2.6.4. Systemic Arthritis Cases

Question 1

How many joints must be involved for a condition to be polyarthritis?

Answer 1

More than 3 joints

Question 2

Generally describe osteoarthritis

Answer 2

a disease in which all structures of the joint have undergone pathologic change

Question 3

What are the clinical features of osteoarthritis?

Answer 3

Pain, Morning stiffness, Pain worse with activity, Stiffness after inactivity (gelling), Joint enlargement/instability, Periarticular muscle atrophy, Crepitus DIPs, PIPs, CMC (squaring), Cervical/lumbar spine, Hips, Knees, 1st MTP Joints that are not involved: wrists, elbows, ankles, MCPs, 2nd-5th MTPs

Question 4

Osteoarthritis is associated with what considering age and gender?

Answer 4

Associated with increased age (women > men)

Question 5

What is the pathology of osteoarthritis?

Answer 5

Early: swelling of articular, loosening of collagen framework, increased water content, increased PG synthesis and degradative enzymes Later: decreased PG content, thinning and softening of cartilage, fissuring and cracking of cartilage, exposure of underlying bone

Question 6

What lab findings do we expect to see with osteoarthritis?

Answer 6

Rheumatoid factor (-), CBC (normal), ANA (-), ESR (Normal)

Question 7

What should we see on radiographs of osteoarthritis?

Answer 7

A- no ankylosis; B- bony subchondral sclerosis and cysts; C- cartilage space narrowing; D- deformities common; E- erosion absent; S- soft tissue swelling

Question 8

What treatments do we have for osteoarthritis?

Answer 8

Medications Acetaminophen, NSAIDS, Opioid analgesics Injections Corticosteroids and Viscosupplementation

Question 9

What is Calcium Pyrophosphate Deposition? (CPPD)

Answer 9

CPPD is a syndrome caused by deposition of calcium pyrophosphate dihydrate in cartilage (called chondrocalcinosis on radiographs and pseudogout when it is present acutely like gout)

Question 10

What are the risk factors for CPPD?

Answer 10

Previous joint surgery, epiphyseal dysplasias, hereditary Disease associated Hyperparathyroidism, Hemochromatosis, Hypophosphatasia, Hypomagnesemia, and Post-meniscectomy

Question 11

What are some risk factors for osteoarthritis?

Answer 11

Risk factors: Age, Mechanical trauma, weight-bearing, occupational use, previous inflammatory arthritis, avascular necrosis, metabolic disorders, genetic predisposition, race/ethnicity

Question 12

CPPD is most commonly associated with what?

Answer 12

Most commonly associated with aging and most patients are asymptomatic

Question 13

What are the clinical features of CPPD?

Answer 13

Clinical features Asymptomatic Lanthanic Acute Pseudogout Subacute or Chronic Pseudo- rheumatoid arthritis Pseudo-osteoarthritis Pseudo-neuropathic Pseudo-spondylitic

Question 14

What joints are involved in CPPD?

Answer 14

Joint Involvement (larger > smaller joints) Knee, wrist, MCPs, Hip, Shoulder, Spine, Elbow Gout involves smaller joints like MTP, metatarsophalangeal, etc.

Question 15

What lab findings shoudl we see in CPPD?

Answer 15

Radiographs demonstrating punctate or linear calcifications Finding rhomboid, square, or rod-like crystals is the only way to make a definitive diagnosis Weakly positively birefringent Synovial fluid is typically inflammatory (2,000-50,000 WBCs)

Question 16

Compare Gout vs. Pseudogout (CPPD)

Answer 16

1. Crystal
   
   1. Gout: Urate
   2. Pseudogout: CPPD
2. Shape
   
   1. Gout: Needle
   2. Pseudogout: Rhomboid/rectangular
3. Birefringence
   
   1. Gout: Negative
   2. Pseudogout: Positive
4. Color of crystals
   
   1. Gout: Yellow
   2. Pseudogout: Blue

Question 17

What should we see on radiographs of CPPD?

Answer 17

A-ankylosis uncommon; B-bone mineralization decreased; C-calcifications; D-deformities common; E-erosions common; S-soft tissue swelling usually present

Question 18

What is the treatment for CPPD?

Answer 18

1. Treatment
   
   1. Joint aspiration
   2. NSAIDs, corticosteroids (oral or injection), ACTH, Colchicine

Question 19

How does arthritis present in time with psoriatic arthritis when compared with the skin symptoms?

Answer 19

Skin precedes joint disease (60-70%), they appear within one year of each other (15-20%)

Question 20

In Psoriatic Arthritis (PA), what joint involvment do we see?

Answer 20

DIP only (15%), Asymmetric oligoarthritis (30%), symmetric polyarthritis (40%), axial involvement (5%), arthritis mutilans (5%)

Nail changes (90%), dactylitis (>30%), enthesitis (increased, underappreciated on examination), conjunctivitis (20%), iritis (7%)

Question 21

Compare Rheumatoid Arthritis (RA) to PA.

Question 22

What lab work should we see with PA?

Answer 22

Rheumatoid factor (-), CBC (normal), Chemistry (uric acid may be elevated), ANA (-), CRP and ESR (may be elevated), synovial fluid (WBC count <1000-2000/mm3)

Question 23

What should we see on radiology of PA?

