1. Inflammatory Arthritis and Autoimmunity
Sunil Abraham, MD
Ellis Rheumatology Associates

2. No disclosures

3. Classification Arthritis Inflammatory Infectious Septic Osteomyelitis
Crystalline
Monosodium urate
Calcium pyrophosphate
Autoimmune
Rheumatoid
Seronegative (HLA-B27)
ANA related
Vasculitis, Sarcoid, Misc
Polymyalgia rheumatica
Non-Inflammatory
Osteoarthrosis

4. Case presentations

5. Case #1
46 year old white female with 4 month history of progressive fatigue associated with worsening joint pains
In the morning her knees are very stiff (1 hour) and her first few steps out of bed are very painful
She has noticed MCP swelling and that her rings are getting tighter
There is numbness and tingling in her fingertips
ROS negative

7. Case #2
28 year old male presents with a 5 year history of recurring bilateral ankle pain and swelling. It is associated with extreme morning stiffness. He denies any back pain. He has nail pitting
His brother recently developed a rash on his elbows
MRI of the of right ankle showed significant tendon swelling and subcortical erosions

9. Case # 3
82 year white female with history of diabetes, hypertension and coronary disease presents with 2 month history of progressive fatigue, malaise and stiffness in her hips and shoulders
She has never taken an hmg coa reductase inhibitor
Review of systems is negative
Sedimentation rate is normal

10. Case # 4
An 87 year old white female presents to your office with acute right dorsal wrist swelling, redness, warmth and pain that has been present for 3 weeks
No constitutional symptoms are present
Two courses of antibiotics provide no relief
Xray of her wrist shows chondrocalcinosis of the TFCC; ESR is 90

12. Inflammatory Arthritis
Infiltration of synovial capsule and surrounding joint capsule with lymphocytes, neutrophils, and macrophages
Cardinal signs of inflammation:
Rubor, Calor, Tumor, Dolor
Potential for joint disruption and destruction

13. Acute Inflammatory arthritis
Abrupt onset (hours to days)
Hot, red, swollen, exquisitely tender joint
Constitutional symptoms (fevers, chills, sweats)
Mono-, oligo-, poly- articular

14. Acute Inflammatory arthritis
Differential
Infectious
Bacterial, mycobacterial, fungal
Opportunistic
Lyme (3rd stage)
Crystalline
Monosodium urate- ‘Gout’
Calcium pyrophosphate- ‘Pseudogout‘

15. Acute Inflammatory arthritis
Rule out mechanical/traumatic injury
Olecranon bursitis, rotator cuff/ achilles tendonitis
Fracture

16. Chronic inflammatory arthritis
Progressive, insidious (>6 weeks)
Morning stiffness > 1 hour
Additional signs of inflammation
Fatigue, malaise, anhedonia
Weight loss, anorexia
‘Flu like’

17. Chronic inflammatory arthritis
Extra-articular manifestations
Rash (psoriatic, erythema nodosum)
Urethritis or sexually transmitted disease
History of bowel infection (salmonella, shigella)
Inflammatory bowel disease (colitis)
Uveitis
Sicca

18. Connective tissue disease
Disorder with collagen and elastin
Supporting structures
Non-heritable (genetics/environmental)
Rheumatoid arthritis
Systemic lupus erythematosus
Sjogrens Syndrome
Polymyositis, Scleroderma
Heritable
Osteogenesis imperfecta, Marfans, Ehlers-Danlos

19. Connective tissue disease
Review of systems
Signs of inflammation
Arthritis
Patchy alopecia
Oral/nasal ulcerations
Raynauds
Xerophthalmia/ Xerostomia
Rash (distribution, photosensitive)
Proximal muscle weakness

22. Connective tissue diseases
Rheumatoid Arthritis
Systemic Lupus Erythematosus
Sjogrens Syndrome
Systemic Scleroderma
Polymyositis/ Dermatomyositis
Mixed Connective Tissue Disease

23. Labs for Autoimmunity

24. ACR Position Statement
Immunofluorescence testing is the gold standard for ANA testing
HEp-2 cells have multiple autoantigens (>100)
Need to have results reported with titer and pattern
Current technology employs ELISA and multiplex technologies
Allows processing of large volumes
Limits diagnostic accuracy
8-10 autoantigens

25. Conditions with positive ANA
Essential for diagnosis
SLE
Systemic sclerosis
Mixed connective tissue disease
Somewhat useful
Poly-, Dermatomyositis
Sjogrens
Other conditions with +ANA
Autoimmune hepatitis/thyroid disease
Multiple sclerosis
Malignancy
Age
Infection

26. ANA pearls Not a screening test Is there a high pre-test likelihood:
SLE
Scleroderma
Sjogrens
Autoimmune myopathy
Obtain results in titer and pattern
Consider other causes for positivity

27. Related AutoantibodiesRA
MCTD
SLE
Sjogrens
PM/DM
Scl
RNP
SSA/B
Jo-1
dsDNA
Smith
Scl-70
Centromere RF
CCP
“ANA-negative”

28. Seronegative Arthritis
Associated conditions:
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis
Enteropathic related
Undifferentiated spondyloarthropathy
HLA-B27
Not useful as a diagnostic test
Presence in 6% of normal population

29. Polymyalgia Rheumatica
?Autoimmune inflammatory condition
Periarthritis
Subdeltoid bursitis, glenohumeral synovitis, biceps tenosynovitis
Consider diagnosis is those >50 years old, especially >70
~15% association with Giant Cell Arteritis
Check ESR, CRP, SPEP
Exquisitely responsive to glucocorticoids
1-2 years with slow taper

30. Crystalline Arthritis
Monosodium urate deposition (Gout)
Affects 1st MTP, knees, wrist
Destructive
Consider in post menopausal women
Gold standard diagnosis is by joint fluid analysis
Goal uric acid <6
Calcium pyrophosphate deposition (Pseudogout)
Disruption of cartilage calcification
Senior population

31. Cases Revisited

32. Case #1
46 year old white female with 4 month history of progressive fatigue associated with worsening joint pains
In the morning her knees are very stiff (1 hour) and her first few steps out of bed are very painful
She has noticed MCP swelling and that her rings are getting tighter
There is numbness and tingling in her fingertips

33. Case #2
28 year old male presents with a 5 year history of recurring bilateral ankle pain and swelling. It is associated with extreme morning stiffness. He denies any back pain. He has nail pitting
His brother recently developed a rash on his elbows
MRI of the of right ankle showed significant tendon swelling and subcortical erosions

34. Case # 3
82 year white female with history of diabetes, hypertension and coronary disease presents with 2 month history of progressive fatigue, malaise and stiffness in her hips and shoulders
She has never taken an hmg coa reductase inhibitor
Review of systems is negative.
Sedimentation rate is normal

35. Case # 4
An 87 year old white female presents to your office with subacute right dorsal wrist swelling, redness, warmth and pain that has been present for 3 weeks
No constitutional symptoms are present
Two courses of antibiotics provide no relief
Xray of her wrist shows chondrocalcinosis of the TFCC; ESR is 90; Uric acid 5.4

36. Conclusions
Appreciate the spectrum of inflammatory arthritis and its relation to connective tissue diseases
Understand the importance of patient demographics in narrowing your differential
Before ordering an ANA, consider whether the patient truly has a connective tissue disease
Always make sure ANA’s are ordered by IFA with titer and pattern
Don’t forget about psoriatic arthritis and pseudogout!