APPROACH TO THE PATİENTS WİTH CHRONIC ARTHRITIS

1. APPROACH TO THE PATİENTS WİTH CHRONIC ARTHRITIS Dr. MÜGE BIÇAKÇIGİL KALAYCI

2. CHRONIC MONOARTHRITIS • ESSENTIAL FEATURES • Chronic inflammatory monoarthritis • infection, crystal-induced arthritis, sarcoidosis, or monoarticular presentation of oligoarthritis or polyarthritis • Chronic noninflammatory monoarthritis • osteoarthritis, mechanical , Chondromalacia patellae, and osteonecrosis. • Arthrocentesis and imaging studies are important dignostic tests

3. CHRONIC MONOARTHRITIS •  INITIAL CLINICAL EVALUATION • Infections, particularly indolent infections, are a concern with inflammatory monoarthritis that lasts from weeks to months. • The particular joint involved influences the differential diagnosis.

4. CHRONIC MONOARTHRITIS • LABORATORY EVALUATION • A critical step is to determine whether the monoarthritis is inflammatory, preferably by analyzing synovial fluid. • Synovial fluid should be sent for culture (bacterial, mycobacterial, and fungal), WBC count, and gram stain and examined for crystals by polarized light microscopy.

5. CHRONIC MONOARTHRITIS • Routine laboratory studies (eg, complate blood cell count, creatinine, and urine analysis) and determination of the ESR or CRP and uric acid level can provide helpful information. • Patients with inflammatory monoarthritis and negative bacterial cultures shoud be tested for reactivity to purified protein derivative (PPD)

6. CHRONIC MONOARTHRITIS • IMAGING STUDIES • Unlike in acute monoarthritis , radiographs can be helpful in evaluating chronic monoarthritis and can point to correct diagnosis in cases of infection, osteoarthritis, and osteonecrosis.

7. Differential diagnosis of chronic inflammatory monoarthritis

8. CHRONIC MONOARTHRITIS • Tuberculous infection of a joint can present after days, weeks or months of symptoms. • Smears for acid fast bacilli are positive only 20% of cases, • Cultures for mycobacteria are positive in 80 %, but test results take weeks. • Synovial biopsy can expedite the diagnosis of tuberculous arthritis , and is also indicated in suspected cases of fungal arthritis.

9. CHRONIC OLIGOARTHRITIS • ESSENTIAL FEATURES • Careful description of arthritis and detection of extraarticular disease facilitate accurate diagnosis. • Radiographs are often of diagnostic value.

10. CHRONIC OLIGOARTHRITIS

11. CHRONIC OLIGOARTHRITIS • Spondyloartropathies are the most common cause of chr. Oligoarthritis • Early onset rheumatoid arthritis must be distinquished. • Osteoarthritis presents as oligoarthritis of the hips or knees

12. CHRONIC OLIGOARTHRITIS • Laboratory evaluation • Synovial fluid analysis- culture- crystals • RF-dd(x) of RA • HLA B 27- limited value

13. CHRONIC OLIGOARTHRITIS • Radiographs and Imaging studies-considerable value • Evidence of sacroitis indicates a spondyloarthropaty and narrow dd(x) • Erosions of RA and Gout

14. CHRONIC OLIGOARTHRITIS • Spondyloartropaties- asymmetric oligoarthritis • RA- symmetric poliarthritis • İn early RA- oligoartitis • Stiffness and pain in low back- Spa • RA- only cervical spine

15. CHRONIC OLIGOARTHRITIS • Dactylitis(sausage digits)- sPA, gout, sarcoidosis • Extraarticular manifestations that point to correct diagnosis • Psoriasis –umblicus, external auditory canal, scalp and anal creft • Diarrea- inflammatory bowel disease. • Anterior uveitis

16. CHRONIC POLYARTHRITIS • ESSENTIAL FEATURES • Rheumatoid arthritis and Osteoarthritis are leading causes. • Careful delineation of the joints involved, particularly in the hands, can help to the correct d(x) • The distinction between inflammatory non inflammatory is critical

17. CHRONIC POLYARTHRITIS

18. CHRONIC POLYARTHRITIS • Laboratory evaluatıon • If arthrosentesis is feasible- joint aspiration- cell count and crystals • CBC • RFT • Urine analysis • ESR_CRP • RF-ANA- hepatitis B and C serology

19. CHRONIC POLYARTHRITIS • Radiographs are indicated in most cases of chronic polyarthritis • Erosion-RA-OA-hemachromatosis-gout- SPA • Non-erosive- SLE-drug induced SLE-chronic hepatitis C.

20. DD(x) of chronic polyarthritis • Osteoarthritis and Rheumatoid arthritis have different patterns of joint involvement in the hand. • OA- involves DIP, PIP and first MCP joints. • RA- PIP- MCP and wrist

21. Osteoarthritis and Rheumatoid arthritis spare certain joints • OA- does not involve MCP, wrist, elbow, ankles • RA- spare DIP, thoracic and lumbosacral spine and sacroiic joints • Psoriatic arthritis- DIP joints

22. ASSOCIATED HISTORY • •Predisposing factors • •Medication • •Bowels • •Urinary • •Rashes • •Eyes • •Raynaud’s • •Sicca • •Family History

24. EXAMINATION •Multi-system •Disability •Range of movement •Signs of inflammation

26. INVESTIGATIONS • •FBE/E/LFT • •ESR/CRP • •Iron studies • •Uric Acid • •Auto antibodies • •HLA-B27 • •Viral serology • •Joint fluid • •Imaging

27. Skin and nail findings and arthritis

28. Skin rashes • Diffuse eruption with fever and systemic findings • Generally viral or due to primary immunological disease • Must be differentiated from bacterial diseases • SLE, DM • Rheumatic fever • Still disease • Kawasaki disease

29. Adult still disease

30. Papulosquamauslesions • Psoriatic arthritis • Reiter Syndrome • SLE

33. SLE

34. Annular lesions • Rheumatic fever • Subcutaneous Lupus

36. Facial lesions • Malar and discoid rash • Lupus pernio: Sarcoidosis • Dermatomyositis-gottron papules-heliotrope rash • Lupus vulgaris: cutanous tuberculosis

41. Nodular lesions • RA, ARA, crystal artropathies • Erythema nodosum: Behçet’s disease,Sarcoidosis, spondyloartropathies, tbc

44. Erysipel like rash (FMF)

45. Acneiform lesions( behçet’s disease)

46. Purpura • purpura:vasculitis

48. Skin thickening • Scleroderma • Eosinophilic fasitis and eosinophilic myalgia syndrome.