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Joints, Rheumatology, and the Shelf. Paul Johnson prepared by Ryan Sanford Chief Lecture. The Joints.

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Joints rheumatology and the shelf

Joints, Rheumatology, and the Shelf

Paul Johnson

prepared by Ryan Sanford

Chief Lecture


The joints
The Joints

44F mother of four children ages 3-8y is evaluated for 2wk of aching in joints of wrists, hands, and knees. Pain and swelling were severe for ~ 1 week, then subsided to aching. Pain is worse in the morning and abates somewhat with activity. On PE there is tenderness with pressure on the dorsa of the wrists and pain with wrist motion. One side of the patient’s face shows faint redness. She has noticed patchy sloughing of the epidermis of her hands. What is the diagnosis?

What is the DDx for acute arthritis?


Joint pain
Joint Pain

Duration

Chronic

Acute

Infection [septic arthritis]

Trauma/Blood

Crystals! Gout and CPPD

Reactive

Parvovirus B19

Early Chronic

Activity doesn’t help

Inflammation?

Activity helps, stiff in AM [>1h]!

No = OA

# Joints Involved

Poly

Oligo

Mono

RA = symmetric

SLE = symmetric

Systemic Sclerosis = symmetric

Indolent infection

Early oligo/poly

Spondyloarthropathy

Indolent infection

Early poly



Hand pains
Hand Pains

  • 82F w/ chronic non-inflammatory hand pain and nodules at DIP joint -- Disease and Eponym?

    • OA and Heberden’s Nodes

  • Pencil in cup Deformity on Hand X-Ray?

    • Psoriatic Arthritis, occurs at DIP, is erosive

  • Ulnar Deviation?

    • Rheumatoid Arthritis

  • Dactylitis? AKA?

    • Reactive Arthritis, Sickle Cell Anemia, Psoriasis, AkylosisingSpondylitis, Tb

  • + anti cyclic citrullinated peptide?

    • RA

  • Nodules filled with urate over fingers?

    • Gout

  • MCP pain and a discoid rash?

    • SLE



Osteoarthritis
Osteoarthritis

  • On Radiographs

    • Joint Space Narrowing

    • Subchondral Cysts

    • Osteophyte Formation

    • Subchondral Sclerosis

  • The Patient Says

    • Not too stiff upon awakening [<30 min]

    • Pain gets worse with activity

    • Can have some effusions, esp at knees

  • Tx:

    • OTC analgesia – APAP, NSAIDS. No Narcotics

    • Intra-articular injections

    • PT and periarticular muscle strengthening

    • Joint replacement



Diagnostic criteria for sle
Diagnostic Criteria for SLE

  • Skin

    • Malar Rash

    • Discoid Rash

    • Photosensitivity

    • Oral/Nasal Ulcers

  • MSK

    • Non-erosive arthritis

  • Serologies

    • ANA

    • Anti dsDNA, anti-smith, APLA

  • Cardiopulmonary

    • Serositis

  • Renal

    • Proteinuria or cellular casts

  • CNS

    • Seizures, psychosis, etc

  • Heme

    • Hemolytic anemia OR

    • Leukopenia OR

    • Lymphopenia OR

    • thrombocytopenia

1

8

2

9

3

4

10

5

11

6

7

But ALSO: constitutional complaints, abd pain, alopecia, vasculitis, raynaud’s, eye problems, etc.


Autoantibodies
Autoantibodies

  • Most specific for SLE

    • Anti Smith Ab

  • Prognositic for SLE and kidney disease

    • Anti ds DNA Ab

  • APLA – bleeding or clotting?

    • Clotting, veins AND arteries

  • ANCA?

    • Wegener’s granulomatosis, Microscopic polyangiitis, Churg-Strauss syndrome

      • Wegener’s: c-ANCA, anti-PR3

      • Microscopic Polyangiitis: p-ANCA, anti-MPO

  • Hematuria and Hemopytisis, not ANCA related

    • Goodpasture’s, anti-GBM Ab disease

    • Could also be SLE

  • Taking hydralazine, now have arthritis and malar rash?

