Polyarthritis Case of the Week

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Polyarthritis Case of the Week

• Dr. Andy Thompson
• Assistant Professor of Medicine
• Division of Rheumatology
• University of Western Ontario

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Objectives

• Gain a basic understanding of an approach to
  polyarthritis
• Understand the differences between inflammatory,
  degenerative, and chronic pain conditions

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Patient Presentation Mrs. B.

• Mrs. B is a 41-year old woman referred to the
  rheumatology service by her family doctor
• She is from Exeter, Ontario
• She is married with 3 children
• She is employed as a teacher
• Seen on June 29, 2006

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Mrs. B.

• Past Medical History
• Graves Disease treated with radioactive iodine
  now on thyroid replacement
• Tubal ligation
• Current Medications
• Eltroxin 0.15 mg per day
• Allergies
• NKDA

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Mrs. B.

• Mid April 2006
• Pain in both knees
• One week later her feet started to hurt
• A week later her hands and wrists became painful
• Then her elbows, shoulders, and neck became
  involved
• Noticed increasing fatigue
• Mild weight loss of 5-7 lbs

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Patient Presentation

• Definite joint swelling in hands, knees, and feet
• Stiffness lasting all day but particularly
  prominent in the morning for one hour
• Having some to much difficulty with simple
  activities of daily living

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Exam
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Mrs. B. asks you

• What is going on with me?

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You tell her

• I need some more information
• Tell me how you felt when this first started in
  April, 2006?
• Any other questions?

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Don't Panic
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It's ok to Panic a bit here
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What could it be?
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Lets Get Back to Basics!
INFLAMMATORY CONDITIONDEGENERATIVE
CONDITIONCHRONIC PAIN CONDITION

• Patient presenting with pain and stiffness in
  multiple areas of the body

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Inflammatory Condition

• Rubor Redness
• Tumor Swelling
• Calor Heat
• Dolor Pain
• Functio Leasa Loss of Function

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Inflammatory Arthritis
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Inflammatory Arthritis

• Inflammation of the synovium (lining of the
  joint) results in
• Increased fluid production (swelling)
• Warmth
• Pain
• Stiffness
• Sometimes redness (infections crystals)

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Why does the Synovium Become Inflamed?

• Self
• Bodys immune system attacks itself
• Foreign
• Bodys immune system attacks something foreign in
  the joint
• Infection
• Crystals
• Monosodium Urate Gout
• Calcium Pyrophosphate

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Degenerative Condition

• Breakdown of Cartilage
• e.g. osteoarthritis

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Chronic Pain

• Diffuse soreness and stiffness in the joints and
  surrounding muscles
• No joint swelling, redness, or warmth
• Experience pain and loss of function
• E.g. Fibromyalgia

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Sorting it out
INFLAMMATORY
DEGENERATIVE
CHRONIC PAIN
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Sorting it Out

• Who gets it?
• How does it start?
• What joints are affected?
• What are the usual symptoms?

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Who gets it Age
Rare to start in younger ages
Degenerative
Rare to start in older ages
Chronic Pain
Inflammatory
Age 40
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Who gets it Sex

• Inflammatory Arthritis More common in women
• Degenerative Arthritis More common in women
• Chronic Pain More common in women

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How does it Start

• Inflammatory
• Additive (adds joints) and Insidious (over weeks
  to months)
• Acute (rare but does happen)
• Degenerative
• Usually slowly with joints getting worse over a
  period of months to years
• Chronic Pain
• May be triggered
• Insidious onset of diffuse aching pain

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What Joints are Involved?

• Chronic Pain
• No truly swollen joints on examination
• Patients may complain of subjective experience of
  swelling
• Degenerative Inflammatory
• Characteristic involvement

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What Joints are Involved Now?

• Number of Joints
• Monoarthritis (1)
• Oligoarthritis (2-4)
• Polyarthritis (gt4)
• Distribution of Involvement
• Degenerative Pattern
• Inflammatory Pattern

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Distribution of Joints
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What are the Symptoms?
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New Onset Polyarthritis

• Inflammation in 5 or more joints
• Oligoarthritis 2-4 Joints
• Monoarthritis 1 Joint

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Mrs. B.

• Mrs. B. you have a polyarthritis that has been
  going on for 2 ½ months!
• Thats Easy!

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Guess what!

• She already figured that out on the Internet!

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Notice Something Here

• We have made a broad diagnosis without
• Lab Tests
• X-Rays
• It is a CLINICAL DIAGNOSIS
• You dont need a bone scan
• You dont need an MRI or CT

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Differential Diagnosis

• A systematic method physicians use to identify
  the disease causing a patient's symptoms.
• The physician lists the most likely causes
• The physician asks questions and performs tests
  to eliminate possibilities until he or she is
  satisfied that the single most likely cause has
  been identified
• Result Working Diagnosis

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Most Likely Causes

• INFLAMMATORY POLYARTHRITIS
• Infection
• Rheumatoid Arthritis
• Seronegative Arthritis (Psoriatic)
• Connective Tissue Disease (SLE etc)
• Associated with another Systemic Disease

