1. Managing Rheumatoid arthritis
Chandrashekara .S

2. Diagnostic dilemmas Early presentation-
Typical but no serological markers positive especially RF.
No EMS or erosions.

3. Hand and foot arthritis- is it RA
Other features
RF and Anti-CCP
Joint pattern
Other unusual mimickers

4. Single large joint Duration, feature and inflammations RF/ anti-CCP +
infection exclusion
X ray of joint
MRI role
Imaging other site- Pelvis for sacroiilitis
Synovial biopsy

5. Other special tests in monoarthritis
PCR- Variety
Tb work-up
HLA B 27
Synovial fluid ADA

6. Radiology in monoarthritis
Plain radiography- May not be useful in early 6 weeks- except in osteomyelitis, Aggressive infective arthritis,
Pherstister triad-no joint narrowing, marginal erosion and juxtra articular osteoporosis.
Osteo-arthritis- can be misleading. ? Something is missing?

7. Other Imaging
MRI- soft tissue, pannus, and ligament injury even infection and infiltrative pathology, few changes and scoring pattern for RA and SSA are being developed
CT- may be a replacement but not a substitute
Nuclear scan may help to work-up if asymptomatic other joint inflammation or metastasis is considered as Diagnosis

8. Synovial fluid analysis
All tapped fluid unless sure of diagnosis should be evaluated
Collection is critical including sterility of container
An EDTA tube collection willhelp to delineate cells better
Interpretation algorithms are available.

9. How much is less in clinical history and examination
MORE is not enough
Each finding should preferably explainable
Often missed info- Raynuds, ulcers, skin rashes, drug abuse, eye disease, steroid use, urethritis, drugs like PZA, tophi

10. X ray Pelvis Presence of inflammatory back pain
Atypical oligo arthritis presentation with restricted back movement (Shober’s)
Presence of eye problem with atypical arthritis
Young male with arthritis
Family history
Other modalities- MRI, CT and Nuclear Scan

11. Hand X- rays Differential diagnosis Severity Pattern of involvement
Erosions
Marginal
Central
Degree of Changes
Osteoporosis/sclerosis
Severity

12. Red flag signs to evaluate further
Life threatening
Infection in joints or elsewhere
SLE or Vasculitis
Organ threatening
Rising creatinine and urine sediment
Eye disease association
Lung symptoms
Neurological changes
Window of Opportunity

13. Atypically typical
RF /anti-CCP +, normal inflammatory parameter, symptomatic and joint swelling +
Asymmetrical and less than 2 weeks
Less than 2 weeks typical
How to proceed

14. Co-morbidity
RFT
LFT
CPK
X ray Chest
HTN DM
others

15. Infection with chronic viral disease
HIV
Hepatitis B
Hepatitis C
Should we screen all
How and when

16. Disease Burden estimation
Damage
Extent
Severity
Duration.

17. Future How to start therapy Counseling and issue in counseling
Pregnancy and other personal perspectives
Issues related to compliance
Exercise or rest
Physiotherapy
Managing Pain and patients symptoms

18. Future volume Initiating DMARD Managing AE
Attempting combinations and their rationale
Biologics
Other issues of concern

19. Thank U