This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Presented By: Ali Al-blowi Medical Student Arthritis Mono vs. Poly Presented By: Ali Al-blowi Medical Student

Defenitions Causes History Examination Investigation Conclusion

Definitions

Arthritis = inflammation of a joint Arthritis = inflammation of a joint. Inflammation = Joint pain, stiffness, tenderness, redness, hotness, swelling & limited movement. Mono arthritis = one joint affected. Poly arthritis > 4 joints affected. Oligo/pausi-arthritis = 2-4 joints affected.

Acute = < 6 weeks Chronic = > 6 weeks Symptoms: Articular symptoms Non articular symptoms

Causes

Monoarthritis mimickers: Common inflammatory processes occur in the soft tissues around joints: Tendonitis of the shoulder. Olecranon bursitis of the elbow. Prepatellar bursitis of the knee.

Diseases Causing Monoarticutar Symptoms: A) Septic Bacterial Mycobocterial Lyme disease Fungal B) Traumatic Fracture Internal derangement Hemarthrosis

C) Crystal deposition dis Gout Osteoarthritis CPPD Hydroxyapatite DD Calcium oxalate DD Palindromic rheumatism D) Others Juvenile RA (Pseudogout) Avascular N Foreign-body S Pigmented villonodular syno. Synovioma Coagulopathy

Polyarticular diseases occasionally present with a monoarticular onset? Rheumatoid arthritis Reiter's syndrome/reactive arthritis Juvenile rheumatoid arthritis Psoriatic arthritis Viral arthritis Enteropathic arthritis Sarcoid arthritis Whipple's disease

Structural abnormality Internal derangement The most likely causes of chronic monoarthritis (inflammation within a single joint for > 6 weeks). INFLAMMATORY NON-INFLAMMATORY Inflammatory synovial fluid Mycobacterial infection Fungal infection Lyme arthritis Monoarticular presentation of RA Seronegauve spondyloarthropathies Sarcoid arthritis Foreign-body synovitis Structural abnormality Internal derangement Osteoarthritis Internal derangement of the knee Avascular necrosis of bone Pigmented villonodular synovitis Synovioma

Causes of acute polyarthritis: Infection Other Inflammatory Gonococcal Meningococcal Lyme arthritis Acute rheumatic fever Bacterial endocarditis Viral (rubella, H BV & HCV, EBV& HIV) RA Polyarticular and syst JRA Polyarticular gout SLE Reiter's syndrome Psoriatic arthritis Sarcoid arthritis

Causes of chronic polyarthritis: INFLAMMATORY NON-INFLAMMATORY RA Enteropathic arth Polyarticular JRA SLE * SSc CPPD, Polyarticular gout Polymyositis Sarcoid arthritis Reiter's syndrome Vasculitis Psoriatic arthritis Polymyalgia Rh. OA Paget's disease CPPD Fibromyalgia Benign hypermobility syndrome Polyarticular gout Hemochromatosis

Rheumatologic emergency Acute monoarthritis = the joint is infected until proven otherwise. The septic joint must be diagnosed quickly and managed aggressively to avoid permanent structural damage.

History

History taking from a patient with monoarthritis Onset of pain: sudden, in seconds or minutes? (Consider fracture and internal derangement). Over several hours or 1-2 days? (Consider infection, crystal deposition diseases, inflammatory arthritis and palindromic rheumatism). Insidiously over days to weeks? (Consider indolent infections, such as mycobacteria and fungi, osteoarthritis, tumor, and infiltrative diseases).

Overused or damaged joint, either recently or in the past Overused or damaged joint, either recently or in the past? (Consider traumatic causes). History of IV drug abuse? Recent infection of any kind? (Consider septic arthritis). Previous acute attacks of joint pain and swelling that resolved spontaneously? (Consider crystal deposition and other inflammatory arthritis).

Treatment with a prolonged course of corticosteroids Treatment with a prolonged course of corticosteroids? (Consider infection or osteonecrosis of bone). Associated skin rash, low-back pain, diarrhea, urethral discharge, conjunctivitis, or mouth sores? (Consider Reiter's syndrome, psoriatic, or enteropathic arthritis). History of a bleeding diathesis? treatment with anticoagulants? (Consider hemarthrosis).

