1. Diagnosing inflammatory arthritis
Dr Jane Bleasel
RPAH

2. 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

3. Pathology of synovitis

4. 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

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

6. 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?

7. 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?

8. 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.

9. Clinical photo

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

11. 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

12. Xray of hand
Soft tissue swelling
Para-articular
osteoporosis

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

14. “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