology

1. History


3. Routine lab


6. Serology (RF)




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Psoriatic arthritisDistinctive clinical features

1. Asymmetrical polyarthritis

2. Predominance of DIP joint involvement3. Tenosynovitis (sausage digit)

4. Psoriatic skin or nail lesions

Saturn was a demonic god who ate his own children.

The Romans noticed similarities between symptoms of gout

(caused by lead poisoning) and the irritable god,

and named the disease after him.

Saturnine gout (Ancient Rome)

Saturnine gout = moonshine gout

Gout in chronic lead poisoning :

Consumption of moonshine whiskey contaminating lead.

Severe proliferative psoriasis

Gaucher's disease

Chronic hemoolytic anemia

Infectious mononucleosis

myelo or lymphoproliferative disorders

Specific enzyme defectsSpecific enzyme defects

SecondaryPrimary

Increased uric acid production

Chronic renal disease, kidney injury

Volume depletion, Hypertension

Sickle cell anemia, Hypothyroidism

Down's syndrome

Beryllium or lead poisoning

Cystinuria

Drugs (diuretics, low dose aspirin)

SecondaryPrimary

Decreased uric acid excretion (90%)

Idiopathic (90%)

Familial juvenile goutynephropathy

Poly-Mono-Number of joint

involved

Renal impairment,

osteoarthritis

Obesity, hypertension,

hyperlipidaemia, high

alcohol intake

Associations

EarlyLateTophi development

UncommonCommonAcute attacks

ElderlyMiddle agedAge

Male = femaleMale much more than

femaleSex

Secondary goutPrimary goutCriterion

Calcifictendinitis

Rotator cufftendinitis Frozen shoulder(adhesive periarthritis)Rotator cuffrupture

Subacromialor subdeltoidbursitis

Bicipital

tendinitis

Shoulder

arthritis

Disease causing shoulder pain

Subluxationofacromioclavicular joint

Arthritis ofSternoclavicular joint

Physical Examination

Arthritis ofshoulder joint


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1. Subacromial space:

2. Bicipital groove:

3. Acromioclavicular joint:

4. Anterior glenohumeral joint:

5. Sternoclavicular joint:

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2

4

Rotator cuff tendinitis / impingement syndrome,

rotator cuff tear, calcific tendinitis, subacromial bursitis)

Bicipital tendinitis, biceps tendon subluxation / tear.

RA, OA, SpA, septic arthritis.

RA, OA, SpA, pseudogout, septic arthritis,

apatite arthropathy, osteonecrosis, glenoid labrum tear, frozen shoulder.

SpA, RA, septic arthritis, OA.

6. Posterior edge of acromion:

7. Suprascapular notch:

8. Quadrilateral space:

8

7


Rotator cuff tendinitis, rotator cuff

tear, calcific tendinitis, subacromial

bursitis.

Suprascapular nerve entrapment

Axillary nerve entrapment.

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6

Winging of scapula


Taut band

Trigger points

Drop arm test

Shrug sign

Yergasons test

Painful arc Empty cane beer test(Supraspinatus)

Lift-off test(Subscapularis)

Speeds test

Biceps tendinitis

InfraspinatusTeresmajor

Acromioclavicularpathology

Neertest(Impingement test)

Hawkins test(Impingement test)

Back painBack painBack painBack pain1. Non-specific or mechanical type

2. Specific type or medical type

Injury

Degeneration

Congenital

Inflammation (Infectious, non-infectious)

Non-inflammation (Fracture, malignancy)

Inflammatory diseases

Infectious

Non-infectious

Non-inflammatory diseases

Metabolic bone disease

Malignancy

Hematologic diseases

Psychogenic rheumatism

Malingering

Referred pain

Medical back pain


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Age range associated with back pain

