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Sunil Abraham, MD Ellis Rheumatology Associates Inflammatory Arthritis and Autoimmunity.

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Presentation on theme: "Sunil Abraham, MD Ellis Rheumatology Associates Inflammatory Arthritis and Autoimmunity."— Presentation transcript:

1 Sunil Abraham, MD Ellis Rheumatology Associates Inflammatory Arthritis and Autoimmunity

2 No disclosures

3 Classification Arthritis Inflammatory Infectious Septic Osteomyelitis CrystallineMonosodium urateCalcium pyrophosphateAutoimmuneRheumatoidSeronegative (HLA-B27)ANA related Vasculitis, Sarcoid, Misc Polymyalgia rheumatica Non-Inflammatory Osteoarthrosis

4 Case presentations

5 Case #1 46 year old white female with 4 month history of progressive fatigue associated with worsening joint pains In the morning her knees are very stiff (1 hour) and her first few steps out of bed are very painful She has noticed MCP swelling and that her rings are getting tighter There is numbness and tingling in her fingertips ROS negative

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7 Case #2 28 year old male presents with a 5 year history of recurring bilateral ankle pain and swelling. It is associated with extreme morning stiffness. He denies any back pain. He has nail pitting His brother recently developed a rash on his elbows MRI of the of right ankle showed significant tendon swelling and subcortical erosions

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9 Case # 3 82 year white female with history of diabetes, hypertension and coronary disease presents with 2 month history of progressive fatigue, malaise and stiffness in her hips and shoulders She has never taken an hmg coa reductase inhibitor Review of systems is negative Sedimentation rate is normal

10 Case # 4 An 87 year old white female presents to your office with acute right dorsal wrist swelling, redness, warmth and pain that has been present for 3 weeks No constitutional symptoms are present Two courses of antibiotics provide no relief Xray of her wrist shows chondrocalcinosis of the TFCC; ESR is 90

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12 Inflammatory Arthritis Infiltration of synovial capsule and surrounding joint capsule with lymphocytes, neutrophils, and macrophages Cardinal signs of inflammation: – Rubor, Calor, Tumor, Dolor Potential for joint disruption and destruction

13 Acute Inflammatory arthritis Abrupt onset (hours to days) Hot, red, swollen, exquisitely tender joint Constitutional symptoms (fevers, chills, sweats) Mono-, oligo-, poly- articular

14 Acute Inflammatory arthritis Differential Infectious Bacterial, mycobacterial, fungal Opportunistic Lyme (3 rd stage) Crystalline Monosodium urate- ‘Gout’ Calcium pyrophosphate- ‘Pseudogout‘

15 Acute Inflammatory arthritis Rule out mechanical/traumatic injury Olecranon bursitis, rotator cuff/ achilles tendonitis Fracture

16 Chronic inflammatory arthritis Progressive, insidious (>6 weeks) Morning stiffness > 1 hour Additional signs of inflammation Fatigue, malaise, anhedonia Weight loss, anorexia ‘Flu like ’

17 Chronic inflammatory arthritis Extra-articular manifestations Rash (psoriatic, erythema nodosum) Urethritis or sexually transmitted disease History of bowel infection (salmonella, shigella) Inflammatory bowel disease (colitis) Uveitis Sicca

18 Connective tissue disease Disorder with collagen and elastin Supporting structures Non-heritable (genetics/environmental) Rheumatoid arthritis Systemic lupus erythematosus Sjogrens Syndrome Polymyositis, Scleroderma Heritable Osteogenesis imperfecta, Marfans, Ehlers-Danlos

19 Connective tissue disease Review of systems Signs of inflammation Arthritis Patchy alopecia Oral/nasal ulcerations Raynauds Xerophthalmia/ Xerostomia Rash (distribution, photosensitive ) Proximal muscle weakness

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22 Connective tissue diseases Rheumatoid Arthritis Systemic Lupus Erythematosus Sjogrens Syndrome Systemic Scleroderma Polymyositis/ Dermatomyositis Mixed Connective Tissue Disease

23 Labs for Autoimmunity

24 ACR Position Statement Immunofluorescence testing is the gold standard for ANA testing HEp-2 cells have multiple autoantigens (>100) Need to have results reported with titer and pattern Current technology employs ELISA and multiplex technologies Allows processing of large volumes Limits diagnostic accuracy 8-10 autoantigens

25 Conditions with positive ANA Essential for diagnosis SLE Systemic sclerosis Mixed connective tissue disease Somewhat useful Poly-, Dermatomyositis Sjogrens Other conditions with +ANA Autoimmune hepatitis/thyroid disease Multiple sclerosis Malignancy Age Infection

26 ANA pearls Not a screening test Is there a high pre-test likelihood: SLE Scleroderma Sjogrens Autoimmune myopathy Obtain results in titer and pattern Consider other causes for positivity

27 Related Autoantibodies RAMCTDSLEPM/DMSclSjogrens dsDNA Smith RNPSSA/BJo-1 Scl-70 Centromere RFCCP “ANA-negative”

28 Seronegative Arthritis Associated conditions: Psoriatic arthritis Ankylosing spondylitis Reactive arthritis Enteropathic related Undifferentiated spondyloarthropathy HLA-B27 Not useful as a diagnostic test Presence in 6% of normal population

29 Polymyalgia Rheumatica ?Autoimmune inflammatory condition Periarthritis Subdeltoid bursitis, glenohumeral synovitis, biceps tenosynovitis Consider diagnosis is those >50 years old, especially >70 ~15% association with Giant Cell Arteritis Check ESR, CRP, SPEP Exquisitely responsive to glucocorticoids 1-2 years with slow taper

30 Crystalline Arthritis Monosodium urate deposition (Gout) Affects 1 st MTP, knees, wrist Destructive Consider in post menopausal women Gold standard diagnosis is by joint fluid analysis Goal uric acid <6 Calcium pyrophosphate deposition (Pseudogout) Disruption of cartilage calcification Senior population

31 Cases Revisited

32 Case #1 46 year old white female with 4 month history of progressive fatigue associated with worsening joint pains In the morning her knees are very stiff (1 hour) and her first few steps out of bed are very painful She has noticed MCP swelling and that her rings are getting tighter There is numbness and tingling in her fingertips

33 Case #2 28 year old male presents with a 5 year history of recurring bilateral ankle pain and swelling. It is associated with extreme morning stiffness. He denies any back pain. He has nail pitting His brother recently developed a rash on his elbows MRI of the of right ankle showed significant tendon swelling and subcortical erosions

34 Case # 3 82 year white female with history of diabetes, hypertension and coronary disease presents with 2 month history of progressive fatigue, malaise and stiffness in her hips and shoulders She has never taken an hmg coa reductase inhibitor Review of systems is negative. Sedimentation rate is normal

35 Case # 4 An 87 year old white female presents to your office with subacute right dorsal wrist swelling, redness, warmth and pain that has been present for 3 weeks No constitutional symptoms are present Two courses of antibiotics provide no relief Xray of her wrist shows chondrocalcinosis of the TFCC; ESR is 90; Uric acid 5.4

36 Conclusions Appreciate the spectrum of inflammatory arthritis and its relation to connective tissue diseases Understand the importance of patient demographics in narrowing your differential Before ordering an ANA, consider whether the patient truly has a connective tissue disease Always make sure ANA’s are ordered by IFA with titer and pattern Don’t forget about psoriatic arthritis and pseudogout!

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