APPROACH TO THE PATİENTS WİTH CHRONIC ARTHRITIS Dr. MÜGE BIÇAKÇIGİL KALAYCI

CHRONIC MONOARTHRITIS ESSENTIAL FEATURES Chronic inflammatory monoarthritis infection, crystal-induced arthritis, sarcoidosis, or monoarticular presentation of oligoarthritis or polyarthritis Chronic noninflammatory monoarthritis osteoarthritis, mechanical , Chondromalacia patellae, and osteonecrosis. Arthrocentesis and imaging studies are important dignostic tests

CHRONIC MONOARTHRITIS  INITIAL CLINICAL EVALUATION Infections, particularly indolent infections, are a concern with inflammatory monoarthritis that lasts from weeks to months. The particular joint involved influences the differential diagnosis.

CHRONIC MONOARTHRITIS LABORATORY EVALUATION A critical step is to determine whether the monoarthritis is inflammatory, preferably by analyzing synovial fluid. Synovial fluid should be sent for culture (bacterial, mycobacterial, and fungal), WBC count, and gram stain and examined for crystals by polarized light microscopy.

CHRONIC MONOARTHRITIS Routine laboratory studies (eg, complate blood cell count, creatinine, and urine analysis) and determination of the ESR or CRP and uric acid level can provide helpful information. Patients with inflammatory monoarthritis and negative bacterial cultures shoud be tested for reactivity to purified protein derivative (PPD)

CHRONIC MONOARTHRITIS IMAGING STUDIES Unlike in acute monoarthritis , radiographs can be helpful in evaluating chronic monoarthritis and can point to correct diagnosis in cases of infection, osteoarthritis, and osteonecrosis.

Differential diagnosis of chronic inflammatory monoarthritis Infection Nongonococcal septic arthritis Gonococcal Mycobacterial Fungal Viral Crystal-induced aarthritis Gout Pseudogut Monoarticular presentation of oligoarthritis or polyarthritis Spondyloarthropathies Rheumatoid arthritis Lupus and other systemic autoimmune diseases. Sarcoidosis Uncommon or rare FMF Amyloidosis Pigmented villonodular synovitis Non-inflammatory Osteoarthritis Internal derangements (eg,torn,meniscus) Chondromalacia patella Osteonecrosis Neıropathic (charcot) arthropathy

CHRONIC MONOARTHRITIS Tuberculous infection of a joint can present after days, weeks or months of symptoms. Smears for acid fast bacilli are positive only 20% of cases, Cultures for mycobacteria are positive in 80 %, but test results take weeks. Synovial biopsy can expedite the diagnosis of tuberculous arthritis , and is also indicated in suspected cases of fungal arthritis.

CHRONIC OLIGOARTHRITIS ESSENTIAL FEATURES Careful description of arthritis and detection of extraarticular disease facilitate accurate diagnosis. Radiographs are often of diagnostic value.

CHRONIC OLIGOARTHRITIS Common inflammatory causes Spondyloartropaties Reactive arthritis Ankylosing spondylitis Psoriatic arthritis Inflammatory bowel disease Uncommon-rare inflammatory arthritis Subacute bacterial endocarditis Sarcoidosis Behçet disease Celiac disease Common non-inflammatory causes Osteoarthritis Uncommon-rare non inflammatory Hypotyroidism amyloidosis

CHRONIC OLIGOARTHRITIS Spondyloartropathies are the most common cause of chr. Oligoarthritis Early onset rheumatoid arthritis must be distinquished. Osteoarthritis presents as oligoarthritis of the hips or knees

CHRONIC OLIGOARTHRITIS Laboratory evaluation Synovial fluid analysis- culture- crystals RF-dd(x) of RA HLA B 27- limited value

CHRONIC OLIGOARTHRITIS Radiographs and Imaging studies-considerable value Evidence of sacroitis indicates a spondyloarthropaty and narrow dd(x) Erosions of RA and Gout

CHRONIC OLIGOARTHRITIS Spondyloartropaties- asymmetric oligoarthritis RA- symmetric poliarthritis İn early RA- oligoartitis Stiffness and pain in low back- Spa RA- only cervical spine

CHRONIC OLIGOARTHRITIS Dactylitis(sausage digits)- sPA, gout, sarcoidosis Extraarticular manifestations that point to correct diagnosis Psoriasis –umblicus, external auditory canal, scalp and anal creft Diarrea- inflammatory bowel disease. Anterior uveitis

