Ambulatory Morning Report – February 29
38 y/o AA woman
“My joints hurt”
Thoughts?
135 100 21 TSH: 1.02
CRP: 0.6
93 ESR: 12
4.0 24 0.6 CPK: 327
UA: All negative
ANA: (+) 1:320
RF: (+) 1:16
Ro: (-)
5.6 359 La: (-)
35.8 Smith: (-)
ds DNA: (-)
MCV = 92
135 100 21 TSH: 1.02
CRP: 0.6
93 ESR: 12
4.0 24 0.6 CPK: 327
UA: All negative
ANA: (+) 1:320
RF: (+) 1:16
Ro: (-)
5.6 359 La: (-)
35.8 Smith: (-)
ds DNA: (-)
MCV = 92
CCP: 319
Differential Dx
Workup
Patient outcome
A few words on RA
Pain in >4 joints
EXTREMELY vast differential diagnosis
Very difficult diagnosis
Labs with poor specificity
Infectious Crystal
Bacterial Gout / Pseudogout
Viral Rheumatic
Spondyloarthropathy RA
AS SLE
IBD Endocrine
Psoriasis Hypothyroid
Reactive arthritis Systemic
Osteoarthritis Sarcoidosis
Hemochromatosis
Parvovirus B19
RA
SLE
OA
Fibromyalgia
AS
Psoriatic arthritis
Key things to ask about and look for
Demographics
Chronology
Symptoms of inflammation
Distribution (symmetry?)
Extra articular manifestations?
Gender: Race:
F >M: rheumatic White: PMR,
process Wegener’s
Age: Black: Sarcoid, SLE
Younger: rheumatic FHx
Older: OA, vasculitis HLA B-27:
Seronegative
spondyloarthropathies
Rheumatic disease will have >6 weeks of
symptoms
1 hr indicative of inflammatory process
Also seen in some non inflammatory
Fibromyalgia
Not typically seen in OA for >1 hr
Patterns
DIP and PIP OA
MCP and PIP RA
Lumbar spine and SI joint AS
Symmetry
Symmetric pain most potent discriminating
feature in RA
La Montagna GL et al. Clin Exp Rheumatol 1997; 15:481-5.
Sausage
digits of
Psoriatic
arthritis
Malar rash of SLE
Erythema Chronicum Migrans
Lyme Disease
Classic findings of OA
Limited ROM in AS
Blood work
Interpret antibodies with a grain of salt!
Can be very misleading and confusing
Imaging
Joint aspiration
ESR
Non specific markers of inflammation
CRP
CMP
CBC
Antibodies
RF
ANA
ANA
(+) in 5-10% of population
Very sensitive for SLE
RF
Poor sensitivity and specificity
(+) in 5-10% of population
25% of RA have (-) RF
Anti-CCP
More specific for RA
Often times normal early in disease
Usually not useful to image every painful
joint
Peri articular osteopenia!
Felt somewhat better with Naproxyn
Seen by rheumatology
Diagnosed with RA as well as SLE
Started on Methotrexate, prednisone
Joint pain completely improved
1% prevalence in the US
Female > Male (2:5 to 1 ratio)
Typical age of onset 30-50 y/o
Symptoms and history are key to
diagnosis
4 of 7 criteria (mostly H&P based)
AM stiffness >1 hr for >6 weeks
Swelling of wrist, MCP, PIP for >6 weeks
Swelling of 3 joints for >6 weeks
Symmetric joint swelling >6 weeks
Rheumatoid nodules
Erosive synovitis on Xrays
Rheumatoid factor (+)
Unclear prevalence
~30% of RA patients
Often asymptomatic
Cord compression sx
Headache
Tingling in arms
Dizziness
Check for this pre
op before
intubation!
C1-C2 Subluxation
Nodule
s
Pleural effusion
Mononeuritis - LOW glucose (4 joints, chronic if >6
weeks
Synovitis = joint inflammation
Classic symptoms of RA symmetric,
multiple joints, AM stiffness >1 hr
Remember C1-C2 subluxation in RA
patients
RA pleural effusion VERY low glucose
DMARDS are key – especially MTX