    • Anti-HistoneAb for drug induced Lupus

  • Anti-Mitochondrial Ab

    • Primary Biliary Cirrhosis

  • Anti-EndomysialAb and Tissue TransglutaminaseAb

    • Celiac disease

  • Autoimmune Hepatitis

    • Anti Smooth Muscle Ab


Wegener s granulomatosis
Wegener’s Granulomatosis


Autoantibodies pearls
Autoantibodies + Pearls

  • Limted Scleroderma – Ab and Symptoms?

    • Anti-CentromereAb

    • CREST [calcinosis, raynaud’s, esophageal dysmotility, sclerodactyly, telangiectasias]

  • Diffuse Scleroderma -- Ab

    • Anti SCL-70

  • Autoimmune cause of oral and genital ulcers?

    • Behcet’s Syndrome

  • Young Asian female with loss of radial pulses, constitutional symptoms?

    • Takayasu’sArteritis

  • 85F with amaurosisfugax, headaches, scalp tenderness on same side, Dx? Tx? Work up?

    • Temporal Arteritis AKA Giant Cell Arteritis

    • ESR very high

    • Treat with high dose steroids – IMMEDIATELY; to prevent blindness

    • Get a temporal artery biopsy

  • I have IBD and now an elevated bilirubin and alkaline phosphatase?

    • Primary sclerosingcholangitis


Takayasu s arteritis
Takayasu’sArteritis



I got a uri now i have a rash and bloody urine
I got a URI, now I have a rash and bloody urine . .

  • HenonchShonleinpurpurua

  • IgA Nephropathy [synpharyngitic]

  • Post Streptococcal GN occurs after the pharyngitis


  • 29 AA Fw/ 2mo of arthralgias of knees, elbows, hands, and swelling in legs. BP 150/95. HR 79. 2+ pitting LEE.

  • HCT 35%; C3 60; C4 12; ANA positive; 24 Urine protein 4.6g. Urine sediment with erythrocyte casts, oval fat bodies.

  • DDx? Likely Dx?

  • Work-up?


Nephrotic syndrome
NephroticSyndrome

  • >3.5g of protein in 24h U collection

  • Can present with either nephrosis or nephritis

  • Causes of this Syndrome

    • Diabetic Nephropathy

    • Minimal Change Disease – think young, Kids!; heme CA

    • Membranous Nephropathy – HBV, solid tumors, class V SLE nephritis, NSAIDS

    • FSGS [obesity, HIV, idiopathic, heroin]

    • Myeloma

    • Amyloidosis

  • Urine Sediment: oval fat bodies or benign

  • General Tx: ACEI, diurese, treat underlying illness



  • 66F with severe pain in L calf, sudden onset. Has RA of many joints. Has had many knee injections because of pain and effusions with triamcinolone. Now is treated with etanercept and methtotrexate. PE with large R knee effusion and L knee is smaller in size. The knee was similar in size to the R until the pain began. The L calf is 5cm larger in diameter than the R.

  • Diagnosis?


RA many joints. Has had many knee injections because of pain and effusions with

  • Chronic, symmetric, inflammatory, destructive

  • Joints – PIPs, MCPs, wrists, knees, ankles, MTPs

  • C1-C2 instability – A Classic Question

  • S/Sx:

    • Constitutional: fever, weight loss, malaise

    • Pulm: ILD, nodules, fibrosis, pleuritis +/- effusions

    • Vascular: leukocytoclasticvasculitis

    • Cardiac: pericarditis, myocarditis


Seldom seen
Seldom Seen many joints. Has had many knee injections because of pain and effusions with


Nodules
Nodules many joints. Has had many knee injections because of pain and effusions with


Diagnostic criteria for ra 4 out of 7
Diagnostic Criteria for RA? 4 out of 7 many joints. Has had many knee injections because of pain and effusions with

  • AM Stiffness >1h

  • Hand Joint Arthritis >6wk

  • Rheumatoid Nodules

  • X-ray changes – erosions or periarticularosteopenia

  • Arthritis of >3 joints simultaneously >6wk

  • Symmetric involvement >6wk

  • +RF [but check the CCP]


Diagnosis
Diagnosis? many joints. Has had many knee injections because of pain and effusions with


Diagnosis1
Diagnosis? many joints. Has had many knee injections because of pain and effusions with


Gout n egatively birefringent n eedle shaped crystals
Gout: many joints. Has had many knee injections because of pain and effusions with Negatively BirefringentNeedle Shaped Crystals


Pseudogout many joints. Has had many knee injections because of pain and effusions with = Calcium Pyrophosphate Deposition DiseaseWeakly Positive Birefringent Rhomboid Shaped Crystals


What is this
What Is This? many joints. Has had many knee injections because of pain and effusions with


Gout many joints. Has had many knee injections because of pain and effusions with

  • SHELF: obese, drinking, male, middle aged, carnivorous

  • AcuteMonoarticular Arthritis

    • 1st MTP = Podagra

    • Overlying skin, dusky, red, tense, red

    • Also at feet, ankles, knees

  • Don’t check serum uric acid during a flair!

