Hossein Soleymani , MD Assistant Professor of Rheumatology

2. Diagnosis of Rheumatoid Arthritis January 2015 HosseinSoleymani, MD Assistant Professor of Rheumatology ShahidSadughi Medical University, ShahidSadughi Hospital

3. IN THIS LECTURE Differential diagnosis Diagnostic tests Classification criteria Unusual presentations of RA

4. RHEUMATOID ARTHRITIS AS MANY DOCTORS KNOW IT

5. AN AUTOIMMUNE DISEASE THAT IS CHARACTERIZED BY: CLINICALLY: SYMMETRICAL POLYARTHRITIS MAINLY HANDS AND FEET JOINTS IN TIME, CRIPPLING JOINT DEFORMITIES LABORATORY: POSITIVE RF, Anti CCP, HIGH ESR, CRP PLAIN RADIOLOGY: ARTICULAR EROSIONS MANAGEMENT: Need treat to target: Remission or Low disease activity

6. Cartilage destruction and bone erosion are common Uncontrolled synovitis lead to sever deformity Loss of function Increased mortality due to accelerated atherosclerosis

7. RHEUMATOID ARTHRITIS AS MANY DOCTORS MIGHT NOT KNOW IT RA may present as unusual pictures

8. ABOUT THE PRESENTATION OF RHEUMATOID ARTHRITIS TRUE: THE MOST COMMON PRESENTATION IS A SYMMETRICAL POLYARTHRITIS IN ADDITION TO A SYMMETRICAL POLYARTHRITIS WHICH IS SOMETIMES RATHER SUBTLE, WE HAVE OTHER PRESENTATIONS TOO;

9. WE HAVE THE RELUCTANT RA THE STUTTERING RA THE ACHES ALL OVER RA THE DISGUISED RA THE PUFFY RA

10. PRESENTATION 1 OF 5 A 42-YEAR OLD MALE WITH RECCURRENT ATTACKS OF PAIN AND SWELLING OF A WRIST OR A SHOULDER OR AN ANKLE FOR 2 YEARS. DURATION OF EACH ATTACK:3-7 DAYS ATTACK FREE PERIOD:2-3 MONHTS THE RELUCTANT RA OR PALINDROMIC RHEUMATISM

11. PRESENTATION 2 OF 5 2012: A 33-YEAR OLD FEMALE PRESENTED WITH INFLAMMATORY MONOARTHRITIS OF THE RIGHT WRIST PLAIN FILM OF HER HANDS: NORMAL MRI: EFFUSION, SYNOVIAL THICKENING, BONE MARROW EDEMA EARLY 2012: SHE STARTED TO COMPLAIN OF PAIN AND MS OF HER RIGHT WRIST LATE 2012: PAIN AND SWELLING OF THE ELBOWS, KNEES, ANKLES S T U T T E R I N G RA ANY POLYARTHRITIS CAN INITIALLY START AS A MONOARTHRITIS

12. RA RA RA ON TOP OF OA OR DISGUISED RA FEMALE; 48Y-OLD OA KNEES / HANDS LATELY PAIN NOCTURNAL PAINS REC EFFUSIONS PLAINS: OA ESR 50 RF +VE SYNOVIONALYSIS: INFLAMMATORY SF PRESENTATION 3 OF 5

13. PRESENTATION 4 OF 5 Sara, a 32-year old female, presented with diffuse aches all over of 3 months’ duration. She had a MS of 10-60 minutes and nocturnal pain sometimes. She was afraid she might have cancer or rheumatoid arthritis but had been reassured by her family doctor that she didn’t have cancer and that her RF test was negative.

14. Examination revealed a very anxious patient with inconsistent tenderness over several small joints of the hands but also over the trunk as well as the flesh of the forearms and legs. Investigations: ESR 21 CBC, liver, kidney, electrolytes: normal RF; ANA: negative Hepatitis serology: negative A plain film of the hands and feet were normal

15. A Tc99 bone scan was done DIFFUSE ACHES ALL OVER RA OR FIBROMYALGIC RA

16. Early rheumatoid arthritis can sometimes be a vague diagnosis Bone scan helps to settle the diagnosis in such situations

17. PRESENTATION 5 OF 5 Mr Ali, a 59-year old male, presented with gradual onset of pain and swelling of his hands with NP and MS of 4 hours Examination: diffuse swelling (puffinness) of the dorsum of both hands; tenderness of the MCPs, and wrists LABS: ESR 70; Hb 11gm%; RF: Negative RS3PE REMITTING SYMMETRICAL SERONEGATIVE SYNOVITIS WITH PITTING EDEMA OR PUFFY RA

18. THE RELUCTANT RA THE STUTTERING RA THE ACHES ALL OVER RA THE DISGUISED RA THE PUFFY RA

19. Diagnosis of RA • Early recognition and treatment with disease-modifying antirheumatic drugs (DMARDs) is important in achieving control and preventing joint destruction • In suspected patients take careful Hx and PE • Selected laboratory tests