Is the age of the patient useful in the differential diagnosis? I- In children, consider: Congenital dysplasia of the hip. Slipped femoral epiphysism. Monoarticular presentation of JRA. Children are unlikely to have GOUT.

II- In young adults, consider: Seronegative spondyloarthropathy. RA. Internal derangement of the joint. They are less likely to have GOUT. A septic- joint is often due to gonococcal infection.

III- Older adults : Crystalline arthritis. OA. Osteonecrosis. Internal derangement of the joint. A septic joint in these individuals is less likely due to gonococcal organisms.

What are the most likely diagnoses in hospitalized patients with acute monoarthritis?

Acute monoarthritis: * Pyogenic infection * Acute crystal deposition diseases Risk factors known to provoke gout or pseudogout: trauma, surgery, hemorrhage, infection or medical stress such as: CRF, MI & CVS.

Polyarthritis Pains differ: Polyarthritis = inflammation (swelling, tenderness, warmth) of > 4 joints by examination. Polyarthralgia = pain in > 4 joints without demonstrable inflammation; eg: SLE, systemic sclerosis, vasculitis, polymyalgia rheumatica, and chronic non-inflammatory. Diffuse aches and pains are poorly localized symptoms originating in joints, bones, muscles, or other soft tissues. Polymyalgia rheumatica, fibromyalgia, polymyositis, and hypothyroidism.

Sequence of joint involvement: 1- Migratory (fleeting) polyarthritis: Symptoms disappear in the affected joints to reappear in others. Ex.: ARF, Gonococcal, Viral, early phase of Lyme. 2- Additive: Symptoms persist with addition of new joint inflammation Ex.: RA, SLE. 3- Intermittent: Attacks of remissions & exacerbations in the same joint. Ex.: Gout, sarcoid arthritis, Reiter's syndrome and psoriatic. Gout - Chronic tophaceous gout in an untreated patient with end-stage renal disease

Benign hypemobility syndrome. What are the most likely diagnoses in women aged 25-50 who present with chronic polyarticular symptoms? OA. RA. SLE. Fibromyalgia. Benign hypemobility syndrome.

Ankylosing Spondylitis. OA. Hemochromatosis. What are the most likely diagnoses in men aged 25-50 who present with chronic oligoarticular or polyarticular symptoms? Gonococcal arthritis. Reiter Syndrome. Ankylosing Spondylitis. OA. Hemochromatosis.

And in patients over age 50 presenting with chronic polyarticular symptoms? OA. RA. CPPD disease. Polymyalgia rheumatica. Paraneoplastic polyarthritis.

Distribution of Joint Involvement Symmetrical Asymmetrical Ex. RA SLE Reiter PA AS Axial Peripheral PA (70% also affects IPJ--- sausage digits) Large Small Seronegative ARF

DISEASE JOINTS COMMONLY INVOLVED SPARED Knee, wrist, ankle, hand IP Gonococcal arthritis Knee, wrist, ankle, hand IP Axial Lyme arthritis Knee, shoulder, wrist, elbow Rheumatoid arthritis Wrist, MCP, PIP, elbow, glenohumeral, cervical spine, hip, knee, ankle, tarsal, MTP DIP, thoracolumbar spine OA First CMC, DIP, PIP, cervical spine, thoraco-lumbar spine, hip, knee, first MTP, toe IP MCP, wrist, elbow, shoulder, ankle, tarsal Reiter's syndrome Knee, ankle, tarsal. MTP, toe IP, elbow, axial Psoriatic arthritis Knee, ankle, MTP. toe IP, wrist. MCP, hand IP. axial Enteropathic arthritis Knee, ankle, elbow, shoulder, MCP, PIP, wrist, axial Polyarticular gout First MTP, instep, heel, ankle, knee CPPD disease Knee, wrist, shoulder, ankle, MCP, hand IP, hip, elbow Sarcoid arthritis Ankle, knee Heroochromatosis MCP, wrist, knee, Hip, feet, shoulder

Extra-articular Organ Involvement: ARF Ht, pleura Viral A. Liver SBE Ht valves & kidney RA Lung, pl., ht. SLE Lung, pl., ht., kidney, CNS Scleroderma Lung, pl., ht., kid., GI., Liver

PM/DM Lung, pl., ht. Reiter Valves, GI. Enteropathic A: GI., Liver Gout Kidney Sarcoid A: Lung, Liver Vasculitis Lung, Kidney Hemochromatosis: Ht, liver, Pnc

Morning stiffness Morning stiffness = time it takes for patients with polyarthritis to move after arising in the morning, or after rest. Site: Affecting hands in RA & back in AS. Inflammatory arthritis, morning stiffness lasts > I hour & tends to parallel the activity. Non-inflammatory, eg. OA, ---MS < 15 minutes.

