Diagnosing inflammatory arthritis Dr Jane Bleasel RPAH

What is inflammatory arthritis? Inflammation in joints Inflammation in synovium (lining of joints) = synovitis  Joint effusions Inflammation in tendon sheaths = tenosynovitis +/- Systemic features of inflammation fever, fatigue, weight loss

Pathology of synovitis

Inflammatory arthritis HISTORY IS KEY Symptoms STIFFNESS IN JOINTS, esp early morning aftr inactivity, > 30 minutes, may be many hours Stiffness improved with activity, hot shower Swelling Pain (not specific to inflammatory arthritis) Limitation of movement (not specific) +/- constitutional symptoms: fever, weight loss, fatigue, anorexia

Inflammatory arthritis- signs Signs of inflammation Warmth Redness (not always present) Tenderness Swelling, soft tissue, boggy sensation +/- effusions

History is the key Pattern of joint involvement Nature of onset Symmetrical or asymetrical, peripheral joints or spinal joints Nature of onset Acute, subacute or chronic Is there evidence of a systemic process? Are there extra-articular features?

History is the key Pattern of joint involvement Nature of onset Symmetrical or asymetrical, peripheral joints or spinal joints Nature of onset Acute, subacute or chronic Is there evidence of a systemic process? Are there extra-articular features?

Case history 1 45 year old women, gradual development of pain, swelling & stiffness small joints of hands and wrists. Also noticed pain and stiffness under balls of feet and knees. Joints stiff in mornings for around 2 hours, improved with movement. Feeling fatigued. Physical examination: symmetrical swelling over MCPs, PIPs, wrists, soft tissue swelling, reduced grip strength.

Clinical photo

Investigations Hb 105, MCV 85, plts 500, WCC 8.7 ESR 65, CRP 30 UEC, LFT normal What other investigations?

What other investigations? RF ANA if ANA +, dsDNA, ENA SLE inflammatory arthritis looks the same as RA Early scleroderma has diffusely “puffy” hands Xray hands and feet for erosions

Xray of hand Soft tissue swelling Para-articular osteoporosis

Investigations Case 1 RF + 320 IU/ml ANA + 1:80 dsDNA negative, ENA negative Xrays: soft tissue swelling, para-articular ostoporosis Diagnosis: rheumatoid arthritis

“Rheumatoid-like” arthritis If fever, rash, marked systemic features think of viral arthritides: Viral causes Ross River virus Barmah Forest Hepatitis B (arthritis precedes jaundice) Rubella Parvo B19 virus EBV