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Hatem H Eleishi, MD Professor of Rheumatology, Cairo University Consultant Rheumatologist, Dr. Soliman Fakeeh Hospital Rheumatoid Arthritis Wednesday,

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Presentation on theme: "Hatem H Eleishi, MD Professor of Rheumatology, Cairo University Consultant Rheumatologist, Dr. Soliman Fakeeh Hospital Rheumatoid Arthritis Wednesday,"— Presentation transcript:

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3 Hatem H Eleishi, MD Professor of Rheumatology, Cairo University Consultant Rheumatologist, Dr. Soliman Fakeeh Hospital Rheumatoid Arthritis Wednesday, April 29 th, 2009 Lecture 1 Rheumatoid Arthritis From the General Practitioner’s Perspective to the Basic Rheumatologist’s Perspective

4 WHAT MANY DOCTORS KNOW ABOUT RHEUMATOID ARTHRITIS WHAT MANY DOCTORS MIGHT NOT KNOW ABOUT RHEUMATOID ARTHRITIS IN THIS LECTURE

5 RHEUMATOID ARTHRITIS AS MANY DOCTORS KNOW IT

6 CLINICALLY: POLYARTHRITIS IN TIME, CRIPPLING JOINT DEFORMITIES LABORATORY: POSITIVE RF, HIGH ESR PLAIN RADIOLOGY: ARTICULAR EROSIONS MANAGEMENT: NO REAL TREATMENT; ONLY NSAIDs, MAY BE STEROIDS MTX WHICH IS VERY TOXIC AN AUTOIMMUNE DISEASE THAT IS CHARACTERIZED BY:

7 IN SHORT A CRIPPLING DISASTER THAT MORE OR LESS HAS NO TREATMENT

8 RHEUMATOID ARTHRITIS AS MANY DOCTORS MIGHT NOT KNOW IT PRESENTATION LABS IMAGING MANAGEMENT

9 ABOUT THE PRESENTATION OF RHEUMATOID ARTHRITIS IN ADDITION TO A SYMMETRICAL POLYARTHRITIS WHICH IS SOMETIMES RATHER SUBTLE, WE HAVE OTHER PRESENTATIONS TOO; TRUE: THE MOST COMMON PRESENTATION IS A SYMMETRICAL POLYARTHRITIS

10 WE HAVE THE RELUCTANT RA THE STUTTERING RA THE DISGUISED RA THE ACHES ALL OVER RA THE PUFFY RA

11 A 42-YEAR OLD MALE WITH RECCURRENT ATTACKS OF PAIN AND SWELLING OF A WRIST OR A SHOULDER OR AN ANKLE FOR 2 YEARS. DURATION OF EACH ATTACK: 3-7 DAYS ATTACK FREE PERIOD: 2-3 MONHTS THE RELUCTANT RA OR PALINDROMIC RHEUMATISM PRESENTATION 1 OF 5

12 2003: A 33-YEAR OLD FEMALE PRESENTED WITH INFLAMMATORY MONOARTHRITIS OF THE RIGHT WRIST PLAIN FILM OF HER HANDS: NORMAL MRI: EFFUSION, SYNOVIAL THICKENING, BONE MARROW EDEMA EARLY 2003: SHE STARTED TO COMPLAIN OF PAIN AND MS OF HER RIGHT WRIST S T U T T E R I N G RA LATE 2003: PAIN AND SWELLING OF THE ELBOWS, KNEES, ANKLES ANY POLYARTHRITIS CAN INITIALLY START AS A MONOARTHRITIS PRESENTATION 2 OF 5

13 RA FEMALE; 48Y-OLD OA KNEES / HANDS LATELY PAIN NOCTURNAL PAINS REC EFFUSIONS PLAINS: OA ESR 50 RF +VE SYNOVIONALYSIS: INFLAMMATORY SF RA ON TOP OF OA OR DISGUISED RA PRESENTATION 3 OF 5

14 Mona, a 32-year old female, presented with diffuse aches all over of 3 months’ duration. She had a MS of minutes and nocturnal pain sometimes. She was afraid she might have cancer or rheumatoid arthritis but had been reassured by her family doctor that she didn’t have cancer and that her RF test was negative. PRESENTATION 4 OF 5

15 Examination revealed a very anxious patient with inconsistent tenderness over several small joints of the hands but also over the trunk as well as the flesh of the forearms and legs. Investigations: ESR 21 CBC, liver, kidney, electrolytes: normal RF; ANA: negative Hepatitis serology: negative A plain film of the hands and feet were normal

16 DIFFUSE ACHES ALL OVER RA OR FIBROMYALGIC RA A Tc99 bone scan was done

17 Early rheumatoid arthritis can sometimes be a vague diagnosis Bone scan helps to settle the diagnosis in such situations

18 Abu-Ismail, a 59-year old male, presented with gradual onset of pain and swelling of his hands with NP and MS of 4 hours Examination: diffuse swelling (puffinness) of the dorsum of both hands; tenderness of the MCPs, and wrists LABS: ESR 70; Hb 11gm%; RF: Negative RS 3 PE R EMITTING S YMMETRICAL S ERONEGATIVE S YNOVITIS WITH P ITTING E DEMA OR PUFFY RA PRESENTATION 5 OF 5

