A BASIC APPROACH TO DIAGNOSIS IN JOINT DISEASES

IS IT ARTHRITIS OR NOT? ARTHRITIS OR ARTHRALGIA

AN IDENTIFIABLE PATHOLOGICAL PROCESS INVOLVING JOINTS MUST BE PRESENT

IS IT AN INFLAMMTORY PROCESS OR NOT

INFLAMMATION SYSTEMIC EFFECTS TARGET ORGAN EFFECTS

REDNESS HEAT SWELLING PAIN LOSS OF FUNCTION

Soft tissue swelling Early morning joint pain and stiffness

INFLAMMATORY>5,000 white cells/ mm³ “NON-INFLAMMATORY”<1,000 white cells/mm³

SYSTEMIC EFFECTS OF INFLAMMATION 1.CLINICAL tiredness wt loss fever growth retardation 2.LABORATORY acute phase reactants

Haemoglobin↓ White cell count↑ or normal Platelets↑ or normal ESR↑

CRP (C reactive protein)↑ Gamma globulins(immunoglobulins)↑ Albumin↓ Alkaline phosphatase (ALP)↑ Iron and TIBC↓ Ferretin↑

WHICH INFLAMMATORY JOINT DISEASE?

COMMON MODES of PRESENTATION of RHEUMATIC DISEASES SYSTEMIC POLYARTICULAR MONO / OLIGOARTICULAR AXIAL

ACUTE CHRONIC

JOINT FLUID White cell count Examination for crystals Culture and sensitivity

Multiple pathologies can coexist in the one joint

PATTERN OF JOINT INVOLVEMENT NON-JOINT MANIFESTATIONS

Pattern of Involvement In distributionsymmetrical or not small or large joints axial or peripheral many, few or single joint In timeepisodic flitting constant additive Associated extra-articular problems

Joints Skin Eyes Lymph nodes – spleen Lungs Kidneys

Rheumatoid Factor≠Rheumatoid arthritis ANA≠Systemic lupus HLA B27≠Ankylosing spondylitis High urate≠Gout

HLA B27 ANKYLOSYNG SPONDYLITIS90% NORMAL POPULATION 9%

BACK PAIN THAT IMPROVES WITH ACTIVITY CONSIDER THE POSSIBILITY of INFLAMMATORY SPONDYLARTHROPATHY

Rheumatoid arthritis: hands, advanced deformity (radiograph)

Klareskog L et al Arthritis Rheumatism 2006

Rheumatoid Arthritis Early intervention matters Smoking is a risk factor

Hypouricaemic therapy Can precipitate gout in the introductory phase of treatment & needs to be covered Do not stop because of breakthrough flare Treat to target serum urate level

Multiple pathologies can coexist in the one joint

REDNESS HEAT SWELLING PAIN LOSS OF FUNCTION

Tendinitis Enthesitis Fibrositis

DIAGNOSIS EVALUATION

SYSTEMIC

MONO or OLIGOARTICULAR

Rheumatoid Arthritis A systemic inflammatory disease of unknown cause, with a particular predilection to involve the synovium

Osteoarthritis A localised disease of joints, thought to arise as a consequence of cartilage degeneration

POLYARTICULAR

Basics of diagnosis by G Major