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Rheumatology teaching

Rheumatology teaching. Pilot 4 sessions Consultant Rheumatologist/student presentation Based on Phase II objectives Polyarthritis, Monoarthritis, Back pain, Soft-tissue disorders Ward 2 Rheumatology. Approach to Polyarthralgia. Dr Jaya Ravindran Consultant Rheumatologist UHCW.

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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 AGEFEMALEMALE 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. Chronic Tophi Erosions Polyarticular crystal eg gout

  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

  29. 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

  30. What other conditions present with elevated RF?

  31. 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

  32. What are the ANA and ENA?

  33. 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

  34. What is ANCA ?

  35. 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

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

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

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

  39. Radiology - PsA • Erosion • Osteolysis • Bone proliferation • Ankylosis

  40. Thank-you

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