  • The joint fluid: lots of WBCs [20-100k]; majority are PMNs. Find the crystals! Get a Gram Stain!

  • Tx

    • Acute: NSAIDS, colchicine, maybe steroids

    • Chronic: decrease purine intake, daily colchicine

      • Allopurinol or probenecid

      • not until acute issues resolved; tx w/ colchicine or nsaidsconcominantly while reducing UA levels


Calcification of cartilage as seen on x ray
Calcification of cartilage as seen on X-ray? many joints. Has had many knee injections because of pain and effusions with

Chondrocalcinosis of CPPD or Pseudogout


26f w multiple sexual partners
26F w/ multiple sexual partners many joints. Has had many knee injections because of pain and effusions with

  • Migratory polyathralgias

  • True inflammation  tenosynovitis

  • Synovial fluid  50K WBC, mainly PMNs

  • Blood Cultures growing GN diploocci

    Cause?

    Treatment?


Disseminated gonococcal infections
Disseminated many joints. Has had many knee injections because of pain and effusions with Gonococcal Infections

  • Most common infectious arthritis of sexually active young adults

  • Preceded by mucosal infection – can be ASx

    • Cervicitis

    • Urethritis

    • Pharyngitis

  • Migratory Polyarthralgias

  • Tx with ceftriaxone x7d, must also treat for Chlamydia – azithromycin or doxycycline


Doc since i was 20 i ve had low back pain especially in the morning
“Doc, since I was 20 I’ve had low back pain, especially in the morning . . .”

SI JOINT

Picture 1


And his spine films
And his spine films . . . in the morning . . .”

PICTURE 2


What does seronegative spondyloarthropathy mean
What does in the morning . . .” SeronegativeSpondyloarthropathy Mean?

  • Absence of rheumatoid factor, autoantibodies

  • Inflammatory! Aseptic. ESR elevated

  • Has a tendency to affect spine, SI joint, but also other joints

  • Also can affect eyes [uveitis, scleritis, iritis, conjuntivitis]

  • Associated with HLA-B27

  • Think of 4 illnesses

    • Ankylosingspondylitis

    • Psoriatic arthritis

    • Enteropathicartritis

    • Reactive arthritis


Ankylosing spondylitis
Ankylosing in the morning . . .” Spondylitis

  • Classically: starts in late teens, early 20s; gradual onset low back pain, worse in AM [inflammatory!], improves with movement/exercise

  • Progressive involvement of spine, starting at SI Joint [picture 1]  erosions and sclerosis

  • Also inflammation at insertion sites for tendons/ligaments  enthesitis

    • Achillies pain

    • Plantar Fasciitis

    • Spine  Bamboo Spine [picture 2] – spinal ligament calcification and bridging syndesmophytes

  • Also could see uveitis



Psoriatic arthritis
Psoriatic Arthritis in the morning . . .”

  • Can have various presentations . . .

    • Monoarticular/dactylitis – Esp DIP

    • Polyarthritis

    • Axial involvement – like AS

  • Arthritis can preceded skin findings by years

  • Enthesitis

  • Pitting fingernails

  • Joint Films

    • ‘Pencil in Cup’ deformity at DIPs


And the 2 other seronegative spondyloarthropathies
And the 2 Other in the morning . . .” SeronegativeSpondyloarthropathies

Reactive Arthritis

Enteropathic IBD Associated

Can look just like AS

Also can see

Erythemanodusum

Pyodermagangrenosum

  • Follows GU or GI infection

  • The Triad

    • Seronegative arthritis

    • Urethritis

    • Conjunctivitis

  • Males > Females


Erythema nodosum
Erythema in the morning . . .” Nodosum


Pyoderma gangrenosum
Pyoderma in the morning . . .” Gangrenosum


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