1. Approach patient with ARTHRITIS DR. MOHAMMED O. AL-RUKBAN Assistant Professor Department of Family and Community Medicine College of Medicine King Saud University

2. Normal Joint..

3. Introduction.. Causes include various self-limited illness and disabling and life- threatening. Causes include various self-limited illness and disabling and life- threatening. Is it Arthritis or Arthralgia? Is it Arthritis or Arthralgia? Musculoskeletal emergencies (infection, sepsis, compartment syndrome…). Musculoskeletal emergencies (infection, sepsis, compartment syndrome…).

4. Arthralgia.. Fibromyalgia Fibromyalgia Bursitis Bursitis Tendinitis Tendinitis Hypothyroidism Hypothyroidism Neuropathic pain Neuropathic pain Metabolic bone disease Metabolic bone disease Depression Depression

5. Monoarthritis.. Trauma Trauma Infection: Infection: DGI ± Skin lesion. DGI ± Skin lesion. Nongonococcal bacterial infections: large joints. Nongonococcal bacterial infections: large joints. Mycobacterial and fungal infection. Mycobacterial and fungal infection. Crystal induced arthritis Crystal induced arthritis Monosodium Urate crystals (MPJ) Monosodium Urate crystals (MPJ) Ca pyrophosphate dihydrate crystals (knee) Ca pyrophosphate dihydrate crystals (knee) Lyme disease Lyme disease Systemic Rheumatoid diseases: Systemic Rheumatoid diseases: Seronegative spodyloarthropathy (Reactive arthritis, psoriatic arthritis, Inflammatory BD..) Seronegative spodyloarthropathy (Reactive arthritis, psoriatic arthritis, Inflammatory BD..) Sarcoid periarthritis Sarcoid periarthritis RA RA Osteoarthritis Osteoarthritis

6. Polyarthritis.. Rheumatoid Arthritis Rheumatoid Arthritis Systemic lupus Erythrematosus Systemic lupus Erythrematosus Viral arthritis Viral arthritis Reiter’s disease Reiter’s disease Psoriatic arthritis Psoriatic arthritis Reactive arthritis Reactive arthritis

7. Migratory Arthritis.. Differential diagnosis: Differential diagnosis: Rheumatic fever Rheumatic fever Gonococcemia Gonococcemia Meningococcemia Meningococcemia Viral Arthritis Viral Arthritis SLE SLE Acute Leukemia Acute Leukemia

8. Rheumatic Fever.. Majer Criteria: 1- Carditis 2- Polyarthritis 3- Chorea 4- Erythema Marginatum 5 5- Subcutaneous nodules ● Minor criteria: 1- Arthralgia 2- Ferver 3- Acute phase reactant (ESR, CRP). 1- Arthralgia 2- Ferver 3- Acute phase reactant (ESR, CRP). 4- Prolong PR interval 5- Evidence of group A streotococcal infection (AST, Throat culture…) 4- Prolong PR interval 5- Evidence of group A streotococcal infection (AST, Throat culture…)

9. History.. Age <30= SLE, Ankylosis spodylitis, Reactive Arthritis. <30= SLE, Ankylosis spodylitis, Reactive Arthritis. 30-50= RA, Systemic sclerosis, Gout. 30-50= RA, Systemic sclerosis, Gout. >50= OA, Pseudogout, PMR >50= OA, Pseudogout, PMR Any Age group= Psoriatic arthritis, Enteropathic arthritis Any Age group= Psoriatic arthritis, Enteropathic arthritis

10. History.. Sex >Female: >Female: SLE, RA, OA, Systemic sclerosis, Ankylosis spodylitis, PMR. SLE, RA, OA, Systemic sclerosis, Ankylosis spodylitis, PMR. Male=Female: Male=Female: Psoriatic arthritis, Enteropathic arthritis Pseudogout. Psoriatic arthritis, Enteropathic arthritis Pseudogout. >Male: >Male: Gout, Reactive Arthritis. Gout, Reactive Arthritis.

