Rheumatology teaching

1
Rheumatology teaching

• Pilot 4 sessions
• Consultant Rheumatologist/student presentation
• Based on Phase II objectives
• Polyarthritis, Monoarthritis, Back pain,
  Soft-tissue disorders
• Ward 2 Rheumatology

2
Approach to Polyarthralgia

• Dr Jaya Ravindran
• Consultant Rheumatologist
• UHCW

3
Approach to Polyarthralgia

• Aims
• Differential diagnosis of polyarthralgia/polyarthr
  itis
• Investigations

4

• What conditions present with
• polyarthalgia?

5
Differential diagnosis of polyarthalgia/polyarthri
tis

• Poly gt 4 joint
• Rheumatoid arthritis
• Polyarticular OA
• Sero-ve Spondyloarthropathy (eg psoriatic,
  reactive)
• Polyarticular crystal arthropathy
• Multi-organ disease CTD and vasculitis
• Viral arthritis (eg parvovirus, rubella,
  hepatitis)
• (Polymyalgia rheumatica/GCA)

6
Differential diagnosis of polyarthalgia/polyarthri
tis

• Poly gt 4 joints
• Medical conditions
• thyroid disease / hyperparathyroidism /
  osteomalacia
• diabetic cheiroarthropathy
• paraneoplastic syndromes, multiple myeloma
• infective endocarditis
• sarcoidosis
• Fibromyalgia

7
Age and sex Incidence

• 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

8

• What clues are there to
• diagnosis?

9
CLUES

• Prodromal event eg GI/GU infection
• Associated conditions eg psoriasis, colitis,
  iritis
• Inflammatory or mechanical
• Pattern of joint and symmetry eg RA vs PsA vs OA
• Multi-organ disease
• Fibromyalgia symptoms

10

• How do you differentiate
• between mechanical and
• inflammatory symptoms?

11
Mechanical vs Inflammatory

• Inflammatory Mechanical
• Immobility stiffness latter day
• EMSgt30-60 mins EMSlt30-60 mins
• Better with activity and NSAIDs worse with
  activity
• Joint swelling,erythema,heat instability
• Systemic symptoms locking
• Multi-organ involvement trauma,
  strain overusage

12

• Pattern and Symmetry?

13
Pattern and symmetry

• RA - PIP, MCP, wrists, elbows, shoulders, neck,
  knee, ankle, MTP, symmetrical
• Sero-ve DIP, asymmetrical, dactylitis,
  enthesitis, spinal
• OA DIP, PIP, CMC, ACJ
• Weight bearing joints

14
Sero-ve Spondyloarthritis psoriatic arthritis

• DIP, poly, dactylitis,
• enthesitis, spinal

15
Osteoarthritis

• Mechanical symptoms
• Bony swelling, crepitus
• DIP (Heberden), PIP (Bouchard), 1st CMCJ, neck,
  lower back, hips, knees, 1st MTP

16
Polyarticular crystal eg gout

• Chronic
• Tophi
• Erosions

17
Fibromyalgia

• All over pain
• Fatigue
• Sleep disturbance
• Depression
• Anxiety
• Irritable bowel
• Tender spots
• Diagnosis of exclusion

18

• What are CTD and what
• symptoms and signs are seen?

19
Connective tissue disease

• Eg SLE, scleroderma, polymyositis, Sjogrens
• Auto-immune
• Multi-organ
• Anti-nuclear antibodies

20
Connective tissue disease symptoms

• Photosensitive rashes
• Skin tightness
• Raynauds late onset, trophic changes
• Mouth ulcers

21
Connective tissue disease symptoms

• Dry eyes and mouth
• Arthralgias, arthritis non deforming
• Proximal myopathy pain and weakness (PMR pain
  and stiffness think also GCA)

22
Connective tissue disease symptoms

• Swallowing
• Serositis/ILD pleurisy, dyspnoea, cough
• RENAL DISEASE silent, URINE DIP BP
• Systemic - fatigue, fever, weight loss

23
Connective tissue disease symptoms

• Vasculitis petechial, purpura, ulcer

24

• What are the vasculitides and what type of
  symptoms and signs?

25
Vasculitis

• Small, medium, large vessel
• Eg MPA, Churg Strauss, PAN, Wegeners, GCA
• ANCA

26
Vasculitis

• Systemic, vasculitic ulcers/rashes,
  arthralgias/arthritis non deforming
• ENT - sinusitis
• Pulmonary haemoptysis, late onset asthma
• Cardiac failure
• RENAL URINE DIP BP
• Neuropathy eg footdrop

27

• PMR and GCA features?

28
Polymyalgia rheumatica and GCA

• Over 50s
• Proximal inflammatory pain and stiffness
• GCA large vessel arteritis
• Temporal headache, jaw claudication visual
  disturbance, systemic upset
• Raised ESR and CRP urgent steroids
• TA biopsy

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Investigations

• Inflammatory arthritis RA
• FBC, ESR, CRP, UE, LFT, RF, XR Hands and feet
• ? CTD/vasculitis - ANA, ENA, RF, DNA binding,
  ANCA, complement
• Urine dip and BP
• Organ based investigations
• Diffuse symptoms CK, Ca, ALP, TFT
• Viral Parvovirus, LFTHepatitis

31

• What other conditions present
• with elevated RF?

32
Rheumatoid factor

• Infection Acute infection eg infectious
  mononucleosis Chronic
• infection eg SBE, TB Parasitic eg malaria
  vaccination
• Inflammatory disease RA, CTD, Fibrosing
  alveolitis, Chronic active
• hepatitis, cryoglobulinaemia
• Malignancy Lymphoma, leukaemia, myeloma, solid
  tumours
• 5 healthy population
• RF lt15 not significant unless associated with
  appropriate clinical scenario

33

• What are the ANA and ENA?

34
ANA and ENA

• ANA 1/40 not significant unless associated with
  appropriate clinical scenario
• Also in RA, cirrhosis, ai liver disease,
  neoplasia, healthy population
• ENA extractable nuclear antigens
• Anti-Ro and anti-La - Sjogrens
• Scl 70 and anti-centromere Scleroderma
• Anti-RNP mixed CTD
• Anti-Jo1 - myositis

35

• What is ANCA ?

36
ANCA

• Antibodies vs specific antigens in cytoplasm of
  neutrophils
• ANCA reactive to myeloperoxidase (MPO)
  perinuclear pattern of staining P-ANCA eg
  microscopic polyarteritis
• ANCA reactive to proteinase 3 (PR3) cytoplasmic
  pattern of staining C-ANCA eg Wegeners
  granulomatosis

37

• What are the radiological
• feature of OA, RA (and PsA) ?

38
Radiology - OA

• Four cardinal features
• Joint space narrowing
• Sclerosis
• Subchondral cysts
• Osteophytes

39
Radiology - RA

• soft tissue swelling
• juxta-articular osteoporosis
• juxta-articular and subchondral erosions
• joint space narrowing subluxation
• secondary OA bony ankylosis

40
Radiology - PsA

• Erosion
• Osteolysis
• Bone
• proliferation
• Ankylosis

41

• Thank-you