Answer 23

A-ankylosis may be seen; B-bone mineralization decreased, C-cartilage space narrowing; D-deformities common; E-erosion common; S-soft tissue swelling usually present

Question 24

What is the treatment for PA?

Answer 24

1. Coordinate therapy for skin and joint disease
2. Immunosuppressive agents
   
   1. Methotrexate, Sulfasalazine, Cyclosporine, Antimalarials
3. Anti- TNF alpha therapy
   
   1. Etanercept, Infliximab, Adalimumab

Question 25

What are the six key features to look for of appendicular arthritis?

Answer 25

Articular vs. non-articular Acute (\<6 weeks) vs. chronic (\>6 weeks) Inflammatory vs. non-inflammatory Distribution Pattern Symmetry

Question 26

What do we mean by articular or non-articular with appendicular arthritis?

Answer 26

Articular = painful with limited active/passive ROM Peri- or non-articular = painful w/ active ROM only

Question 27

What can cause non-articular pain?

Answer 27

Non-articular pain can be caused by trauma/fracture, fibromyalgia (nerve system responding to normal stimuli as if it were painful), bursitis, tendinitis, and polymyalgia rheumatica (whole body bursitis)

Question 28

What questions should we ask to characterize a chronic symptom?

Answer 28

Is there prolonged morning stiffness; is there soft tissue swelling; are there systemic symptoms; is the ESR or CRP elevated

Question 29

What are systemic symptoms we look for?

Answer 29

Systemic symptoms = fevers, weight loss, rashes, nodules, mucosal sores, weakness

Question 30

What are some conditions that involve inflammatory connective tissue?

Answer 30

Rheumatoid, psoriatic, and reactive arthritis SLE (picture of girl below), Scleroderma, Polymyositis 

Question 31

What might be some actue conditions?

Answer 31

Septic arthritis, Gout (picture of ear below), Pseudogout, Reactive arthritis, Initial presentation of chronic arthritis 

Question 32

What are some common differences between inflammatory and non-inflammatory complaints?

Answer 32

Inflammatory: stiffness \> 1hr, R/C/D/T, pain at rest, improves with exercise, constitutional complaints Non-inflammatory: stiffness \< 30 min, no signs of inflammation, better with rest, worse with exercise, no constitutional complaints

Question 33

What are the different kinds of distribution we may see?

Answer 33

Monoarthritis (ANA and RF are not helpful) Polyarthritis Oligoarthritis (seen below) 

Question 34

What are the three patterns we may see?

Answer 34

Additive (most common, least specific) Migratory Intermittent

Question 35

What are some examples of additive conditions?

Answer 35

Examples: RA, Connective Tissue disease (SLE, systemic sclerosis, idiopathic inflammatory myopathies), Spondyloarthritis (psoriatic and reactive)

Question 36

What are some examples of migratory conditions?

Answer 36

Gonococcal (neisseria infections), Rheumatic Fever, Lyme, Childhood Leukemia

Question 37

What are some examples of intermittent disorders?

Answer 37

Crystalline Gout and Pseudogout Palindromic rheumatism, periodic fever syndromes Whipple’s disease Systemic inflammatory arthritis early in the course of the disease

Question 38

What does symmetry suggest to us in arthritis cases?

Answer 38

Symmetry suggests RHEUMATOID ARTHRITIS (or other systemic inflammatory connective tissue disease) Especially in the Wrist, MCP, and PIP

Question 39

What kind of demographics help us in arthritis cases, and what do we expect to see in each group?

Answer 39

1. Children 1. JIA, Infection 2. Young adults 1. Septic, Gonococcal, Spondyloarthritis, RA, Internal derangement 3. Older adults 1. Crystal, OA, AVN, Systemic disease, Internal derangement 4. Gender 1. Men 1. Gout, Spondyloarthritis 2. Women 1. RA, SLE 5. Lifestyle 1. Bacteria, Gout (alcohol), Endocarditis (IV drugs), Disseminated gonorrhea, Lyme, Avascular necrosis (alcohol)

Question 40

What do we expect if the first joint involved is: First CMC, or IP joint of hand Wrist First MTP Knee Ankle

Answer 40

1. First CMC 1. OA 2. IP joint of hand 1. OA, PSA, RA 3. Wrist 1. CPPD, Gonococcal, Early RA (both wrists) 4. First MTP 1. Gout, OA 5. Knee 1. Bacteria, JIA, OA, Crystal, Internal derangement 6. Ankle 1. Sarcoid, Reiter’s

Question 41

What is the single most important test in the evaluation of a monoarthritis?

Answer 41

Aspiration of the joint

Question 42

Why do we aspirate the joint?

Answer 42

Rule out infection (gram stain/culture)

Question 43

What kind of cell counts should we see in joint aspirate, and what does each number range mean?

Answer 43

\<200 = normal 200-2,000 = Non-inflammatory 2,000-50,000 = Inflammatory If you look at the test tube, even before you send it to the labs, and can’t see through it then it is probably \>2,000 and you should prepare for lots of additional testing \>80,000 = purulent