Download Approach to Polyarthralgia

Polyarthralgia
Tanya Potter
Consultant Rheumatologist
UHCW
Aims
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Differential diagnosis of
polyarthralgia/polyarthritis
Investigation of joint pains
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What is polyarthralgia?
What conditions present with
polyarthralgia?
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Inflammatory
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Mechanical
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Pain syndromes
How do you differentiate
between mechanical and
inflammatory symptoms?
Mechanical vs Inflammatory
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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
Age and sex Incidence
AGE
Young adults
Middle age
Old age
FEMALE
MALE
Age and sex Incidence
AGE
FEMALE
Young adults
RA
SLE
Middle age
Old age
MALE
Reactive arthritis
(Sero-ve)
Age and sex Incidence
AGE
FEMALE
Young adults
RA
SLE
Middle age
Old age
MALE
Reactive arthritis
(Sero-ve)
Psoriatic arthritis
(Sero-ve)
RA
Age and sex Incidence
AGE
FEMALE
Young adults
RA
SLE
Middle age
Old age
MALE
Reactive arthritis
(Sero-ve)
Psoriatic arthritis
(Sero-ve)
RA
OA
Crystal arthritis
OA
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Clinical features
Osteoarthritis
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Mechanical symptoms
Bony swelling,
crepitus
DIP (Heberden), PIP
(Bouchard), 1st CMCJ,
neck, lower back,
hips, knees, 1st MTP
Pathophysiology?
Pathophysiology
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Imbalance between degradative and
reparative connective tissue processes
within joint leading to failure of joint
Occasional genetic association
Pathological stresses may lead to micro
trauma and inflammatory change
Radiology - OA
Radiology - OA
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Four cardinal
features:
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Joint space narrowing
Sclerosis
Subchondral cysts
Osteophytes
Other features associated with
athralgia
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Prodromal events
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Associated conditions
CLUES
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Prodromal event eg GI/GU infection –
reactive arthritis
Associated conditions eg psoriasis, colitis,
iritis
 Pattern
and Symmetry?
CLUES
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Multi-organ disease
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Fibromyalgia symptoms
Rheumatoid
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Female ~ 1 in 100
symmetrical polyarthritis, targeting small joint
and large
DIP sparing
Pathophysiology
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Inflammatory condition
Strong genetic component- HLA DR4
Environmental effects
Inflammation of synovium with high levels
of chemokines and cytokines and resultant
tissue damage
o
Systemic features?
Psoriatic arthritis
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Psoriasis 2-3% population
5-10% of these will develop Ps arthritis
Family history 55X more likely (40%)
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Pathophysiology?
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HLA B27 related arthritis
Arthritis and enthesitis possibly T cell
driven, with tissue damage
Sero-ve Spondyloarthritis –
psoriatic arthritis
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DIP, poly, dactylitis,
enthesitis, spinal
Younger age
•
•
•
•
•
Soft tissue swelling
Joint space narrowing
Mouse ear erosions
Periostitis with new bone
formation
DIP joint involvement
Polyarticular crystal arthropathy eg gout
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Chronic
Tophi
Erosions
Older age
Nb pseudogout
polyarthalgia/polyarthritis
o
o
o
Multi-organ disease – CTD and vasculitis
Viral arthritis (eg parvovirus, rubella,
hepatitis)
Medical conditions eg
o
o
diabetic cheiroarthropathy
Sarcoidosis-
Sarcoid
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Acute or chronic
Multisystem disorder, non caseating
granulomas
Acute: spring time (?viral) young adults
sudden onset of lower limb arthritis and
erythema nodosum & red eyes
Fever and cough
Ix
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Raised serum ACE
Raised Ca
ESR, CRP
Chest xray
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Outcome of acute:
good, NSAIDs, oral
prednisolone
Chronic: afrocarribean
Grumbling lung
disease, jt, muscle,
liver disease
Treatment unclearprednisolone,
methotrexate
What are CTD?
Symptoms and signs?
Connective tissue disease
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Eg SLE, scleroderma, polymyositis,
Sjogren’s
Auto-immune
Multi-organ
Anti-nuclear antibodies
SLE
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Raynauds
Rashes
Arthralgia
Haem
CNS
Renal
Serositis
thrombosis
Sle- skin
o
o
Photosensitive rashes
eg SLE
Discoid lupus
Sle- renal
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Significant cause of
morbidity and mortalitycondition and treatment
Sjogrens syndrome
o
o
o
o
Destruction of exocrine glands
Dry eyes and mouth- caries
Liver, lungs, gut, arthralgia, MNM
Increased B cell lymphoma risk
Scleroderma
o
o
o
o
o
Localised (CREST)
Diffuse
Raynauds, finger
ulcers
Sclerosis of most
organs
GI, skin, ILD, renal
crisis
Myositis
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Inflammatory muscle
condition
Demato or
polymyosits
Proximal painless
weakness
What are the vasculitides and
what type of symptoms and
signs?
Vasculitis
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Small, medium, large
vessel
Eg MPA, Churg
Strauss, PAN,
Wegeners, GCA
ANCA
Vasculitis- skin
o
Vasculitis – petechial,
purpura, ulcer
Vasculitis
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Systemic, vasculitic ulcers/rashes,
arthralgias/arthritis – non deforming
Pulmonary – haemoptysis
Vasculitis
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RENAL – URINE DIP
+ BP
ENT –eg Wegener’s
Neuropathy eg
footdrop
PMR and GCA features?
Polymyalgia rheumatica and GCA
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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
Fibromyalgia
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“All over pain”
Fatigue
Sleep disturbance
Depression
Anxiety
Irritable bowel
Tender spots
Diagnosis of exclusion
Investigations
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Inflammatory arthritis –
Investigations
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Inflammatory arthritis – RA
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FBC, ESR, CRP, U+E, LFT, RF, anti-CCP,
ANA,
XR Hands and feet and chest
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Viral – Parvovirus
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Investigations
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? CTD/vasculitis -
Investigations
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? CTD/vasculitis - ANA, ANCA,
complement
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Urine dip and BP
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Organ based investigations
Investigations
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Diffuse symptoms – CK, Ca, ALP, TFT
Crystal – joint aspirate, radiology, urate,
U+E
What is RF and what other
conditions present with elevated
RF?
Rheumatoid factor
Autoantibody vs Fc portion of IgG – any isotype but
typically IgM RF
Acute infection eg infectious mononucleosis
Chronic infection eg SBE, TB
Inflammatory disease: CTD, Fibrosing alveolitis,
Malignancy: Lymphoma, leukaemia
5% healthy population
Anti-CCP
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Anti-cyclic citrullinated peptide
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More specific for RA than RF
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May predict erosive damage
What are the ANA and ENA?
ANA and ENA
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ANA 1/40 not significant unless associated
with appropriate clinical scenario
Also in RA, auto immune liver disease,
neoplasia, healthy population…
ANA and ENA
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ENA – extractable nuclear antigens (ANA
subtypes)
Anti-DNA - SLE
Anti-Ro and anti-La - Sjogrens
Scl 70 and anti-centromere – Scleroderma
Anti-RNP – mixed CTD
Anti-Jo1 - myositis
What is ANCA ?
ANCA
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Antibodies vs specific antigens in
cytoplasm of neutrophils
ANCA reactive to myeloperoxidase (MPO)
– perinuclear pattern of staining P-ANCA
eg microscopic polyarteritis
ANCA
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ANCA reactive to proteinase 3 (PR3) –
cytoplasmic pattern of staining C-ANCA eg
Wegener’s granulomatosis
Thank-you