1. APPROACH TO THE PATİENTS WİTH CHRONIC ARTHRITIS
Dr. MÜGE BIÇAKÇIGİL KALAYCI

2. CHRONIC MONOARTHRITIS
ESSENTIAL FEATURES
Chronic inflammatory monoarthritis
infection, crystal-induced arthritis, sarcoidosis, or monoarticular presentation of oligoarthritis or polyarthritis
Chronic noninflammatory monoarthritis
osteoarthritis, mechanical , Chondromalacia patellae, and osteonecrosis.
Arthrocentesis and imaging studies are important dignostic tests

3. CHRONIC MONOARTHRITIS
 INITIAL CLINICAL EVALUATION
Infections, particularly indolent infections, are a concern with inflammatory monoarthritis that lasts from weeks to months.
The particular joint involved influences the differential diagnosis.

4. CHRONIC MONOARTHRITIS
LABORATORY EVALUATION
A critical step is to determine whether the monoarthritis is inflammatory, preferably by analyzing synovial fluid.
Synovial fluid should be sent for culture (bacterial, mycobacterial, and fungal), WBC count, and gram stain and examined for crystals by polarized light microscopy.

5. CHRONIC MONOARTHRITIS
Routine laboratory studies (eg, complate blood cell count, creatinine, and urine analysis) and determination of the ESR or CRP and uric acid level can provide helpful information.
Patients with inflammatory monoarthritis and negative bacterial cultures shoud be tested for reactivity to purified protein derivative (PPD)

6. CHRONIC MONOARTHRITIS
IMAGING STUDIES
Unlike in acute monoarthritis , radiographs can be helpful in evaluating chronic monoarthritis and can point to correct diagnosis in cases of infection, osteoarthritis, and osteonecrosis.

7. Differential diagnosis of chronic inflammatory monoarthritis
Infection
Nongonococcal septic arthritis
Gonococcal
Mycobacterial
Fungal
Viral
Crystal-induced aarthritis
Gout
Pseudogut
Monoarticular presentation of oligoarthritis or polyarthritis
Spondyloarthropathies
Rheumatoid arthritis
Lupus and other systemic autoimmune diseases.
Sarcoidosis
Uncommon or rare
FMF
Amyloidosis
Pigmented villonodular synovitis
Non-inflammatory
Osteoarthritis
Internal derangements (eg,torn,meniscus)
Chondromalacia patella
Osteonecrosis
Neıropathic (charcot) arthropathy

8. CHRONIC MONOARTHRITIS
Tuberculous infection of a joint can present after days, weeks or months of symptoms.
Smears for acid fast bacilli are positive only 20% of cases,
Cultures for mycobacteria are positive in 80 %, but test results take weeks.
Synovial biopsy can expedite the diagnosis of tuberculous arthritis , and is also indicated in suspected cases of fungal arthritis.

9. CHRONIC OLIGOARTHRITIS
ESSENTIAL FEATURES
Careful description of arthritis and detection of extraarticular disease facilitate accurate diagnosis.
Radiographs are often of diagnostic value.

10. CHRONIC OLIGOARTHRITIS
Common inflammatory causes
Spondyloartropaties
Reactive arthritis
Ankylosing spondylitis
Psoriatic arthritis
Inflammatory bowel disease
Uncommon-rare inflammatory arthritis
Subacute bacterial endocarditis
Sarcoidosis
Behçet disease
Celiac disease
Common non-inflammatory causes
Osteoarthritis
Uncommon-rare non inflammatory
Hypotyroidism
amyloidosis

11. CHRONIC OLIGOARTHRITIS
Spondyloartropathies are the most common cause of chr. Oligoarthritis
Early onset rheumatoid arthritis must be distinquished.
Osteoarthritis presents as oligoarthritis of the hips or knees

12. CHRONIC OLIGOARTHRITIS
Laboratory evaluation
Synovial fluid analysis- culture- crystals
RF-dd(x) of RA
HLA B 27- limited value

13. CHRONIC OLIGOARTHRITIS
Radiographs and Imaging studies-considerable value
Evidence of sacroitis indicates a spondyloarthropaty and narrow dd(x)
Erosions of RA and Gout

14. CHRONIC OLIGOARTHRITIS
Spondyloartropaties- asymmetric oligoarthritis
RA- symmetric poliarthritis
İn early RA- oligoartitis
Stiffness and pain in low back- Spa
RA- only cervical spine

15. CHRONIC OLIGOARTHRITIS
Dactylitis(sausage digits)- sPA, gout, sarcoidosis
Extraarticular manifestations that point to correct diagnosis
Psoriasis –umblicus, external auditory canal, scalp and anal creft
Diarrea- inflammatory bowel disease.
Anterior uveitis

16. CHRONIC POLYARTHRITIS
ESSENTIAL FEATURES
Rheumatoid arthritis and Osteoarthritis are leading causes.
Careful delineation of the joints involved, particularly in the hands, can help to the correct d(x)
The distinction between inflammatory non inflammatory is critical

