Week 10 – Polyarthritis week

Dr. Roman Jurencak

Objectives• Define osteoarthritis (OA) & rheumatoid arthritis (RA). • Describe clinical, radiological and laboratory features of OA

& RA.

• Describe extra articular features of RA.‐• Describe the rheumatoid factor test and its significance.• Describe the pathophysiology of RA. • Explain the pathogenesis of joint destruction in RA. • Identify the radiological features of RA on X ray. ‐• Describe approaches to treatment of RA.

• Contrast features of RA with OA both clinically and radiologically.

Case 1

• Joan, a 60-year-old obese woman presents with complaints of bilateral knee pain and pain in the fingers of both hands for the past 12 months. The pain tends to get worse with use and better with rest. She reports morning stiffness lasting 10 minutes in the same joints.

Question?

What is the most likely cause?

A.Rheumatoid ArthritisB.OsteoarthritisC.Systemic lupus erythematosusD.Crystalline arthropathy

Physical exam

Knee: • small effusions

bilaterally• no erythema• crepitus and mild pain

with motion• limited range of motion

Fingers:• - enlarged DIPs and PIPs• - pain with motion• - limited range of

motion

Question?

How would you classify this presentation?

A.chronic polyarthritisB.chronic oligoarthritisC.migratory polyarthritisD.acute polyarthritis

Question

Which of the following structures represents the initial target of injury in this disease:

A.Intra-articular bonesB.tendon insertionsC.musclesD.cartilage

Question?

You decide to obtain X rays of her hands and knees. What radiographic finding is specific for osteoarthritis (as opposed to rheumatoid arthritis)?

A.OsteophytesB.Joint space narrowingC.Periarticular soft tissue swellingD.Periarticular osteopenia

Question?

How would you counsel your patient regarding prognosis of osteoarthritis?

• the disease is slowly progressive • the disease can be well controlled with use of

appropriate immunosuppressive drugs• the disease can cause a lot of joint pain but usually

does not lead to disability • the disease tends to burn out after several years of

symptoms

Question?

What kind of non-pharmacologic therapy would you recommend for this patient?

A.resting the affected joints as much as possible as activity makes the pain worse

B.weight loss and aerobic or resistance training program

C. modified diet with focus on reduction of unsaturated fatty acids and sufficient intake of vitamin E

D.ultrasound therapy

Case 2

• Jenny is a 3-year-old girl brought to your office for assessment of her limp. Her mother reports that Jenny has had abnormal gait for the past 2 months. She never complained of any pain. There are no other clinical symptoms. On exam, you can appreciate mild swelling of both knees, decreased range of motion in the left ankle with some stress pain on motion and a moderate effusion in the right wrist. The rest of the physical examination is completely normal.

Question?

What is the most important piece of information on history?

A.there is a case of Crohn’s disease in the maternal grandmother

B. Jenny had an episode of acute gastroenteritis 4 weeks ago. It lasted 4 days

C. Her limp is most obvious in the morning, however, it does not limit her physical activity

D.Immunizations are up to date.

Question?

What is the most likely diagnosis?

A.Oligoarticular juvenile idiopathic arthritisB.Reactive arthritisC.Rheumatic feverD.Systemic lupus erythematosus

Question?You order some blood work and X rays. Which

results would NOT be in keeping with her diagnosis?

A.antinuclear antibodies (ANA) positive & HLA B 27Ag negative

B.completely normal CBC & differential C. ESR 60mm/hr (norm < 20mm/hr) & rheumatoid

factor positiveD.No pathology detected on X rays of her knees

and ankles. Right wrist X ray showed mild soft tissue swelling.

Question?

What additional investigations should be ordered? (Choose the most important one.)

A.Ultrasound of the affected jointsB.Bone scanC.Referral to ophthalmologyD.Joint aspiration

Question?After discussing the diagnosis with Jenny’s mom,

you outline the treatment plan. Which recommendation is NOT appropriate?

A.Start taking a nonsteroidal anti-inflammatory such as Naproxyn

B.Try to limit her physical activityC. Consider injection of her inflamed joints with

steroidsD.Ensure frequent eye exams (every three moths)

regardless whether she has ocular symptoms or whether her arthritis is active.

Question?Rheumatoid arthritis is characterized by:

A. formation of a pannus in the affected jointsB. morning stiffness lasting <30minC. osteophyte formation D. presence of accompanying uveitis in many patients

Question?Please choose the correct statement:

A. Osteoarthritis is frequently associated with positive rheumatoid factor

B. Osteoarthritis results in loss of hyaline articular cartilage and bony remodelation with cystic degeneration

C. Rheumatoid arthritis frequently affects distal interphalangeal joints

D. Inflammatory cytokines do not play a role in pathogenesis of osteoarthritis

Question?Risk factors for osteoarthritis do not include the

following:

A. age B. obesityC. repetitive injuryD. history of rheumatic fever

Question? What is not in keeping with suspected diagnosis

juvenile idiopathic arthritis?

A. negative rheumatoid factorB. episodic bouts of synovitis lasting 1-3days C. absent ANAD. normal inflammatory markers

Case 3

• Rebecca presents to your office for evaluation of increasing fatigue, poor appetite, joint pains and rash. She is 21 years old and previously healthy. For the past 6 months she has been experiencing increasing malaise along with a ten pound weight loss. She has also been experiencing persistent pain and swelling of proximal interphalangeal joints of both hands and pain in her right knee. She tends to get erythematous rash on sun exposed areas which she didn’t have in the past.

Question?

What is the most likely diagnosis?

A.Systemic lupus erythematosus (SLE)B.Rheumatoid arthritis C.OsteoarthritisD.Lyme disease associated arthritis

Question?

What is the most sensitive test for lupus?

A.anti double stranded DNA antibodiesB.C-reactive proteinC.antinuclear antibodiesD.antiphospholipid antibodies

Question?

What is the most common vital organ involvement is SLE?

A.Kidney – glomerulonephritisB.CNS – psychosis or seizure disorderC.Liver – lupus hepatitisD.Lungs – interstitial lung disease

Question?Which statement is FALSE?

A. treatment of SLE is driven by the most severely affected organ

B. arthritis associated with SLE is usually progressive and destructive

C. urinalysis with 24hr urine collection is very sensitive for detection of lupus nephritis

D. serologic findings frequently associated with SLE include low complement levels, hypergammaglobulinemia, elevated ESR