11. History.. Sx Site: Site: Symmetrical= RA, SLE, Systemic sclerosis Symmetrical= RA, SLE, Systemic sclerosis Asymmetrical=OA Asymmetrical=OA Large joints=OA Large joints=OA DIP= OA, Psoriatic arthritis DIP= OA, Psoriatic arthritis MCP, PIP= RA, SLE MCP, PIP= RA, SLE 1 st MTP= Gout, OA 1 st MTP= Gout, OA Spine= OA, Ankylosis spodylitis, Psoriatic arthritis, Reactive arthritis Spine= OA, Ankylosis spodylitis, Psoriatic arthritis, Reactive arthritis Shoulder= PMR Shoulder= PMR

12. History.. Sx Pain character: Pain character: Aggravated by motion= Mechanical Aggravated by motion= Mechanical Relieved by motion= Inflammatory. Relieved by motion= Inflammatory. Duration: Duration: <6 wks= viral arthritis, systemic rheumatic diseases <6 wks= viral arthritis, systemic rheumatic diseases >6 wks=systemic rheumatic diseases >6 wks=systemic rheumatic diseases Associated Sx: Associated Sx: Morning stiffness: >1hr= RA, PMR, Inflammatory Morning stiffness: >1hr= RA, PMR, Inflammatory >30 min= OA >30 min= OA

13. History.. Sx Associated Sx: Associated Sx: Multi-system involvement= Systemic rheumatic diseases. Multi-system involvement= Systemic rheumatic diseases. Past Medical history: Past Medical history: Trauma, fracture, surgical procedures… Trauma, fracture, surgical procedures… Medication list: Medication list: Drug induced lupus. Drug induced lupus. Diuretics. Diuretics.

14. Phy. Examination.. Joint: Joint: Soft tissue swelling, warm, effusion…= Inflammation. Soft tissue swelling, warm, effusion…= Inflammation. Inflammation signs extended= septic arthritis, crystal induced arthritis, fracture. Inflammation signs extended= septic arthritis, crystal induced arthritis, fracture. Passive motion (N), active(↓↓)= bursitis, tendinitis, muscle injury. Passive motion (N), active(↓↓)= bursitis, tendinitis, muscle injury. Passive motion (↓↓), active(↓↓)= Synovitis Passive motion (↓↓), active(↓↓)= Synovitis

15. Phy. Examination.. General Examination: General Examination: LAP, parotid enlargement, oral ulceration, heart murmurs, pericardial or pleural friction rubs, crackle…= systemic disease. LAP, parotid enlargement, oral ulceration, heart murmurs, pericardial or pleural friction rubs, crackle…= systemic disease. Fever= infection, reactive arthritis, RA, SLE, Crystal induced arthritis… Fever= infection, reactive arthritis, RA, SLE, Crystal induced arthritis… Subcutaneous nodules= RA, RHD, Gout (tophi) Subcutaneous nodules= RA, RHD, Gout (tophi) Skin manifestations= psoriasis, RA, SLE… Skin manifestations= psoriasis, RA, SLE… Eye disease (keratoconjunctivitis sicca, uveitis. Conjunctivitis, episcleritis…) Eye disease (keratoconjunctivitis sicca, uveitis. Conjunctivitis, episcleritis…)

20. Laboratory Studies.. Can be misleading. Can be misleading. Basic: CBC, Urinalysis, U&E, LFT. Basic: CBC, Urinalysis, U&E, LFT. Acute phase reactant: ESR, CRP. Acute phase reactant: ESR, CRP. Antibody tests: Antibody tests: ANA= SLE ANA= SLE Anti-dsDNA= SLE Anti-dsDNA= SLE Anti-native DNA, anti-Sm= SLE Anti-native DNA, anti-Sm= SLE RF= RA RF= RA Anti-CCP antibody=RA Anti-CCP antibody=RA

21. Rheumatoid Factor.. Rheumatoid Arthritis Rheumatoid Arthritis Connective tissue diseases Connective tissue diseases Viral infection Viral infection Leishmaniasis Leishmaniasis Leprosy Leprosy Tuberculosis Tuberculosis Sarcoidosis Sarcoidosis Liver diseases Liver diseases Subacute bacterial endocarditis Subacute bacterial endocarditis

22. Laboratory Studies.. Uric acid concentration= Gout Uric acid concentration= Gout Synovial fluid analysis= infection, crystal induced arthritis, inflammatory.. Synovial fluid analysis= infection, crystal induced arthritis, inflammatory.. Hepatitis B and C Hepatitis B and C Parvovirus serology Parvovirus serology

23. Imaging Studies.. X-ray: X-ray: RA RA Chronic Gout Chronic Gout OA OA Ankylosing spondylosis. Ankylosing spondylosis. MRI: MRI: Ankylosing spondylosis. Ankylosing spondylosis.