17. CHRONIC POLYARTHRITIS
Inflammatory –Common
Rheumatoid arthritis
SLE
spondyloartropaties (especiaally Psoriatic art)
Gout
Chronic hepatitis C infection
Drug induced lupus syndrome
Inflammatory-Uncommon
Paraneoplastic polyarthritis
Remitting seronegative symmetric polyarthritis with pitting edema (RS3PE)
Adult onset still disease
Inflammatory- uncommon
Vasculitiitis
Sjögren’s syndrome
Viral infections other than hepatitis C
Non inflammatory
Osteoarthritis
Hemachromatosis

18. CHRONIC POLYARTHRITIS
Laboratory evaluatıon
If arthrosentesis is feasible- joint aspiration- cell count and crystals
CBC
RFT
Urine analysis
ESR_CRP
RF-ANA- hepatitis B and C serology

19. CHRONIC POLYARTHRITIS
Radiographs are indicated in most cases of chronic polyarthritis
Erosion-RA-OA-hemachromatosis-gout- SPA
Non-erosive- SLE-drug induced SLE-chronic hepatitis C.

20. DD(x) of chronic polyarthritis
Osteoarthritis and Rheumatoid arthritis have different patterns of joint involvement in the hand.
OA- involves DIP, PIP and first MCP joints.
RA- PIP- MCP and wrist

21. Osteoarthritis and Rheumatoid arthritis spare certain joints
OA- does not involve MCP, wrist, elbow, ankles
RA- spare DIP, thoracic and lumbosacral spine and sacroiic joints
Psoriatic arthritis- DIP joints

22. ASSOCIATED HISTORY •Predisposing factors •Medication •Bowels •Urinary
•Rashes
•Eyes
•Raynaud’s
•Sicca
•Family History

24. EXAMINATION
•Multi-system •Disability •Range of movement •Signs of inflammation

26. INVESTIGATIONS •FBE/E/LFT •ESR/CRP •Iron studies •Uric Acid
•Auto antibodies
•HLA-B27
•Viral serology
•Joint fluid
•Imaging

27. Skin and nail findings and arthritis

28. Skin rashes Diffuse eruption with fever and systemic findings
Generally viral or due to primary immunological disease
Must be differentiated from bacterial diseases
SLE, DM
Rheumatic fever
Still disease
Kawasaki disease

29. Adult still disease

30. Papulosquamaus lesions
Psoriatic arthritis
Reiter Syndrome
SLE

33. SLE

34. Annular lesions
Rheumatic fever
Subcutaneous Lupus

36. Facial lesions Malar and discoid rash Lupus pernio: Sarcoidosis
Dermatomyositis-gottron papules-heliotrope rash
Lupus vulgaris: cutanous tuberculosis

41. Nodular lesions RA, ARA, crystal artropathies
Erythema nodosum: Behçet’s disease,Sarcoidosis, spondyloartropathies, tbc

44. Erysipel like rash (FMF)

45. Acneiform lesions( behçet’s disease)

46. Purpura
purpura:vasculitis

48. Skin thickening Scleroderma
Eosinophilic fasitis and eosinophilic myalgia syndrome.

51. Photosensitive skin eruption
Connective tissue diseases, SLE, DLE, DM...
Phototoxic drug allergies (sulfa, thiazid..)

52. Oral ulcers Genital ulcers Behçet ‘s disase Crohn disease
Spondyloarthropathies
SLE
Genital ulcers
Behçets disease
Reactive arthritis

55. Sousage digits/Enthesopathy
Reactive arthritis
Psoriatic arthritis

56. Sousoge digits

57. Achille tendinitis

58. Raynaud Primary or secondary Primary- female- %5-8
Secondary – connective tissue disorders
Scleroderma, SLE, SS, RA, DM/PM...

60. Fever, weight loss, malaise and arthritis

61. Fever and rheumatological diseases
ARA
FMF
JRA/JİA
Adult onset Still disease
SLE
Vasculitis
Behcet ‘s disease
Scleroderma
DM/PM
Sarcoidosis

62. Eye and arthritis

63. Eye and rheumatological diseases
Uveitis
Anterior uveitis: BH, Spondyloarthropathies, Sarkoidosis, JRA..
Posterior Uveitis: BH, SLE, Sarkoidosis...
Cornea Involvement
Marginal erosion: RA
Skleritis/episkleritis: RA
Keratoconjonktivitis sicca
Primary or secondary Sjögren syndrome

64. Anterior uveitis an hypopyon

65. Dry eye and sclera erosions

66. Abdominal symptoms and arthritis

67. Abdominal symptoms and arthritis
Diarrea
Abdominal pain
Intestinal bleeding
Enteropahtic arthritis
Reactive arthritis
Behcet disease
FMF
Vasculitis
Connective tissue diseases
Mono-oligoarthritis
Poliarthritis
Axial involvement