19 THE RELUCTANT RA THE STUTTERING RA THE SNEEKY RA THE ACHES ALL OVER RA THE PUFFY RA

20 RHEUMATOID ARTHRITIS AS MANY DOCTORS MIGHT NOT KNOW IT PRESENTATION LABS IMAGING MANAGEMENT

21 ABOUT THE LABORATORY INVESTIGATIONS IN RHEMATOID ARTHRITIS

22 THERE ARE CAUSES FOR A POSITIVE RF OTHER THAN RA SO YOU CANNOT RELY SOLELY ON A POSITIVE RF TO DIAGNOSE RA POSITIVE RHEUMATOID FACTOR “THE RHEUMATOID CETRTIFICATE”

23 RHEUMATOID FACTOR IS POSITIVE IN ONLY 70% OF PATIENTS AND NEGATIVE IN 30% SO A NEGATIVE RF DOESN’T RELIABLY EXCLUDE RA NEGATIVE RHEUMATOID FACTOR

24 ESR IS NOT INVARIABLY ELEVATED IN RA ESR

25 ABOUT THE IMAGING OF RHEUMATOID ARTHRITIS

26 NOT EVERY RHEUMATOID DISEASE IS NECESSARILY EROSIVE

27 BEFORE LOOKING FOR EROSIONS, LOOK FIRST FOR: JAO JSN

28 IN EARLY RA, PLAIN FILMS MAY BE NORMAL ANYWAY OTHER IMAGING MODALITIES MAY THEN BE NEEDED TO CONFIRM THE DIAGNOSIS

29 What is the most important thing that is needed to make the diagnosis of RA? A good lab An imaging center A chair A screening questionnaire for the population Knowing the family history of your patient Two doctors rather than one

30 HISTORY-TAKING IS THE MOST IMPORTANT STEP TO COME TO THE CORRECT DIAGNOSIS

31 THERE ARE 3 TYPES OF HISTORY THAT COULD BE TAKEN FROM A PATIENT: THE POLICE OFFICER’S HISTORY THE JOURNALIST’S HISTORY THE GOOD DOCTOR’S HISTORY

32 GOOD DOCTORS DO NOT DIAGNOSE DISEASES THEY JUST LEAVE DISEASES DIAGNOSE THEMSELVES

33 الأمراض مثل البشر ، لكل مرض ملامحه المميزة و طبائعه الخاصة التي يدرسها الطبيب ثم تزداد و تصقل معرفته بها بالممارسة و البحث و الإطلاع المستمر. يتعرف الطبيب على هذه الملامح المميزة في أثناء الحوار مع المريض وعلى هذا فإن أهم خطوة لتشخيص المرض هي: الإستماع الجيد إلى المريض و إلى إجاباته على أسئلة الطبيب

34 ماذا يحدث بالإستماع الجيد إلى المريض و إلى إجاباته على أسئلة الطبيب؟ يقع المريض في حفرة يسيبه يقع لوحده، ما يزقوش ماذا يفعل الطبيب في هذه الحالة؟

35 ABOUT THE MANAGEMENT OF RHEUMATOID ARTHRITIS

36 MANAGEMENT OF RA COMPRISES: PATIENT EDUCATION AND INSTRUCTIONS MEDICAL TREATMENT REHABILITATION SURGICAL TREATMENT SOMETIMES

37 DON’T UNDERESTIMATE THE POWER OF TALKING TO YOUR PATIENT PATIENT EDUCATION

38 MEDICAL TREATMENT REHABILITATION NSAIDs AND PHYSIOTHERAPY Hydroxychloroquine, sulfasalazine, gold Methotrexate, lefulonamide Biological Agents Aim of medical treatment: Induction and maintenance of remission

39 Severe systemic illness Bridge therapy Intra-articular steroids Corticosteroids are not part of the medical treatment of RA except in very selected situations as:

40 Conclusions

41 THERE IS MUCH MORE ABOUT RHEUMATOID ARTHRITIS THAN JUST: A CRIPPLING JOINT DISEASE WITH A POSITIVE RF AND NO TREATMENT

42 A SYMMETRIC POLYARTHRITIS IS THE COMMONEST PRESENTATION, BUT THERE ARE OTHER NOT UNCOMMON PRESENTATIONS FOR RHEUMATOID ARTHRITIS AS WELL PRESENTATION

43 THE MOST IMPORTANT STEP TOWARDS A DIAGNOSIS OF RA IS A GOOD HISTORY TAKEN BY A GOOD DOCTOR PRESENTATION

44 A POSITIVE RF DOESN’T NECESSARILY MEAN RA AND A NEGATIVE RF DOESN’T NECESSARILY MEAN NO RA INVESTIGATIONS

45 PLAIN FILMS IN EARLY RA MAY BE NORMAL INVESTIGATIONS

46 DOCTORS ARE MORE THAN JUST TABLETS MANAGEMENT

47 A MOST INDISPENSIBLE STEP IN THE MANGEMENT OF PATIENTS WITH RA IS PATIENT EDUCATION MANAGEMENT

48 CORTICOSTEROIDS HAVE NO PLACE IN THE TREATMENT OF RA EXCEPT IN VERY SPECIAL SITUATIONS MANAGEMENT

49 VARIOUS IMMUNOMODULATORS AND IMMUNOSUPPRESSIVES AND BIOLOGICAL AGENTS ARE AVAILIABLE FOR THE INDUCTION AND MAINTENANCE OF REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS MANAGEMENT

50 Thank you


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