Examination

Is Fever a useful sign? Misleading !! Infectious arthritis. Acute attacks of gout and CPPD disease. RA, juvenile RA. Sarcoidosis. Reiter's syndrome.

Inability to bear weight Skin Nodules: RA, gout tophi Rash: psoriasis, lupus, Still’s, viral etc Inability to bear weight Sepsis Fracture Crystal arthritis Neurologic

Signs of inflammation Range of motion Synovitis (soft tissue swelling) Local heat Effusion Range of motion  Active, N Passive: soft tissue eg bursitis, tendinitis, muscle  Active,  Passive: contracture, synovitis, structural abnormality

Investigations

Monoarthritis Synovial fluid analysis.: Most useful diagnostic study in the initial evaluation of monoarthritis

Almost always indicated 1. Radiograph of the joint: may reveal: Normal, OR unsuspected fracture, Osteonecrosis, OA, or Juxta-articular bone tumor. Chondrocalcinosis, a radiologic feature of CPPD Chronic fungal or mycobacterial infection. Contralateral joint radiograph for comparison. 2. Complete blood count. Leukocytosis + possibility of inf.

Indicated in selected patients Cultures of blood, urine: Mandatory in septic joint. 2. PT & PTT: when anticoagulation or coagulation disorder is suspected. 3. ESR, CRP: nonspecific; significant elevation = inflammation.

Ask for further investigations in chronic cases: Radiograph of sacroiliac joints: asymptomatic sacroiliitis in young males (spondyloarthropathy). Chest radiograph: pulmonary TB or sarcoidosis. Tuberculin test: negative test in excluding TB?. Serologic tests: Lyme disease (Borrelia burgdorferi), RF, ANA, and HLA-B27.

Polyarthritis X-ray Laboratory testing CBC Serum uric acid THS Iron studies Liver enzymes Serum creatinine Urinalysis

ESR ANA RF HLA-B27 antigen Synovial fluid analysis

Conclusion

Acute monoarthritis = joint aspiration to exclude septic & crystal- induced arthritis. Chronic monoarthritis > 6 weeks of unknown cause needs synovial biopsy. Gout does not occur in premenopausal females or in joints close to spine.

Take your time for final diagnosis! Because many chronic polyarticular diseases require months or years to diagnose, patience is often required. Many diseases present insidiously with few objective findings for prolonged times. Many diseases initially represent others before finally take their usual pattern. RA, for example, can present as a monoarthritis before assuming its more typical polyarticular course.

Take your time for final diagnosis! (cont.) Characteristic laboratory abnormalities may require months or years to develop. The joint symptoms precede the extra-articular features by months or years. Joint radiographs may not show characteristic changes of the arthritis for months or years. Not all pts. with +ve RF=RA, nor +ve. ANA = SLE . Remember nothing is 100%

Musculoskeletal complaint 1 Musculoskeletal complaint History & Examination? Articular or non Acute or chr. Inflammatory or non. Number & distribution Non articular Fibromyalgia R Hypermobility S Articular? Acute or Chronic ? Acute<6 W. Chronic>6W. Acute arthritis: Infectious Crystal-induced Reiter’s Presentation of Chr. Arth. Inflammatory or non-infl.

- + + 2 Inflammatory or non-inflam. Chronic inflammatory arthritis= MS>1hr, synovial swelling, warm, tender Joint, +syst. manifes., CRP, ESR Chronic non-inflammatory arthritis >4 J = polyarthritis 1=mono, 2-4=oligo arthritis: PA- RS- PJA Affects Wt. Br. J. (H & k), DIP, CMC Symetrical _ + PA, RS PIP, MCP, MTP OA Osteonecrosis Charcot arthritis - + SLE, SSc, PM RA

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