1. Painful joints Index case Year 2 Michaelmas Term

2. The story…. (see www.dipex.org/) A 53 year old woman, divorced with 2 children born after onset of painful joints, particularly hands and feet Symptoms subsided during 1 st pregnancy, no remission in 2 nd pregnancy Diagnosis made 23 years ago after infection with glandular fever. Had foot surgery and hand surgery planned

3. Features of her illness: Describes intense pain at times- counts the hours between painkillers Finds physiotherapy and hydrotherapy helpful in keeping joints moving Unhappy with results of foot surgery-still has pain Finds complementary therapy too expensive On Incapacity Benefit- would like to have been an artist

5. She comes to see you because: She is a concerned as she has recently noticed increasing shortness of breath She wants to know if there is any new treatment around which might help her If you can help provide any complementary treatments

6. What is the differential diagnosis?

7. Monoarticular or polyarticular?

8. Causes of polyarthritis?

9. Polyarthritis: osteoarthritis Osteoarthritis- disease of synovial joints; loss of articular cartilage and overgrowth of underlying bone Multifactorial causes; usually begins in middle age May be triggered by mechanical damage May be primary or secondary

10. Primary osteoarthritis Classic: pain and dysfunction of one or two weight bearing joints Generalised nodal: affecting finger joints of middle aged women

11. Secondary osteoarthritis Abnormal “wear and tear” following clearly defined insult to joint E.g. Charcot joint 2ry to diabetic neuropathy

12. Polyarthritis: rheumatoid arthritis Chronic systemic disease primarily affecting joints Inflammatory changes in synovial membranes and articular structures, including ligaments Leads to deformity: subluxation, ligament & joint disruption, joint erosion, ankylosis Systemic features develop as disease progresses

13. Rheumatoid arthritis 1-3% population Women:men 3:1 Peak incidence 25-55 Cause unknown ?autoimmunity triggered by viral infection Genetic link: HLA DR4 alleles poor prognostic factor

14. How would you make the diagnosis?

15. Diagnosis of RA: history Bilateral, symmetrical polyarthritis Involves proximal joints of hands and feet Present at least 6 weeks May have subcutaneous rheumatic nodules on hands or elbows

16. Diagnosis of RA: investigations Raised ESR and CRP in active disease +ve Rheumatoid factor in 80% cases High seropositivity with systemic complications Anticitrulline antibody with erosive RA Blood count: may have anaemia, hypoalbuminaemia Proteinuria radiology

19. Features of radiology Synovitis: soft tissue swelling Joint destruction; erosion Deformity Evidence of previous surgery

20. What could be causing her shortness of breath?

21. Extra-articular manifestations of RA respiratory haematological neurological lymphoreticular ocular cardiac systemic

22. Respiratory complications pleurisy pleural effusion pleural nodules pulmonary fibrosis Caplan's syndrome obliterative bronchiolitis cricoarytenoid inflammation

25. Caplan’s syndrome Rheumatoid lung nodules with pneumoconiosis May resemble TB on Xray Restrictive and obstructive defect Airflow limitation and reduced gas transfer

26. What treatments are there for RA?

27. RA management Medical Surgical Physio other

28. Medical treatment 1. Symptom control: NSAIDs, including aspirin Selective COX-2 inhibitors BUT remember NSAIDs may cause gastritis and affect renal function AND COX-2 inhibitors may increase risk of cardiovascular events Use lowest effective dose

29. Medical treatment: 2. Disease-Modifying Anti-Rheumatic Drugs (DMARDs) Low-dose weekly methotrexate Sulfasalazine Hydroxychloroquine, leflonamide Azathioprine, penicillamine, gold salts May use combination in patients at risk of progressive disease NEW! Infliximab tissue necrosis factor blocker (TNF-α)

30. TNF-α Launched for Crohn’s 1999 Very expensive: national guidelines published by BSR 2001 Mainly used if patient resistant to standard DMARD therapy

31. Medical treatment 3. Corticosteroids May use with anti-inflammatories and DMARDs Helps in acute flare-ups Remember side effects: osteporosis, Cushing’s disease, hypertension

32. Surgical management

33. Surgical options Tendon repair or transfer Synovectomy Arthrodesis Joint replacement osteotomy

34. But remember….

35. Physiotherapy and other treatments?

36. Role of physio Rest inflamed joints Use of splints Exercise when inflammation subsides to strengthen surrounding muscles and reduce risk of osteporosis

37. Complementary treatments?

38. Complementary treatment on NHS: Variable between practices No evidence for homeopathy ?acupuncture ?glucosamine ?aromatherapy ?massage

40. Any other causes of polyarthritis?

41. Other causes of polyarthritis Seronegative spondyloarthritis SLE Polyarteritis nodosa Wegener’s granulomatosis Systemic sclerosis Post-infective: rheumatic fever, Reiter’s syndrome, enteric infections Infective: Lyme disease, bacterial endocarditis, gonococcus Sarcoidosis

42. And… any causes of monoarthritis?

43. monoarthritis Infection Haemarthrosis: trauma, esp. haemophilia Tumour: osteoma, sarcoma, metastasis Rheumatic: RA or OA Crystal (gout: urates, pseudogout: calcium pyrophosphate dihydrate))