25. Rheumatoid Arthritis.. Epidemiology : Epidemiology : The world wide incidence of RA is approximately 3 cases per 10,000 population and the prevalence rate is approximately 1% The world wide incidence of RA is approximately 3 cases per 10,000 population and the prevalence rate is approximately 1%

26. Rheumatoid Arthritis..

27. History.. Malaise Malaise fever fever fatigue fatigue weight loss weight loss myalgias myalgias difficulty performing activities of daily living difficulty performing activities of daily living

28. Examination.. Joint affected Joint affected swelling swelling tenderness tenderness warmth warmth decreased range of motion decreased range of motion Atrophy of the interosseous muscles Atrophy of the interosseous muscles deformities deformities

29. Diagnosis.. Morning stiffness Morning stiffness Arthritis of 3 or more joint areas Arthritis of 3 or more joint areas Arthritis of hand joints of at least one area swollen in a wrist, MCP, or PIP joint Arthritis of hand joints of at least one area swollen in a wrist, MCP, or PIP joint Symmetric arthritis Symmetric arthritis Rheumatoid nodules Rheumatoid nodules Serum RF Serum RF Radiographic changes typical of RA Radiographic changes typical of RA

35. Deformities..

38. Extra-articular manifestations.. Rheumatoid nodule Rheumatoid nodule Cardiovascular Cardiovascular Pulmonary Pulmonary GI & Renal GI & Renal Hematological Hematological Skin Skin Vasculitis Vasculitis Neurological Neurological Ocular Ocular

39. Progression of RA.. Stage 1: Stage 1: - no destructive changes. - no destructive changes. - Osteoporosis. - Osteoporosis. Stage 2: Stage 2: - periarticular osteoporosis w/wo slight subchondral bone destruction. - periarticular osteoporosis w/wo slight subchondral bone destruction. - joint mobility limit but no destruction. - joint mobility limit but no destruction. - adjacent muscle atrophy. - adjacent muscle atrophy. - extra-articular soft tissue lesions. - extra-articular soft tissue lesions.

40. Progression of RA.. Stage 3 Stage 3 - cartilage and bone destruction in addition to periarticular osteoporosis. - cartilage and bone destruction in addition to periarticular osteoporosis. - joint deformity w/wo fibrous or bony ankylosis. - joint deformity w/wo fibrous or bony ankylosis. - extensive muscle atrophy. - extensive muscle atrophy. - extra-articular soft tissue lesions. - extra-articular soft tissue lesions. Stage 4 Stage 4 - criteria of stage 3. - criteria of stage 3. - fibrous or bony ankylosis. - fibrous or bony ankylosis.

41. Laboratory.. Hematologic parameters Hematologic parameters Anaemia Anaemia Thrombocytosis Thrombocytosis ↓ Serum iron & IBC ↓ Serum iron & IBC ↑ Serum globuline ↑ Serum globuline ↑ ALP ↑ ALP ↑ Acute phase reactant ↑ Acute phase reactant Immunological parameters Immunological parameters Synovial fluid analysis Synovial fluid analysis

42. Prognosis.. 40 % of patient become disabled after 10 years. 40 % of patient become disabled after 10 years. Persistent active cases more than 1 year likely to lead to joint deformities. Persistent active cases more than 1 year likely to lead to joint deformities. Periods of activity cases have better prognosis. Periods of activity cases have better prognosis. Mortality rate 2.5 times than general population Mortality rate 2.5 times than general population

43. Systemic Lupus Erythrematosis Malar rash Malar rash Discoid rash Discoid rash Photosensitivity Photosensitivity Oral ulcers Oral ulcers Arthritis Arthritis Serositis Serositis Renal disease (proteinuria, cellular cast) Renal disease (proteinuria, cellular cast) Neurologic disease (seizure, psychosis) Neurologic disease (seizure, psychosis) Hematologic disease Hematologic disease Immunologic abnormalities Immunologic abnormalities ANA ANA

44. Summary.. Use of time. Use of time. In one study: 60% of patients with early synovitis diagnosed as: In one study: 60% of patients with early synovitis diagnosed as: Rheumatoid Arthritis. Rheumatoid Arthritis. Spondyloarthropathy. Spondyloarthropathy. 20% had a self limited arthritis. 20% had a self limited arthritis. 20% unclassifiable with good prognosis. 20% unclassifiable with good prognosis. In another study: 36% unclassifiable In another study: 36% unclassifiable When to refer? When to refer?