20 30 40 50 60 70

years

Inflamm. bowel disease

Ankylosing spondylitis

Reiters disease

Psoriatic spondylitis

Muscle strain

Fibrositis

Spinal stenosis

Herniated nucleus pulposus

Isthmic spondylolisthesis

Osteoarthritis

Metastases

Multiple myeloma

Red flags in low back pain

1. Acute onset in patients with risk factors for osteoporosis

2. Constant or progressive back pain3. Nocturnal pain

4. Constitutional symptoms: fever, night sweats and weight loss

5. Morning back stiffness in patientsyounger than 20

(Agency for Health Care Policy and Research, AHCPR guideline)

LowBackPain

6. Progressive bilateral or alternating back pain

7. Severe or progressive neurological abnormalities

8. Cauda equina syndrome: saddle anesthesia, bladder dysfunction

9. Vascular claudication or presence ofabdominal mass

10. Unable to lie still due to pain

11. Patients with risk factors: immunosuppressive state, current or

recent infection, malignancy or major trauma

5. Inflammatory arthritis Family history Nocturnal pain, AM stiffness, arthritis, enthesitis History of uveitis, psoriasis, IBD, etc.

Positive Red flag of recent LBP

1. Neurological compromise Saddle anesthesia Sphincter dysfunction Sensory / motor loss of lower limb

2. Fracture Recent trauma Risk factors for osteoporosis Long term use of corticosteroid

3. Infection Fever chill, weight loss. Risk factors: HIV, DM, drugs, etc. Recent surgery, dental work, sources of infection Shock of unknown origin

4. CancerYoung (55) History of cancer, (+) S/S of malignancy Unexplained weight loss & nocturnal pain

Emergency MRI or CT

Neurosurgical Evaluation

Std.X-raysBone scan

CBC, U/A, ESR, CRP,

hemo & relevant C/S

Bl.chem, Std. X-rays,

MRI, bone scintigraphy

Routine lab, ESR, CRP,

Standard X-rays

bone scan, MRI

ESR, CRP, X-rays KUB,

lumbar spine and heels

Rx. NSAIDs DMARDs

Investigation & Rx. Erythema nodosum Non-specific skin sign in autoimmune dis.

Septal panniculitis without vasculitis

Inflammatory subcutaneous plaques

(nodules) on anterior aspect of shins

Often accompanied by fever, chills,

malaise, leukocytosis and arthritis.

Dx: Typical lesion and typical location

Prognosis: Spontaneous resolve in 3 - 6 wks

without ulcerations or scarring.

Infections

Strept.pharyngitis, TB, leprosy, fungus, Lymes disease,

leptospirosis, yersinia

Drugs

Penicillin, sulfonamide, bromides, contraceptive pills

Autoimmune diseases: Behcet, SLE

Malignancy: RE malignancy

Miscellaneous

Sarcoidosis, pregnancy, IBD (UC > Crohn)

Idiopathic

Erythema nodosum

Rx:

Associated conditions

NSAIDs, steroids, KI

Size of Vessel Involvement in Vasculitis

PAN, cryoglob, SLE, RA, D/M, APL(Sneddons syndrome), lymphoma,TB, syphilis, drug, PRV, IVDU,hypercalcemia, arteriosclerosis.

Small arterioles(perpendicular branches indermis).

LVR

PAN, CS, WG.Arterioles to small arteries.Ulcers

PAN, TK, WG, RA, SLE, infection,drug, Behcets disease, sarcoid,malignancy, UC

Medium-sized vessels.Nodules

Cutaneous

Hypersensitivity vasculitis, PAN,CS, WG, cryoglobulinemia.

Medium sized vessels tocapillaries.

Gangrene

LCV, any type of vasculitis ofmedium and small vessel sizedvasculitis.

Post-capillary venules

(medium-sized vessels) in

dermis.

Less commonly capillaries

and arterioles.

Palpable purpura


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Type of Vessel Involvement in Vasculitis

GCA, SLESmall, medium or large arteriesStroke

PAN, CS, WG,

cryoglobulinemia

Small arteriesPeripheralneuropathies

Neurological

CS, MPASmall to medium sizedvasculitis

Pulmonary infiltratesor cavities

MPA, WGCapillaries; Less commonlysmall to medium sized arteries

Pulmonaryhemorrhage

Pulmonary

PAN, TK (common)

CS, WG (less common)

Small to medium sized arteriesIschemic renalfailure

MPA, WG, CS,

Cryoglobulinemia, HSP

CapillariesGlomerulonephritis

Renal

HSP, PAN, CSCapillaries to medium-sizedarteries

GI bleeding

GI

HSP, PAN, CSSmall to medium sized arteriesAbdominal pain ormesenteric ischemia

Cryoglob.

