CME INDIA Presentation by Dr. Mahadev Desai, Sr. Consultant Physician K. D. City Centre, Ahmedabad.
A patient having pain around joint may consult
- Family Physician
- Consultant Physician
- Orthopedic Surgeon
- Rheumatologist
Goal
- Accurate Diagnosis
- Symptomatic Rx
- Minimum Investigations
- Early initiation of Specific Rx based on diagnosis
Important causes of pain around a Joint
| Viral lnfection Osteoarthritis Rheumatoid Arthritis Reactive Arthritis Septic Arthritis Gout Rheumatic fever | Psoriatic Arthritis SLE Ankylosing Spondylitis Scleroderma Polymyositis / DM Sjogren’s syndrome MCTD | Trauma Fibromyalgia Hemolytic dis. Drug-induced Metabolic Bone Disease |
Pattern Recognition
First ask 5 Questions
| Is it Articular or Non-articular Pain? |
| Is it Acute or Chronic (>6 weeks) |
| Is it Inflammatory or Non-inflammatory? |
| How many Joints are involved and what is the distribution of Joints involved? |
| Which Joints are involved? |
2) Is it Acute or Chronic?
Acute
- Infection
- Gout, Pseudo gout
- Reactive Arthritis (RA)
- Initial presentation of
- Chronic arthritis
Chronic (>6 weeks)
- RA, SLE
- Psoriatic arthritis
- Reactive Arthritis (RA)
- Scleroderma
- Polymyositis
4) How many joints are involved?
| 1 joint | Gout, Septic arthritis, RA, Trauma |
| > 1-3 joints | Gout, Psoriatic, RA, Pauci articular RA |
| ≥ 4 joints | RA, SLE, Scleroderma, Polymyositis, Psoriatic |
5) What is the distribution of joints involved?
Joint involvement
Symmetric -RA/ SLE
Asymmetric – Psoriatic, RA, SpA
Peripheral and / or Axial?
6) Which Joints are involved?
Additional Points
7) Age
Young → RA, SLE, RA
Middle-aged → Fibromyalgia
Elderly → OA, PMR, Osteoporosis
8) Gender
Female → RA, SLE, Fibromyalgia, Osteoporosis
Male → Gout, Spondyloarthropathy
9) Important points in history & examination
- Fever, Weight Loss
- Myalgia
- Skin Rash
- Tightness of Skin
- Oral Ulcers
- Dryness of Mouth, Dry Eye
- Nail Changes
- Raynaud’s Phenomenon
- Hair Loss
- Dysuria
- Tendon Involvement
- Backache
10) Additional points in examination
- Anemia
- Hind-Bound Skin
- TOPHI
- Chest Expansion
- Muscle Tenderness, Tender Points
11) Examination of Joint (s)
- S/O inflammation
- ROM
- Deformity
- Muscle Wasting
12) Investigations
- CBC, ESR, CRP, Urine analysis
- Rheumatoid factor, anti-CCP antibody, ANA, dsDNA, ANA profile…
- X-ray of joint(s)
- S. Uric acid
- Synovial fluid aspiration
- S. CPK, ANCA, S. Complement levels, HbsAg, HCV & HIV antibodies
- Biopsy – muscle, temporal artery, liver, renal
Rheumatoid Factor (RF)
- Also used to be called Rose-Waller test
- Autoantibody, against Fc fragment of IgG
- Insist to get test (with titer) by IF, Nephelometry or ELISA
- Two types: IgM (monoclonal), IgG (polyclonal)
- Titer of >1:40 IgM is diagnostic for RA (sensitivity:28%; specificity 87%, if >1:640 specificity 99%) Higher the titre more destructive the joint damage
- No need for repeated testing unless initial results
- Inconclusive in strongly suspected case
- False positive RF in Malaria, Viral infections, Hepatitis, SLE, Sjogren syndrome, Scleroderma, MCTD, Leukemia
- Keep in mind: RA can be Seronegative
Anti-Cyclic Citrullinated Peptide (anti CCP) antibodies
(Conversion of amino acid arginine in a protein into amino acid citrulline)
- Citrullination* of local synovial proteins like fibrin in a joint → CCP
- Anti-CCP antibodies are potentially important surrogate
- Markers for diagnosis and prognosis in RA
- As sensitive as, & more specific than, RF in early & established RA
- A marker of erosive disease in RA (especially titer>100 U/mL)
- May be detected in healthy individuals, years before onset of clinical RA
- Second-generation anti-CCP antibody assays (anti-CCP2), have improved sensitivity and specificity compared with the original anti-CCP1 assays
Anti-Neutrophil Cytoplasmic Antibodies (ANCA)
- IgG antibodies against antigens in the cytoplasm of neutrophil granulocytes and monocytes → marker of Vasculitis
- Two types → pANCA & cANCA based on the pattern of staining: p for perinuclear & c for cytoplasmic
| Characteristic | pANCA | cANC A |
| Staining pattern | Perinuclear | Cytoplasmic Diffusely granular |
| Antigen target | Myeloperoxidase proteinase-3 (MPO) | Perinuclear (PR3) |
| Commonly Present | Microscopic polyangiitis glomerulonephritis | Wagner’s granulomatosis |
Last Stroke: always remember deceptive conditions
“Great masquerades’ past
- Syphilis
- Tuberculosis
“Great masquerades” in modern times
- Fibromyalgia
- Lupus
- Tuberculosis
- HIV
- Vasculitis
- Sarcoidosis
- Lymphoma
Quick Take-Aways
- Detailed h/o joint pain, onset & evolution of illness & illness & another s/s.
- Systematic examination and Pattern recognition.
- Involved joints are smaller or bigger, Peripheral or Axial etc.
- Specific investigations (at times by specific methods).
- Frequent follow up in undiagnosed cases, as many times.
- s/s of typical disease appear late in the course of the illness.
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