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Infection

• What do you want to ask Mrs. B?
• Acute Inflammatory Polyarthritis is usually
  associated with a viral infection such as
• Parvovirus B19 (same one in kiddies)
• EBV (Epstein Barr Virus)
• Rubella
• Hepatitis B or C
• HIV
• Typically self-limited over 2-6 weeks

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Rheumatoid Arthritis

• A chronic, destructive inflammatory polyarthritis
  
• Prominent morning stiffness
• Fatigue
• Rheumatoid Nodules (very rare in early disease)
• Bone erosions on X-ray (rare in early disease)

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Seronegative Arthritis

• Psoriatic arthritis
• Personal or family history of psoriasis
• Ankylosing Spondylitis
• Inflammatory lower back disease
• Symptoms of sacroiliitis
• Reactive Arthritis
• Arthritis, Conjuctivitis, urethritis after a
  urinary or GI tract infection
• Affects Joints of the Lower extremity
  predominantly
• Arthritis Associated with Inflammatory Bowel
  Disease
• Symptoms of Ulcerative Colitis or Crohns

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Connective Tissue Disorder

• Systemic Lupus Erythematosus
• Sjogrens Syndrome
• Polymyositis/Dermatomyositis
• Systemic Sclerosis
• Mixed Connective Tissue Disorder

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Connective Tissue Disorder

• Connective Tissue Diseases
• No history of inflammatory arthritis
• No history of sicca features (xerostomia,
  xerophthalmia)
• No CNS problems (strokes, seizures, memory loss,
  cognitive function)
• No alopecia or hair loss
• No visual complaints or ocular problems
• No oral/nasal ulcerations
• No facial rashes
• No lymphadenopathy
• No Raynauds Phenomenon
• No other rashes or photosensitivity
• No shortness of breath, cough, chest
  pain/pleurisy
• No known cardiac or pulmonary problems
• No other known GI problems (other than diarrhea)
• No muscle weakness
• No peripheral neurologic complaints (sensory or
  motor)
• No new hypertension/hematuria, no known
  proteinuria or microscopic hematuria

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Associated with another Systemic Illness

• No symptoms

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Revised Differential Diagnosis

• Rheumatoid Arthritis
• Seronegative Arthritis (Psoriatic)
• Connective Tissue Disorder
• Working Diagnosis Rheumatoid Arthritis
• Will Lab tests help us further?

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Investigations

• CBC
• Hemoglobin 120 g/L (N)
• WBC 9.4 x 109/L (N)
• Platelets 457 x109/L (High lt 400)
• ESR 81 (High lt 20)
• CRP 76 (High lt 7.5)
• Albumin 34 (Low 35-50)
• Creatinine 61 (N), Urinalysis negative
• Liver Enzymes Normal

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Investigations

• Hepatitis B C Testing Negative
• Rheumatoid Factor Negative
• ANA Negative
• ENA Negative
• ds-DNA Negative
• Complement (C3/C4) Normal
• IgG 18.7 (High 6.4-13.8)

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Investigations

• Lab tests just showed INFLAMMATION
• Reactive thrombocytosis
• Elevated Acute Phase Reactants (ESR/CRP)
• Low Albumin (Chronic Inflammation)
• Polyclonal increase in IgG Acute inflammation

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Revised Differential Diagnosis

• Rheumatoid Arthritis
• Seronegative Arthritis (Psoriatic)
• Connective Tissue Disorder
• Working Diagnosis Rheumatoid Arthritis

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Mrs. B.

• How do we want to treat Mrs. B?
• Why do we want to treat Mrs. B?

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Its like Diabetes
What would happen if you developed diabetes?
It doesnt go away A Chronic Illness
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Early RA is like an Iceberg
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Its what you dont see!
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Clinical Course of RA
Severity of Arthritis
Years
Type 1 Self-limited5 to 20 Type 2
Minimally progressive5 to 20Type 3
Progressive60 to 90
Pincus. Rheum Dis Clin North Am. 199521619.
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A Fire in the Joints
If theres a fire in the kitchen do you wait
until it spreads to the living room or do you try
and put it out?
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Disability in Early RA

• Inflammation
• Swollen
• Stiff
• Sore
• Warm
• Fatigue
• Potentially Reversible

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The Big Bang
90 of the joints involved in RA are affected
within the first year
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Disability in Late RA

• Damage
• Bones
• Cartilage
• Ligaments and other structures
• Fatigue
• Not Reversible

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Mrs. B.

• July 13, 2006
• Worse
• Discussed Treatment and given a Prescription for
  Methotrexate, Sulfasalazine, and Plaquenil
  (Triple therapy)
• Arthritis Education Day Program

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Mrs. B.

• Questions?

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Mrs. B.

• August 10, 2006
• Slight improvement (too early to tell)
• Application for disability August 9, 2006
• On treatment for 1 month with
• Methotrexate, Sulfasalazine, Plaquenil, Naproxen

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Mrs. B.

• Questions?

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Mrs. B.

• October 25, 2006
• Significant improvement but Arthritis still very
  active
• Injected problematic joints
• Continue on triple therapy

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Mrs. B.

• Questions?

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Thank-you