HSP, cut. LCV

Medium

arteries

WG, CSS,MPA

PAN

KW

TK

GCA

Large

arteries

Small

arteries

Arterioles,

capillaries,venules

Primary

vasculitis

Vasculitis and BV size

HSP. IBDBloody diarrhea, crampy abdomen

PANTesticular tenderness

CSAsthma

TK, PAN, WG, MPAHypertension in young female

WG, MPASinusitis, pulmonary-renal synd.

PAN, WG, CSMononeuritis multiplex

TK, GCAAbsent radial pulses

GCAJaw claudication, visual loss, tender

temporal A, temporal A pulsation

Clinical Features Specific types ofprimary vasculitis

Nicotinic acid (>3g/d)

Salicylates (3g/d)

ProbenecidRibavirin / Interferon

LevodopaGlucocorticoids

Ethambutol / PyrazinamideFructose

Diuretics (except

triamterene, spinorolactone)

Filgrasim

DiazoxideEthanol

Cyclosporin / TacrolimusDidanosine

ACE inhibitors (except

losartan)

Chemothrapeuatic

agents

Renal excretion Production / intake

CANT LEAP : CCCCyclosporin, AAAAlcohol, NNNNicotinic acid, TTTThiazides,

LLLLoop diuretics, EEEEthambutol, AAAAspirin low dose, PPPPyrazinamide.

Drug-induced hyperuricemia

Drug-induced Rheumatic Syndrome

Drug-induced Lupus

Aromaticamine

Inactivemetabolites

Acetylation

Carbamazepine

Chlorpromazine

Ethosuximide

Hydralazine

INH

Methyldopa

Minocycline

Penicillamine

Phenytoin

Procainamide

Quinidine

Sulfasalazine

Slow

or

rapid

genotype

Drug-induced SCLE: Terbinafine, CCB, etanercept.


Drug-induced Anti-phospholipid Syndrome

Chlorothiazide

Chlorpromazine

Ethosuxumide

Hydralazine

Interferon-gamma

Oral contraceptive pills

Phenothiazines

Procainamide

Quinidine

Quinine sulphate


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Drug-induced ANCA-associated Vasculitis

Hydralazine

Methimazole

Minocycline

PTU

d-Penicillamine

Drug-induced Scleroderma

Tryptophan Bleomysin Organic solvents

Vinyl chloride Fosinopril Pentazocine

Drug-induced Myositis

Statins

Drug-induced arthropathy

Fluoroquinolones, retinoids

Cyclosporin, PZA, ETB.

+

Anti-nuclear antibodies(Patterns, ANA specificities, Disease association)

Homogenous

Histone

DIL

ds-DNA

SLE

Speckled

Sm Ro La

SS

U1-RNP

MCTD

Nucleolar

Scl-70

PSS

High titer

Rim

Overlap syndromeor mixed CNT disease

Use immunofluorescent assay for staining pattern Use ELISA or immunodiffusion technique for specific Ab test

Hand edema

Raynauds

Sclerodactyly

Esophageal dysmotility

PHT, IPD

Mixed Connective Tissue Disease

Clinical combination

No other autoAbs

Anti-Sm

Anti-DNA

Anti-Ro

Anti-La

Arthragia or

non-deforming arthritisSerositis

Myositis

PSS

RA

PM

SLE

Chronic non-infectious destructive

inflammatory arthropathy

High titer of

Anti-U1-RNP Ab

Pseudogout (CPPD arthropathy)

Licked candy Overhanging Gull wing

Erlenmeyer flask Pencil in cup (Pestle in mortar)

Spondyloarthropathies

Pertinent findings (asymmetrical involvement)

