Inflammatory arthritis and autoimmunity
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Inflammatory Arthritis and Autoimmunity. Sunil Abraham, MD Ellis Rheumatology Associates. No disclosures. Classification. Case presentations. Case #1. 46 year old white female with 4 month history of progressive fatigue associated with worsening joint pains

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Inflammatory arthritis and autoimmunity

Inflammatory Arthritis and Autoimmunity

Sunil Abraham, MD

Ellis Rheumatology Associates





Case 1
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


Case 2
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


Case 3
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


Case 4
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


Inflammatory arthritis
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


Acute inflammatory arthritis
Acute Inflammatory arthritis

  • Abrupt onset (hours to days)

  • Hot, red, swollen, exquisitely tender joint

  • Constitutional symptoms (fevers, chills, sweats)

  • Mono-, oligo-, poly- articular


Acute inflammatory arthritis1
Acute Inflammatory arthritis

  • Differential

    • Infectious

      • Bacterial, mycobacterial, fungal

      • Opportunistic

      • Lyme (3rd stage)

    • Crystalline

      • Monosodium urate- ‘Gout’

      • Calcium pyrophosphate- ‘Pseudogout‘


Acute inflammatory arthritis2
Acute Inflammatory arthritis

  • Rule out mechanical/traumatic injury

    • Olecranon bursitis, rotator cuff/ achilles tendonitis

    • Fracture


Chronic inflammatory arthritis
Chronic inflammatory arthritis

  • Progressive, insidious (>6 weeks)

  • Morning stiffness > 1 hour

  • Additional signs of inflammation

    • Fatigue, malaise, anhedonia

    • Weight loss, anorexia

    • ‘Flu like’


Chronic inflammatory arthritis1
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


Connective tissue disease
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


Connective tissue disease1
Connective tissue disease

  • Review of systems

    • Signs of inflammation

    • Arthritis

    • Patchy alopecia

    • Oral/nasal ulcerations

    • Raynauds

    • Xerophthalmia/ Xerostomia

    • Rash (distribution, photosensitive)

    • Proximal muscle weakness


Connective tissue diseases
Connective tissue diseases

  • Rheumatoid Arthritis

  • Systemic Lupus Erythematosus

  • Sjogrens Syndrome

  • Systemic Scleroderma

  • Polymyositis/ Dermatomyositis

  • Mixed Connective Tissue Disease



Acr position statement
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


Conditions with positive ana
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


Ana pearls
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


Related autoantibodies
Related Autoantibodies

RA

MCTD

SLE

Sjogrens

PM/DM

Scl

RNP

SSA/B

Jo-1

dsDNA

Smith

Scl-70

Centromere

RF

CCP

“ANA-negative”


Seronegative arthritis
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


Polymyalgia rheumatica
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


Crystalline arthritis
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



Case 11
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


Case 21
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


Case 31
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


Case 41
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


Conclusions
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!


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