Approach To A Patient With Polyarthritis

Approach to a patient with Polyarthritis Dr. K. K. Pruthi Prof & Head S. N. Medical College, Agra

‘ Patterned’ approach Grouping a constellation of symptoms, signs and investigations to arrive at a diagnosis.

POLYARTHRITIS 4 or more joint involvement PAUCI / OLIGOARTHRITIS 2 or 3 joint involvement MONOARTHRITIS 1 joint involvement Definition

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Assessment of joint pain

Site and distribution of pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Site and distribution of pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],Type of pain ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],Type of pain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],Associated features ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Duration & onset ,[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Duration & onset ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Other risk factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Other risk factors AGE FEMALE MALE Young adults RA Reactive arthritis SLE (Sero-ve) Psoriatic arthritis (Sero-ve) Middle age RA RA OA Gout Old age OA PMR Crystal arthritis

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Physical signs ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Differential diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Investigations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Investigations Synovial fluid examination most important !! ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Synovial fluid analysis Apperance Viscosity Cells/mm 3 %PMN Normal Transparent High < 180 < 10% OA Transparent High 200-2000 < 10% RA Translucent Low 2000- Variable 50,000 Psoriatic Translucent Low 2000- Variable Arthritis 50,000 Reactive Translucent Low 2000- Variable Arthritis 50,000 Spondlyo Translucent Low 2000- Variable -arthro. 50,000 Gout Translucent Low 200- > 90% to cloudy 50,000 Pseudo Translucent Low 200- > 90% gout to cloudy 50,000 Bacterial Cloudy Variable > 50,000 > 90% Arthritis

Osteoarthritis (OA) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis Types PRIMARY OA SECONDARY OA

Risk Factors for OA OA Increased age Genetic disposition Gender & hormonal factors Obesity Mechanical factors Systemic factors (Hypertension, raised serum cholesterol, raised uric acid levels) Prior inflammatory disease Osteoarthritis Degenerative disorder Weight bearing joints usually involved

Pathology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis

Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis ,[object Object],[object Object]

Radiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis

Joint space narrowing Subchondral bone sclerosis and cysts Marginal osteophyte formation

Kellegren & Lawrence Scale for Osteoarthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Osteoarthritis

Role of inflammation in OA ,[object Object],[object Object],[object Object],[object Object],Osteoarthritis

[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis

Epidemiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis

Etiology Rheumatoid Arthritis Post viral immunomodulation RA HLA DR4 Genetic disposition monozygotic twins – 15% dizygotic twins – 4% Gender & hormonal factors Prior inflammatory disease Multifactorial etiology

Excised synovial membrane shows many villous folds with compact nodular clusters of lymphocytes and plasma cells. Pathology Rheumatoid Arthritis

Onset ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis

One can confidently make a diagnosis of RA on clinical grounds even if RF is absent. Clinical features ,[object Object],[object Object],[object Object],A negative RF may be repeated 4-6 monthly for the first 2 years of disease, since some patients with RA may take 18-24 months to become seropositive. Rheumatoid Arthritis

Clinical features ,[object Object],[object Object],[object Object],Rheumatoid Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis Clinical features Swan neck deformity Boutonniere deformity Ulnar deviation & nodule Hammer toe deformity Hallux valgus

Radiology ,[object Object],[object Object],[object Object],[object Object],[object Object]

Extra articular findings ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rheumatoid Arthritis Rheumatoid nodule Episcleritis Digital infarcts

Be Cautious to diagnose RA if : ,[object Object],[object Object],[object Object],[object Object],[object Object],Mere presence of rheumatoid factor in blood is not enough to make a diagnosis of RA. Rheumatoid Arthritis

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Not all seropositive arthritides are RA Rheumatoid Arthritis

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],American Rheumatism Association,1997 revised criteria for diagnosing RA Rheumatoid Arthritis

Predictive factors for persistent RA Rheumatoid Arthritis ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Seronegative Inflammatory polyarthritides

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Seronegative Spondyloarthropathies (SpA)

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Seronegative SpA Features

Ankylosing spondylitis ,[object Object],[object Object],[object Object],[object Object]

Etiology ,[object Object],[object Object],[object Object],[object Object],[object Object],Ankylosing spondylitis

Pathology ,[object Object],[object Object],[object Object],[object Object],[object Object],Ankylosing spondylitis

Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ankylosing spondylitis

Radiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ankylosing spondylitis

Crystal Arthropathies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Crystal Arthropathies Types & Causes

Gout ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Crystal Arthropathies

Monosodium Urate Crystal Crystal Arthropathies Positive bifringence & needle shaped

Pseudogout Crystal Arthropathies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Psoriatic Arthritis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Radiology ,[object Object],[object Object],[object Object],[object Object],Psoriatic Arthritis

Reiter’syndrome ,[object Object],[object Object],[object Object],[object Object],Asymmetrical arthritis Urethritis/cervicitis or Diarrhoea Conjunctivitis

Systemic Lupus Erythematous ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Features Photosensitivity Butterfly facial rash Discoid rashes

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Arthritis in SLE SLE

Approach To A Patient With Polyarthritis

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Approach To A Patient With Polyarthritis