1. Rheumatology teaching Pilot 4 sessions Pilot 4 sessions Consultant Rheumatologist/student presentation Consultant Rheumatologist/student presentation Based on Phase II objectives Based on Phase II objectives Polyarthritis, Monoarthritis, Back pain, Soft- tissue disorders Polyarthritis, Monoarthritis, Back pain, Soft- tissue disorders Ward 2 Rheumatology Ward 2 Rheumatology

2. Approach to Polyarthralgia Dr Jaya Ravindran Consultant Rheumatologist UHCW

3. Approach to Polyarthralgia Aims Differential diagnosis of polyarthralgia/polyarthritis Differential diagnosis of polyarthralgia/polyarthritis Investigations Investigations

4. What conditions present with polyarthalgia?

5. Differential diagnosis of polyarthalgia/polyarthritis ‘Poly` > 4 joint ‘Poly` > 4 joint o Rheumatoid arthritis o Polyarticular OA o Sero-ve Spondyloarthropathy (eg psoriatic, reactive) o Polyarticular crystal arthropathy o Multi-organ disease – CTD and vasculitis o Viral arthritis (eg parvovirus, rubella, hepatitis) o (Polymyalgia rheumatica/GCA)

6. Differential diagnosis of polyarthalgia/polyarthritis ‘Poly` > 4 joints ‘Poly` > 4 joints o Medical conditions o thyroid disease / hyperparathyroidism / osteomalacia o diabetic cheiroarthropathy o paraneoplastic syndromes, multiple myeloma o infective endocarditis o sarcoidosis o Fibromyalgia

7. Age and sex Incidence AGEFEMALEMALE Young adults RAReactive arthritis SLE(Sero-ve) Psoriatic arthritis Psoriatic arthritis(Sero-ve) Middle age RARA OAGout Old age OA PMR Crystal arthritis

8. What clues are there to diagnosis?

9. CLUES Prodromal event eg GI/GU infection Prodromal event eg GI/GU infection Associated conditions eg psoriasis, colitis, iritis Associated conditions eg psoriasis, colitis, iritis Inflammatory or mechanical* Inflammatory or mechanical* Pattern of joint and symmetry eg RA vs PsA vs OA* Pattern of joint and symmetry eg RA vs PsA vs OA* Multi-organ disease* Multi-organ disease* Fibromyalgia symptoms* Fibromyalgia symptoms*

10. How do you differentiate between mechanical and inflammatory symptoms?

11. Mechanical vs Inflammatory Inflammatory Mechanical Inflammatory Mechanical Immobility stiffness latter day Immobility stiffness latter day EMS>30-60 minsEMS 30-60 minsEMS<30-60 mins Better with activity and NSAIDsworse with activity Better with activity and NSAIDsworse with activity Joint swelling,erythema,heat instability Joint swelling,erythema,heat instability Systemic symptoms locking Systemic symptoms locking Multi-organ involvement trauma, strain overusage Multi-organ involvement trauma, strain overusage

12. Pattern and Symmetry? Pattern and Symmetry?

13. Pattern and symmetry RA - PIP, MCP, wrists, elbows, shoulders, neck, knee, ankle, MTP, symmetrical RA - PIP, MCP, wrists, elbows, shoulders, neck, knee, ankle, MTP, symmetrical Sero-ve – DIP, asymmetrical, dactylitis, enthesitis, spinal Sero-ve – DIP, asymmetrical, dactylitis, enthesitis, spinal OA – DIP, PIP, CMC, ACJ OA – DIP, PIP, CMC, ACJ Weight bearing joints

14. Sero-ve Spondyloarthritis – psoriatic arthritis DIP, poly, dactylitis, DIP, poly, dactylitis, enthesitis, spinal enthesitis, spinal

15. Osteoarthritis Mechanical symptoms Mechanical symptoms Bony swelling, crepitus Bony swelling, crepitus DIP (Heberden), PIP (Bouchard), 1 st CMCJ, neck, lower back, hips, knees, 1 st MTP DIP (Heberden), PIP (Bouchard), 1 st CMCJ, neck, lower back, hips, knees, 1 st MTP

16. Polyarticular crystal eg gout Chronic Chronic Tophi Tophi Erosions Erosions

17. Fibromyalgia “All over pain” “All over pain” Fatigue Fatigue Sleep disturbance Sleep disturbance Depression Depression Anxiety Anxiety Irritable bowel Irritable bowel Tender spots Tender spots Diagnosis of exclusion Diagnosis of exclusion

