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Rheumatology teaching

Approach to Polyarthralgia . Dr Jaya RavindranConsultant RheumatologistUHCW. . Approach to Polyarthralgia. AimsDifferential diagnosis of polyarthralgia/polyarthritisInvestigations. . What conditions present withpolyarthalgia?. Differential diagnosis of polyarthalgia/polyarthritis .

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Rheumatology teaching

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    1. Rheumatology teaching Pilot 4 sessions Consultant Rheumatologist/student presentation Based on Phase II objectives Polyarthritis, Monoarthritis, Back pain, Soft-tissue disorders Ward 2 Rheumatology

    2. Approach to Polyarthralgia Dr Jaya Ravindran Consultant Rheumatologist UHCW

    3. Approach to Polyarthralgia Aims Differential diagnosis of polyarthralgia/polyarthritis Investigations

    4. What conditions present with polyarthalgia?

    5. Differential diagnosis of polyarthalgia/polyarthritis ‘Poly` > 4 joint Rheumatoid arthritis Polyarticular OA Sero-ve Spondyloarthropathy (eg psoriatic, reactive) Polyarticular crystal arthropathy Multi-organ disease – CTD and vasculitis Viral arthritis (eg parvovirus, rubella, hepatitis) (Polymyalgia rheumatica/GCA)

    6. Differential diagnosis of polyarthalgia/polyarthritis ‘Poly` > 4 joints Medical conditions thyroid disease / hyperparathyroidism / osteomalacia diabetic cheiroarthropathy paraneoplastic syndromes, multiple myeloma infective endocarditis sarcoidosis Fibromyalgia

    7. Age and sex Incidence AGE FEMALE MALE Young adults RA Reactive arthritis SLE (Sero-ve) Psoriatic arthritis (Sero-ve) Middle age RA RA OA Gout Old age OA PMR Crystal arthritis

    8. What clues are there to diagnosis?

    9. CLUES Prodromal event eg GI/GU infection Associated conditions eg psoriasis, colitis, iritis Inflammatory or mechanical* Pattern of joint and symmetry eg RA vs PsA vs OA* Multi-organ disease* Fibromyalgia symptoms*

    10. How do you differentiate between mechanical and inflammatory symptoms?

    11. Mechanical vs Inflammatory Inflammatory Mechanical Immobility stiffness latter day EMS>30-60 mins EMS<30-60 mins Better with activity and NSAIDs worse with activity Joint swelling,erythema,heat instability Systemic symptoms locking Multi-organ involvement trauma, strain overusage

    12. Pattern and Symmetry?

    13. Pattern and symmetry RA - PIP, MCP, wrists, elbows, shoulders, neck, knee, ankle, MTP, symmetrical Sero-ve – DIP, asymmetrical, dactylitis, enthesitis, spinal OA – DIP, PIP, CMC, ACJ Weight bearing joints

    14. Sero-ve Spondyloarthritis – psoriatic arthritis DIP, poly, dactylitis, enthesitis, spinal

    15. Osteoarthritis Mechanical symptoms Bony swelling, crepitus DIP (Heberden), PIP (Bouchard), 1st CMCJ, neck, lower back, hips, knees, 1st MTP

    16. Polyarticular crystal eg gout Chronic Tophi Erosions

    17. Fibromyalgia “All over pain” Fatigue Sleep disturbance Depression Anxiety Irritable bowel Tender spots Diagnosis of exclusion

    18. What are CTD and what symptoms and signs are seen?

    19. Connective tissue disease Eg SLE, scleroderma, polymyositis, Sjogren’s Auto-immune Multi-organ Anti-nuclear antibodies

    20. Connective tissue disease symptoms Photosensitive rashes Skin tightness Raynauds – late onset, trophic changes Mouth ulcers

    21. Connective tissue disease symptoms Dry eyes and mouth Arthralgias, arthritis – non deforming Proximal myopathy – pain and weakness (PMR pain and stiffness – think also GCA)

    22. Connective tissue disease symptoms Swallowing Serositis/ILD – pleurisy, dyspnoea, cough RENAL DISEASE – silent, URINE DIP + BP Systemic - fatigue, fever, weight loss

    23. Connective tissue disease symptoms Vasculitis – petechial, purpura, ulcer

    24. What are the vasculitides and what type of symptoms and signs?

    25. Vasculitis Small, medium, large vessel Eg MPA, Churg Strauss, PAN, Wegeners, GCA ANCA

    26. Vasculitis Systemic, vasculitic ulcers/rashes, arthralgias/arthritis – non deforming ENT - sinusitis Pulmonary – haemoptysis, late onset asthma Cardiac failure RENAL – URINE DIP + BP Neuropathy eg footdrop

    27. PMR and GCA features?

    28. Polymyalgia rheumatica and GCA Over 50’s Proximal inflammatory pain and stiffness GCA – large vessel arteritis Temporal headache, jaw claudication visual disturbance, systemic upset Raised ESR and CRP – urgent steroids TA biopsy

    30. Investigations Inflammatory arthritis – RA FBC, ESR, CRP, U+E, LFT, RF, XR Hands and feet ? CTD/vasculitis - ANA, ENA, RF, DNA binding, ANCA, complement Urine dip and BP Organ based investigations Diffuse symptoms – CK, Ca, ALP, TFT Viral – Parvovirus, LFT+Hepatitis

    31. What other conditions present with elevated RF?

    32. Rheumatoid factor Infection: Acute infection eg infectious mononucleosis; Chronic infection eg SBE, TB; Parasitic eg malaria; vaccination Inflammatory disease: RA, CTD, Fibrosing alveolitis, Chronic active hepatitis, cryoglobulinaemia Malignancy: Lymphoma, leukaemia, myeloma, solid tumours 5% healthy population RF <15 not significant unless associated with appropriate clinical scenario

    33. What are the ANA and ENA?

    34. ANA and ENA ANA 1/40 not significant unless associated with appropriate clinical scenario Also in RA, cirrhosis, ai liver disease, neoplasia, healthy population ENA – extractable nuclear antigens Anti-Ro and anti-La - Sjogrens Scl 70 and anti-centromere – Scleroderma Anti-RNP – mixed CTD Anti-Jo1 - myositis

    35. What is ANCA ?

    36. ANCA Antibodies vs specific antigens in cytoplasm of neutrophils ANCA reactive to myeloperoxidase (MPO) – perinuclear pattern of staining P-ANCA eg microscopic polyarteritis ANCA reactive to proteinase 3 (PR3) – cytoplasmic pattern of staining C-ANCA eg Wegener’s granulomatosis

    37. What are the radiological feature of OA, RA (and PsA) ?

    38. Radiology - OA Four cardinal features: Joint space narrowing Sclerosis Subchondral cysts Osteophytes

    39. Radiology - RA soft tissue swelling juxta-articular osteoporosis juxta-articular and subchondral erosions joint space narrowing & subluxation secondary OA & bony ankylosis

    40. Radiology - PsA Erosion Osteolysis Bone proliferation Ankylosis

    41. Thank-you

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