20. Diagnosis of RA • In very early arthritis: close observation, repeated follow up, serologic test • PE to R/O psoriasis, IBD, SLE and other D&D

21. Diagnostic tests: • Test support diagnosis: RF, Anti CCP • Both tests are informative, positive result for either test increases overall diagnostic sensitivity • While the specificity is increased when both tests are positive • 70% to 80% RF + • Anti CCP 80%-90% • Negative on presentation in 50%, 20% long follow up • ESR, CRP : Typically elevated in RA

22. Diagnostic tests: • ANA: A negative ANA helps exclude SLE • Positive in up to one-third of patients with RA • IN +ANA: anti dsDNA, anti SM help Dx of SLE • CBC: Anemia of CD, Thrombocytosis • Liver and kidney function tests: Dx comorbid Dis, select drugs • Check uric acid and arthrocentesis and crystal search, to exclude gout

23. Diagnostic tests in RA: • We perform the following studies in selected patients: • 1- Serologic studies for infection: HBS, HCV, P B19, Borrelia • 2- Synovial fluid analysis: R/O Crystal, infection • 3- MRI and US

24. Differential Diagnosis • Temperature>40c: 1- Still’s disease 2- Bacterial arthritis 3- SLE

25. Differential Diagnosis • Fever preceding arthritis: 1- Viral arthritis 2- Lyme disease 3- Reactive arthritis 4- Still’s disease 5- Bacterial endocarditis

26. Differential Diagnosis • Migratory arthritis: 1- Rheumatic fever 2- Gonococcemia 3- meningococcemia 4- Viral arthritis 5- SLE 6- Acute leukemia 7- Whipple’s disease

27. Differential Diagnosis • Effusion disproportionately grater than pain: 1- Tuberculous arthritis 2- Bacterial endocarditis 3- Inflammatory bowel disease 4- Giant cell arthritis 5- Lyme disease

28. Differential Diagnosis • Pain disproportionately greater than effusion: 1- Rheumatic Fever 2- Familial Mediterranean fever 3- Acute leukemia 4- Acquired immunodeficiency syndrome

29. Differential Diagnosis • Positive test for rheumatoid factors: 1- Rheumatoid arthritis 2- Viral arthritis 3- Tuberculous arthritis 4- Bacterial endocarditis 5- SLE 6- Sarcoidosis 7- Systemic vasculitis

30. Differential Diagnosis • Morning Stiffness: 1- Rheumatoid arthritis 2- Polymyalgia rheumatic 3- Still’s disease 4- Some viral and reactive arhritis

31. Differential Diagnosis • Symmetric small joint synovitis: 1- Rheumatoid arthritis 2- SLE 3- Viral arthritis

32. Differential Diagnosis • Leukocytosis(>15000/mm): 1- Bacterial arthritis 2- Bacterial endocarditis 3- Still’s disease 4- Systemic vasculitis 5- Acute leukemia

33. Differential Diagnosis • Leukopenia: 1- SLE 2- Viral arthritis

34. Differential Diagnosis • Episodic recurrences: 1- Lyme disease 2- Crystal induced arthritis 3- Inflammatory bowel disease 4- Whipple’s disease 5- Mediterranean fever 6- Still’s disease 7- SLE

35. Criteria RA Diagnosis: • Effective clinical history • Physical examination • Laboratory tests • Exclude differential diagnosis

36. Classification Criteria • 1980 ACR • 2010 ACR/ EULAR

37. Classification criteria: • These criteria were developed for the classification of patients with RA for the purpose of epidemiologic studies and clinical trials, not primarily for clinical diagnosis

38. Classification Criteria • 2010 ACR/EULAR advantage: 1- Grater emphasis in serology 2- Early diagnosis in few joint involvement 3- No need to symmetric synovitis 4- Can use joint MRI or Ultrasound

41. The diagnosis of RA may also be made in some patients who do not meet all of new criteria • The new ACR/EULAR classification criteria seems valid independent of goldstandard and cohort used. Compared to the 1987 criteria they show higher sensitivity and almost equal specificity

42. Seronegative Rheumatoid arthritis: • Lack both RF and anti-CCP antibodies • Appropriate other finding • Differ from CCP+ patients genetically • Differ environmental risks • Differ severity, response to some treatments

43. Recent Onset Rheumatoid arthritis: • Disease for less than six weeks • Appropriate exclusions have been met • Positive Anti CCP

44. Cunclusions: • 1- RA should be suspected in the adult patient who presents with inflammatory polyarthritis • Careful HX and PE • ESR, CRP, RF, Anti CCP, ANA • Imaging, Arthrocentesis • You may visit Pt with classic or without classic findings

45. Thank you