Juxta-articular osteopenia (less severe)

Diffuse joint space narrowing

Bone erosions / osteolysis

(marginal / subchondral bones)

New bone formation

Subchondral bone sclerosis

Peri-articular or marginal bone proliferation

Joint ankylosis (early)

Predominance ofDIP joint involvement

(Psoriatic arthritis, undiff. SNSA)


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Secondary AS Diffuse Idiopathic Skeletal Hyperostosis

DISH

Diffuse Idiopathic Skeletal Hyperostosis

(DISH)

Pertinent positive finding

Flowing ofat least 4 contiguous large

paravertebral bony outgrowths (mug handle-like)

Peri-articular calcifications

Negative findingsNormal disc space and endplate

Normal SI and hip joints

No vertebral endplate / subchondral bone changes

(DDx. OA, SNSA)

OADISH20 AS10 AS

BilateralSacroiliitis

UnilateralSacroiliitis

NoSI joint

Involvement

SIankylosismay occur

Bony Proliferation of Spine

Vertebral Osteomyelitis

Loss of disc space

Destruction of adjacent

vertebral endplates

No vertebral sclerosis

No soft tissue masses

Staph. aureus is the

most common causative

organism

Metastatic

malignancy


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Metastatic spinal fracture

Pertinent findings

Soft tissue mass (tumor extension)Normal (or widening) disc space until late

Localized (diffuse) osteopenia or osteosclerosis

or mixed bone density

Stepping and destruction of vertebral endplate

Asymmetric collapse of vertebral body

Non-homogeneous bone density of collapsed

vertebra

Loss ofpedicle or posterior element destruction

Osteoporotic Fracture of Spine

Osteoporotic spinal fracture

Pertinent findingsGeneralized osteopenia

Widening (or relatively normal)

disc space

Stepping (irregular surface) of

well-defined vertebral endplate

Collapse of vertebral body

Homogeneous bone density and

increased vertical radiodense

striations of collapsed vertebra

Increased bone density

(compact bone + callus)

Normal

Wedged

Pancake

Codfish

Potts

disaease

Spinal

metastasis

Osteoporotic

fractureBacterial

Spdiscitis

1. Soft tissue shadow

2. Intervertebral disc space

3. Vertebral endplate

Bone / Disc Destruction of Spine

4. Bone texture of vertebral body

5. Pedicle

Acute Gout Treatment

Intra-articular

steroid injection or

NSAIDs or colchicine

Acute gouty attack

Single joint

Colchicine0.6 mg x 3

Prednisoone30-60 mg /day then

taper off in 2 wks

Renal or hepaticdisease

Solumedral IM,IV100-150 mg/d x 1-2 days

or

ACTH SC, IM, IV25-40 IU q 12 hrs for 1-3 days

NSAIDs

High risks for cardiacor GI toxicity

Taking oralmedications

Unable to take oralmedications

Normal renal andliver functions

Low risks for cardiacor GI toxicity

Oligo-polyarticular joint

New drugs and sites of action

Uricase(uric oxidase)

Xanthine oxidase OxypurinolFebuxostat

Allopurinol


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Rheumatologys Ten Golden Rules

1. Good history and physical examination with

knowledge ofmusculoskeletal anatomy.2. Most shoulder pain is per-articular.

Most low back pain is non-surgical.

3. Patients with acute monarthritis need a synovial

analysis for diagnosis.

4. Most patients with chronic monarthritis need a

synovial biopsy for diagnosis.

5. Gout rarely occurs in pre-menopausal women or affects

spine and joints nearby spine.

Rheumatologys Ten Golden Rules

6. Patients with uncommon sites ofprimary OA need

to be evaluated for secondary OA.

7. Primary fibromyalgia rarely initially presents after

age of 55 or presents with abnormal lab values.

8. Fever and multi-organ complaints in pts with known

systemic rheumatic diseases need to be excluded

infection and possibly other causes.

9. Why order a lab test?

What to do if it comes back abnormal?

10. Most of asymptomatic persons having positive RF

or ANA have neither RA or SLE.

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