Arthritic Disorders: Cases and Questions

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Arthritic DisordersCases and Questions

• Devin J. Fox, MD, FACP
• Asst. Professor of Medicine
• CU Medical Center

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Learning Objectives

• 1. Be able to discern based on a brief history
  and physical a differential diagnosis of
  rheumatologic conditions.
  
• 2. Be able to discuss methods for diagnosis of
  the arthritic syndromes.
  
• 3. Be able to offer treatment options of the
  various conditions discussed.

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Arthritis

• 1 in 7 visits to the primary care physician
  relate to a musculoskeletal disorder, and even
  more have an arthritic condition as a secondary
  problem.
• Most rheumatologic conditions can be diagnosed
  based on history and a physical exam, without the
  need for expensive diagnostic testing.

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Case 1

• 70 year old female with slowly progressive thumb
  pain for the last year.
  
• Fingers are stiff and sore, worse over the course
  of the day.
  
• Some knee pain, bilateral.

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Osteoarthritis

• Risk Factors?

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Osteoarthritis

• Risk Factors
• Age
• Obesity
• Overuse
• Osteoporosis
• Joint malalignment
• Trauma

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Osteoarthritis

• Pathology
• Loss of normal articular cartilage

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Osteoarthritis

• Evening stiffness
• DIPs and PIPs
• Base of Thumb
• Knees, Hips
• Noninflammatory
• Tx NSAIDs, Tylenol, COX-IIs.

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Case 2

• 45 year-old male with toe pain.

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Monoarticular Arthritis

• Differential Diagnosis

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Monoarticular Arthritis

• Differential Diagnosis
• Gout
• Pseudogout
• Septic Joint
• Acute Inflammatory Joint from Underlying
  Arthritidy

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Joint Aspiration
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Gout

• Monosodium urate crystals
• Undersecretor or Overproducer
• Acute
• Injection of corticosteroids
• Oral NSAIDS, colchicine
• Chronic/Recurrent
• Allopurinol
• Probenicid

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Gout

• Chronic Tophaceous Gout

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Case 3

• 28 year-old female medical resident with hand and
  wrist pain and stiffness.

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Case 3

• Worse with activity
• Elevated ESR and CRP, but normal CCP. Slightly
  elevated uric acid level.

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Psoriatic Arthritis

• Usually more benign course than RA.
• 5 may become very severe and destructuve.
• Whittling of distal ends of phalanges.
• Pencil-in-cup deformity.

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The Seronegative Spondyloarthropathies

• What are they?

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The Seronegative Spondyloarthropathies

• Psoriatic Arthritis
• Ankylosing Spondylitis
• Reactive Arthritis
• IBD-related Spondyloarthropathy
• Undifferentiated Spondyloarthropathy

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Case 4

• 45 year-old female with hand and wrist pain times
  one year.

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Case 4

• Worse in the morning.
• Stiff until gets moving, maybe an hour.
• Some cough and shortness of breath.
• Blood tests?

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Test results

• ESR 60
• RF 250
• ANA Pos at 1320
• CCP 70
• CXR?

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Pulmonary Consequences of Rheumatoid Arthritis

• Interstitial Fibrosis
• Pleural Disease
• Pleuropulmonary Nodules
• Pneumonitis
• Arteritis

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Diagnostic Criteria for SLE

• Malar Rash
• Discoid Rash
• Photosensitivity
• Serositis
• Oral Ulcers
• Arthritis
• Nephritis
• Neurological (Seizures / Psychosis)
• Hematologic (Anemia/Leukopenia/Lymphepenia)
• Immunologic (Anti-dsDNA, Anti-Smith, Anti-P.L.)
• ANA