Rheumatology teaching

Rheumatology teaching      Pilot 4 sessions Consultant Rheumatologist/student presentation Based on Phase II objectives Polyarthritis, Monoarthritis, Back pain, Softtissue disorders Ward 2 Rheumatology Approach to Polyarthralgia Dr Jaya Ravindran Consultant Rheumatologist UHCW Approach to Polyarthralgia Aims   Differential diagnosis of polyarthralgia/polyarthritis Investigations What conditions present with polyarthalgia? Differential diagnosis of polyarthalgia/polyarthritis  „Poly` > 4 joint o o Rheumatoid arthritis Polyarticular OA Sero-ve Spondyloarthropathy (eg psoriatic, reactive) Polyarticular crystal arthropathy Multi-organ disease – CTD and vasculitis Viral arthritis (eg parvovirus, rubella, hepatitis) (Polymyalgia rheumatica/GCA) o o o o o Differential diagnosis of polyarthalgia/polyarthritis  „Poly` > 4 joints o Medical conditions o o o o o thyroid disease / hyperparathyroidism / osteomalacia diabetic cheiroarthropathy paraneoplastic syndromes, multiple myeloma infective endocarditis sarcoidosis o Fibromyalgia Age and sex Incidence AGE Young adults FEMALE RA SLE MALE Reactive arthritis (Sero-ve) Psoriatic arthritis (Sero-ve) Middle age Old age RA OA OA PMR Crystal arthritis RA Gout What clues are there to diagnosis? CLUES       Prodromal event eg GI/GU infection Associated conditions eg psoriasis, colitis, iritis Inflammatory or mechanical* Pattern of joint and symmetry eg RA vs PsA vs OA* Multi-organ disease* Fibromyalgia symptoms* How do you differentiate between mechanical and inflammatory symptoms? Mechanical vs Inflammatory     Inflammatory Mechanical    Immobility stiffness latter day EMS>30-60 mins EMS<30-60 mins Better with activity and NSAIDs worse with activity Joint swelling,erythema,heat instability Systemic symptoms locking Multi-organ involvement trauma, strain overusage  Pattern and Symmetry? Pattern and symmetry  RA - PIP, MCP, wrists, elbows, shoulders, neck, knee, ankle, MTP, symmetrical Sero-ve – DIP, asymmetrical, dactylitis, enthesitis, spinal  OA – DIP, PIP, CMC, ACJ Weight bearing joints  Sero-ve Spondyloarthritis – psoriatic arthritis   DIP, poly, dactylitis, enthesitis, spinal Osteoarthritis    Mechanical symptoms Bony swelling, crepitus DIP (Heberden), PIP (Bouchard), 1st CMCJ, neck, lower back, hips, knees, 1st MTP Polyarticular crystal eg gout    Chronic Tophi Erosions Fibromyalgia         “All over pain” Fatigue Sleep disturbance Depression Anxiety Irritable bowel Tender spots Diagnosis of exclusion What are CTD and what symptoms and signs are seen? Connective tissue disease     Eg SLE, scleroderma, polymyositis, Sjogren‟s Auto-immune Multi-organ Anti-nuclear antibodies Connective tissue disease symptoms o o o o Photosensitive rashes Skin tightness Raynauds – late onset, trophic changes Mouth ulcers Connective tissue disease symptoms o Dry eyes and mouth Arthralgias, arthritis – non deforming o o Proximal myopathy – pain and weakness (PMR pain and stiffness – think also GCA) Connective tissue disease symptoms o Swallowing Serositis/ILD – pleurisy, dyspnoea, cough RENAL DISEASE – silent, URINE DIP + BP Systemic - fatigue, fever, weight loss o o o Connective tissue disease symptoms o Vasculitis – petechial, purpura, ulcer What are the vasculitides and what type of symptoms and signs? Vasculitis    Small, medium, large vessel Eg MPA, Churg Strauss, PAN, Wegeners, GCA ANCA Vasculitis       Systemic, vasculitic ulcers/rashes, arthralgias/arthritis – non deforming ENT - sinusitis Pulmonary – haemoptysis, late onset asthma Cardiac failure RENAL – URINE DIP + BP Neuropathy eg footdrop PMR and GCA features? Polymyalgia rheumatica and GCA       Over 50‟s Proximal inflammatory pain and stiffness GCA – large vessel arteritis Temporal headache, jaw claudication visual disturbance, systemic upset Raised ESR and CRP – urgent steroids TA biopsy Investigations        Inflammatory arthritis – RA FBC, ESR, CRP, U+E, LFT, RF, XR Hands and feet ? CTD/vasculitis - ANA, ENA, RF, DNA binding, ANCA, complement Urine dip and BP Organ based investigations Diffuse symptoms – CK, Ca, ALP, TFT Viral – Parvovirus, LFT+Hepatitis What other conditions present with elevated RF? Rheumatoid factor Infection: Acute infection eg infectious mononucleosis; Chronic infection eg SBE, TB; Parasitic eg malaria; vaccination Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic active hepatitis, cryoglobulinaemia Malignancy: Lymphoma, leukaemia, myeloma, solid tumours 5% healthy population RF <15 not significant unless associated with appropriate clinical scenario What are the ANA and ENA? ANA and ENA        ANA 1/40 not significant unless associated with appropriate clinical scenario Also in RA, cirrhosis, ai liver disease, neoplasia, healthy population ENA – extractable nuclear antigens Anti-Ro and anti-La - Sjogrens Scl 70 and anti-centromere – Scleroderma Anti-RNP – mixed CTD Anti-Jo1 - myositis What is ANCA ? ANCA    Antibodies vs specific antigens in cytoplasm of neutrophils ANCA reactive to myeloperoxidase (MPO) – perinuclear pattern of staining P-ANCA eg microscopic polyarteritis ANCA reactive to proteinase 3 (PR3) – cytoplasmic pattern of staining C-ANCA eg Wegener‟s granulomatosis What are the radiological feature of OA, RA (and PsA) ? Radiology - OA  Four cardinal features:     Joint space narrowing Sclerosis Subchondral cysts Osteophytes Radiology - RA  soft tissue swelling juxta-articular osteoporosis juxta-articular and subchondral erosions joint space narrowing & subluxation secondary OA & bony ankylosis     Radiology - PsA Erosion  Osteolysis  Bone proliferation  Ankylosis  Thank-you