An Approach to Arthritis JoAnn Zell Gillis MD Assistant Professor of Medicine National Jewish Medical and Research Center

Agenda • Approach to arthritis – General principles – 4 cases

What is rheumatology? • “Rheum” Rheum means a kind of watery build-up build up • Rheumatoid arthritis was once called rheumatism: thought to be caused by a build up of fluid in the joints or “water on the joints” joints • We treat conditions which involve joints, muscles l and d or soft ft titissue

Case 1 • 25 yo C male with no pmhx presents with a one year hx of insidious low back pain p and buttock pain • His pain is noted mostly in the mornings or g for long gp periods after sitting • Very stiff in the morning but symptoms p with movement or a hot shower improve • May have injured his back at a football game three months ago g g

Case 1 • Exam – Well appearing – Slight g warmth over L second finger g with decreased range of motion – Decreased range of motion of low back

• Labs: – – – –

Anemia of chronic disease ( (normocytic) ti ) ESR 37 CRP elevated

Case 1 • Is this inflammatory or non inflammatory arthritis? Why? • What is the differential diagnosis? • What other tests might you order?

Inflammatory versus noni fl inflammatory di disease Inflammatory Juvenile arthritis Rh Rheumatoid t id A Arthritis th iti Crystal disease (gout or pseudogout) Ankylosing spondylitis Lyme disease

Non inflammatory Non-inflammatory Osteoarthritis T Trauma Hemarthrosis

Inflammatory versus noni fl inflammatory Inflammatory

Non-inflammatory

Temp

Warm

Cool

Color

Erythema

Normal

Morning stiffness

Yes

No

Joint swelling Yes

Sometimes

Activity

Better

Worse

Inflammatory markers

Elevated

Normal

Other ways to tell tell…joint joint aspiration

Fluid Analysis Noninflammatory

Inflammatory

Septic/ Crystal

50,000

Clear

Cloudy

Pus or toothpaste

Viscous

Watery

Watery

Mostly PMNs

Organsims Crystals Mostly PMNs (>95%) Low

Normal glucose

Sometimes low

Inflammatory versus non i fl inflammatory arthritis hii • A first step in looking at a patient with joint complaints. – Helps you start to categorize

• Can help you with diagnosis and treatment • So what is the disease process in case 1? • HLAB27 is positive, does that help you?

Using diagnostic tests: big for rheumatology h l • SNOUT: a sensitive test helps rule out a diagnosis • SPIN: a specific test helps rule in a diagnosis • HLAB27 is neither 100% sensitive or specific so it might not change your pretest probability

Ankylosing spondylitis • A chronic inflammatoryy disease which affects the axial skeleton • 129/100,000 people • Causes enthesopathy: inflammation at the insertion of ligments or tendons into bone – Along the spine – At the SI joints – Heel pain p

• This inflammation eventually causes bony bridging: especially in the spine

Ankylosing spondylitis • Associated with HLAB27 • May be pathogenic • Other Oth ffeatures t iinclude l d chronic h i uveitis, iti sausage digits, aortic root dilatation, and occultlt b bowell iinflammation fl ti

Dactylitis

Enthesopathy

Early disease

Decreased ROM of spine

Progression over time

Hip replacements done in 1973: posture improves

Treating AS • • • •

Difficult to treat NSAIDS M th t Methotrexate t for f peripheral i h l arthritis th iti TNF alpha inhibitors (only drug shown to prevent bony progression)

Case 2 • 30 yo woman comes to you for pain and swelling in her bilateral mcps and pips. • She recently delivered a healthy baby boy • She reports severe morning stiffness l ti 1 lasting 1-2 2h hours • She may have had a rash a few weeks ago

Case 2 • Exam pale young woman • Temp 37.5 • Symmetric S t i synovitis iti off th the wrists i t mcps and pips

Case 2

Case 2 • Labs: normocytic anemia • Sed rate 50, crp elevated • Normal N l renall ffunction, ti UA negative ti

Case 2 • Is this inflammatory or non inflammatory? • Is it symmetric or asymmetric? • Is I it a polyarthritis? l th iti ? M Monoarthritis? th iti ? Oligoarthritis? • What is the differential diagnosis? • What labs/studies would y you send? • How does her pregnancy play a role?