18. What are CTD and what symptoms and signs are seen?

19. Connective tissue disease Eg SLE, scleroderma, polymyositis, Sjogren’s Eg SLE, scleroderma, polymyositis, Sjogren’s Auto-immune Auto-immune Multi-organ Multi-organ Anti-nuclear antibodies Anti-nuclear antibodies

20. Connective tissue disease symptoms o Photosensitive rashes o Skin tightness o Raynauds – late onset, trophic changes o Mouth ulcers

21. Connective tissue disease symptoms o Dry eyes and mouth o Arthralgias, arthritis – non deforming o Proximal myopathy – pain and weakness (PMR pain and stiffness – think also GCA)

22. Connective tissue disease symptoms o Swallowing o Serositis/ILD – pleurisy, dyspnoea, cough o RENAL DISEASE – silent, URINE DIP + BP o Systemic - fatigue, fever, weight loss

23. Connective tissue disease symptoms o Vasculitis – petechial, purpura, ulcer

24. What are the vasculitides and what type of symptoms and signs?

25. Vasculitis Small, medium, large vessel Small, medium, large vessel Eg MPA, Churg Strauss, PAN, Wegeners, GCA Eg MPA, Churg Strauss, PAN, Wegeners, GCA ANCA ANCA

26. Vasculitis Systemic, vasculitic ulcers/rashes, arthralgias/arthritis – non deforming Systemic, vasculitic ulcers/rashes, arthralgias/arthritis – non deforming ENT - sinusitis ENT - sinusitis Pulmonary – haemoptysis, late onset asthma Pulmonary – haemoptysis, late onset asthma Cardiac failure Cardiac failure RENAL – URINE DIP + BP RENAL – URINE DIP + BP Neuropathy eg footdrop Neuropathy eg footdrop

27. PMR and GCA features?

28. Polymyalgia rheumatica and GCA Over 50’s Over 50’s Proximal inflammatory pain and stiffness Proximal inflammatory pain and stiffness GCA – large vessel arteritis GCA – large vessel arteritis Temporal headache, jaw claudication visual disturbance, systemic upset Temporal headache, jaw claudication visual disturbance, systemic upset Raised ESR and CRP – urgent steroids Raised ESR and CRP – urgent steroids TA biopsy TA biopsy

30. Investigations Inflammatory arthritis – RA Inflammatory arthritis – RA FBC, ESR, CRP, U+E, LFT, RF, XR Hands and feet FBC, ESR, CRP, U+E, LFT, RF, XR Hands and feet ? CTD/vasculitis - ANA, ENA, RF, DNA binding, ANCA, complement ? CTD/vasculitis - ANA, ENA, RF, DNA binding, ANCA, complement Urine dip and BP Urine dip and BP Organ based investigations Organ based investigations Diffuse symptoms – CK, Ca, ALP, TFT Diffuse symptoms – CK, Ca, ALP, TFT Viral – Parvovirus, LFT+Hepatitis Viral – Parvovirus, LFT+Hepatitis

31. What other conditions present with elevated RF?

32. 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

33. What are the ANA and ENA?

34. ANA and ENA ANA 1/40 not significant unless associated with appropriate clinical scenario ANA 1/40 not significant unless associated with appropriate clinical scenario Also in RA, cirrhosis, ai liver disease, neoplasia, healthy population Also in RA, cirrhosis, ai liver disease, neoplasia, healthy population ENA – extractable nuclear antigens ENA – extractable nuclear antigens Anti-Ro and anti-La - Sjogrens Anti-Ro and anti-La - Sjogrens Scl 70 and anti-centromere – Scleroderma Scl 70 and anti-centromere – Scleroderma Anti-RNP – mixed CTD Anti-RNP – mixed CTD Anti-Jo1 - myositis Anti-Jo1 - myositis

35. What is ANCA ?

36. ANCA Antibodies vs specific antigens in cytoplasm of neutrophils 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 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 ANCA reactive to proteinase 3 (PR3) – cytoplasmic pattern of staining C-ANCA eg Wegener’s granulomatosis

37. What are the radiological feature of OA, RA (and PsA) ?

38. Radiology - OA  Four cardinal features:  Joint space narrowing  Sclerosis  Subchondral cysts  Osteophytes

39. Radiology - RA soft tissue swelling soft tissue swelling juxta-articular osteoporosis juxta-articular osteoporosis juxta-articular and subchondral erosions juxta-articular and subchondral erosions joint space narrowing & subluxation joint space narrowing & subluxation secondary OA & bony ankylosis secondary OA & bony ankylosis

40. Radiology - PsA Erosion Erosion Osteolysis Osteolysis Bone Boneproliferation Ankylosis Ankylosis

41. Thank-you