CHRONIC POLYARTHRITIS ESSENTIAL FEATURES Rheumatoid arthritis and Osteoarthritis are leading causes. Careful delineation of the joints involved, particularly in the hands, can help to the correct d(x) The distinction between inflammatory non inflammatory is critical

CHRONIC POLYARTHRITIS Inflammatory –Common Rheumatoid arthritis SLE spondyloartropaties (especiaally Psoriatic art) Gout Chronic hepatitis C infection Drug induced lupus syndrome Inflammatory-Uncommon Paraneoplastic polyarthritis Remitting seronegative symmetric polyarthritis with pitting edema (RS3PE) Adult onset still disease Inflammatory- uncommon Vasculitiitis Sjögren’s syndrome Viral infections other than hepatitis C Non inflammatory Osteoarthritis Hemachromatosis

CHRONIC POLYARTHRITIS Laboratory evaluatıon If arthrosentesis is feasible- joint aspiration- cell count and crystals CBC RFT Urine analysis ESR_CRP RF-ANA- hepatitis B and C serology

CHRONIC POLYARTHRITIS Radiographs are indicated in most cases of chronic polyarthritis Erosion-RA-OA-hemachromatosis-gout- SPA Non-erosive- SLE-drug induced SLE-chronic hepatitis C.

DD(x) of chronic polyarthritis Osteoarthritis and Rheumatoid arthritis have different patterns of joint involvement in the hand. OA- involves DIP, PIP and first MCP joints. RA- PIP- MCP and wrist

Osteoarthritis and Rheumatoid arthritis spare certain joints OA- does not involve MCP, wrist, elbow, ankles RA- spare DIP, thoracic and lumbosacral spine and sacroiic joints Psoriatic arthritis- DIP joints

ASSOCIATED HISTORY •Predisposing factors •Medication •Bowels •Urinary •Rashes •Eyes •Raynaud’s •Sicca •Family History

EXAMINATION •Multi-system •Disability •Range of movement •Signs of inflammation

INVESTIGATIONS •FBE/E/LFT •ESR/CRP •Iron studies •Uric Acid •Auto antibodies •HLA-B27 •Viral serology •Joint fluid •Imaging

Skin and nail findings and arthritis

Skin rashes Diffuse eruption with fever and systemic findings Generally viral or due to primary immunological disease Must be differentiated from bacterial diseases SLE, DM Rheumatic fever Still disease Kawasaki disease

Adult still disease

Papulosquamaus lesions Psoriatic arthritis Reiter Syndrome SLE

SLE

Annular lesions Rheumatic fever Subcutaneous Lupus

Facial lesions Malar and discoid rash Lupus pernio: Sarcoidosis Dermatomyositis-gottron papules-heliotrope rash Lupus vulgaris: cutanous tuberculosis

Nodular lesions RA, ARA, crystal artropathies Erythema nodosum: Behçet’s disease,Sarcoidosis, spondyloartropathies, tbc

Erysipel like rash (FMF)

Acneiform lesions( behçet’s disease)

Purpura purpura:vasculitis

Skin thickening Scleroderma Eosinophilic fasitis and eosinophilic myalgia syndrome.

Photosensitive skin eruption Connective tissue diseases, SLE, DLE, DM... Phototoxic drug allergies (sulfa, thiazid..)

Oral ulcers Genital ulcers Behçet ‘s disase Crohn disease Spondyloarthropathies SLE Genital ulcers Behçets disease Reactive arthritis

Sousage digits/Enthesopathy Reactive arthritis Psoriatic arthritis

Sousoge digits

Achille tendinitis

Raynaud Primary or secondary Primary- female- %5-8 Secondary – connective tissue disorders Scleroderma, SLE, SS, RA, DM/PM...

Fever, weight loss, malaise and arthritis

Fever and rheumatological diseases ARA FMF JRA/JİA Adult onset Still disease SLE Vasculitis Behcet ‘s disease Scleroderma DM/PM Sarcoidosis

Eye and arthritis

Eye and rheumatological diseases Uveitis Anterior uveitis: BH, Spondyloarthropathies, Sarkoidosis, JRA.. Posterior Uveitis: BH, SLE, Sarkoidosis... Cornea Involvement Marginal erosion: RA Skleritis/episkleritis: RA Keratoconjonktivitis sicca Primary or secondary Sjögren syndrome

Anterior uveitis an hypopyon

Dry eye and sclera erosions

Abdominal symptoms and arthritis

Abdominal symptoms and arthritis Diarrea Abdominal pain Intestinal bleeding Enteropahtic arthritis Reactive arthritis Behcet disease FMF Vasculitis Connective tissue diseases Mono-oligoarthritis Poliarthritis Axial involvement