Polyarthritis versus mono/oligoarthritis / li hii Polyarthritis >3 joints Rh Rheumatoid t id A Arthritis th iti Lupus Parvovirus (viral) Osteoarthritis vasculitis

Mono/oligoarthritis men HLA-DR4 Onset variable

RA by American College of Rheumatology Criteria

Arnett, FC et.al. The American Rheumatism 1987 Revised Criteria for Classification of Rheumatoid Arthritis. Arthritis & Rheumatism 1988; 31:315-324

Wide clinical spectrum of RA

Wide clinical spectrum of RA

Ulnar deviation

Erosions of RA

Rheumatoid Arthritis

Treating RA • Depends on the activity • Be aggressive to preserve joints: especially in erosive disease • Steroids • Methotrexate • TNF inhibitors • Rituximab (anti-CD 20)

Biologic agents for the treatment of RA

Case 3 • 55 yo male with a pmhx of htn htn, obesity obesity, and prostate cancer presents with a painful L knee • Sudden onset, unable to move well, swollen and red • No hx of arthritis • No other joints bothersome

Case 3 • Meds: hctz hctz, atenolol • • • •

Temp 101 T L knee very swollen red and tender Unable to fully extend or flex The remainder of joints normal appearing

Case 3 • What kind of arthritis is this? – How would you characterize it

• What is in the differential? • What should you do next? – Labs? – Films? – Other tests?

Case 3 • • • • •

Wbc 15 Hct 41 platelets 500 ESR 100 Creatinine normal Uric acid 9.0

Case 3 • Knee aspriation: 20 cc of cloudy fluid (thick) • Wbc 90 90,000 000 90% pmns • Gram stain negative • Polarized light exam: negatively birefringent crystals seen

Crystals under the slide Regular light

Polarized light

Gout • • • • • • •

Abrupt onset of severe joint inflammation 75% in first MTP Usually monoarticular can be polyarticular Attack usually lasts 3-10 days U t crystals Urate t l are seen in i synovial i l flfluid id Hyperuricemia not always present Can be very inflammatory on tap – >100K wbc and >95% neutrophils

Gout pearls • Crystals on tap does not rule out infection • Think gout in a filipino male • Usually U ll men>women b butt postt menopause can be both • Diuretics, especially hctz can precipitate gout

Gout of hands: can mimic RA

Tophi

Tophus of finger

Using polarized light • Crystals all long and skinny • Think Parallel (yellow) • Crystals will turn yellow when parallel to compensator • Crystals will turn blue when perpendicular to compensator • Opposite is seen with pseudo gout • Pseudo gout crystals are rhomboid shaped

Pseudogout

Crystals are blue when parallel to compensator and yellow when parallel

Gout of first MTP

Gout of the hand

Chondrocalcinosis on knee films

Treatment of gout • Chronic: suppress uric acid – Allopurinol inhbits xanthine oxidase

• Acute: – never stop allopurinol – Nsaids – Steroids orally or IV – Inject with steroids – Never use colchicine for acute gout!

Case 4 • 23 yo Asian female with no pmhx presents with chest pain for the last few days: y g down worse lying • Also notes a fever of 101 and symmetric pain in mcps p p p pips p and knees • She does report stiffness in the morning g and severe fatigue • +weight loss of 10 pounds over the last few months

Case 4 • Familyy hx of rheumatoid arthritis and hashimotos thyroiditis • No medications • • • • • • •

Labs: Wbc 2.9 hct 32 plts 140K Exam: Ill appearing temp 100 hr 110 bp 120/80 Knees slightly warm bilaterally g swelling g noted of bilateral wrists and mcps p Slight

Case 4

Case 4 • How would you define this arthritis? • What labs might you send? • What Wh t iis your diff differential? ti l?

Case 4: more information • • • • •

ANA 1:1280 speckled +smith +DSDNA C3 10 (l (low)) UA 2+ protein Echocardiogram/ekg: cw pericarditis

Systemic lupus erythematosus • Lupus is the prototype of autoimmune disease. • Characterized by the production of autoantibodies, consumption of complement and systemic inflammation inflammation. • Lupus affects nearly every organ system.

Every case of lupus is different • Some have skin and joint • Some with kidney involvement • Some S with ith CNS: CNS seizures, i strokes t k and d psychosis • It usually follows a similar pattern in individual patients.

Who gets SLE In the US?

ACR criteria for lupus • • • • • • • •

Rash: discoid/ulcers/malar/photosensitivity p y Renal:glomerulonephritis Arthritis: usually inflammatory and symmetric S Serositis: iti h heart/lungs/abdomen t/l / bd Hematologic: cytopenias, hemolytic anemia Neurologic: seizures, strokes, psychosis Immunologic: smith, RNP, DSDNA, APLA, SSA or SSB ANA (seen in nearly 100%)

• 4 out 11 criteria

Discoid lupus

Photosensitivity

Butterfly rash

Lupus skin biopsy

Normal skin to the left. Lymphoid proliferation with germinal centers present

SLE arthritis (non deforming)

Renal involvement

IgG deposition in the kidney

Treatment of lupus • Only a few FDA approved drugs for SLE • Steroids • Chemotherapy: Ch th MTX MTX, iimuran, cellcept, ll t cytoxan • Biologics: rituximab, anti-blyss, taci-ig • Anti-antibody: y IVIG,, plasmaphoresis p p

Summary • • • • •

Is it inflammatory Symmetric or asymmetric? P l ti l versus mono versus oligo Polyarticular li Other features of the presentation Consider aspiration if a new arthritis

Questions?