“painful joints” how is a diagnosis reached?library.nhsggc.org.uk/mediaassets/chp...
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“Painful joints”How is a diagnosis reached?
Classification of rheumatic disease
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Terminology – just to be clear!?• -opathy diseased• -itis inflammation• -algia pain
• Arthr- relating to joints• Spondyl- relating to axial joints (ie spine)• Myo- relating to muscles• Dactyl- relating to digits (ie fingers or toes)
• Mono- single• Oligo- several (<5)• Poly- multiple
• And when we are not using classical languages we name them afterhistorical physicians!
– Wegener’s, Heberden’s, Sjogren’s
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Joint pain
• The medical term is “arthralgia”• Up to 25% of all GP visits are due to
musculoskeletal pain• Mostly this is due to “soft tissue
rheumatism”• Many have osteoarthritis• A minority of patients have inflammatory
arthritis
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• Autoimmune Inflammatory Arthritis
• Rheumatoid arthritis– Seropositive, Seronegative, Anti-
CCP positive, “Nodular”, “Erosive”• Seronegative spondyloarthritis
– Psoriatic arthritis, reactive arthritis, ankylosing spondylitis, inflammatory bowel – related arthritis
• Connective tissue disease– Vasculitis, systemic lupus
erythematosis, systemic sclerosis, Primary Sjogrens, dermatomyositis, PMR
• Clinical diagnoses based on pattern recognition supported by clinical test results
• Non-inflammatory causes of joint pain
• Trauma• Osteoarthritis
– “nodal”, “spondylosis”• Malignancy – usually metastatic• Metabolic
– Pagets• Etc, etc
• Clinical diagnosis often based on imaging
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Other inflammatory conditions….
• Septic arthritis– Native or replaced joint– Emergency with up to 50% mortality rate
• Crystal induced arthritis– Gout, pseudogout
• Diagnosis based on joint aspiration• Look identical clinically!
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First question..• Is pain due to inflammation?
– Swelling?– Early morning stiffness greater than one
hour?– Raised inflammatory markers?
• Many conditions can cause pain• GPs are excellent at managing joint symptoms with pain relief• Swelling indicates a need for additional more specific treatments• Rheumatologists are “inflammation doctors”
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Second question
• What is the pattern of joint swelling?
• How many joints are involved?• Which joints are involved?• Acute or gradual onset?• Duration of swelling?• Associated features?
– Diagnosis is based on pattern recognition
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Rheumatoid Arthritis
Commonest reason for chronic DMARD therapy
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Rheumatoid diseaseChronic symmetrical deforming arthritis of many small and
large joints. Not only the joints are involved.
CARDIOVASCULAR RISK= DM
osteoporosis
lymphoma
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Early rheumatoid arthritis
Methotrexate
Combination DMARDS
Steroid injections
Multidisciplinary team
ESR/CRP likely to be elevated
RF or anti-CCP may be positive or negative
Xrays normal, ultrasound may be used to detect subtle swelling
Non-specific changes to Hb, plt, alk phos, GGT, total protein inkeeping with inflammation
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Goals of treatment
• Aim for remission!!
• Treating swelling and tenderness can:-– Prevent joint damage– Maintain function– Protect family roles and independence– Maintain employment
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Key points
• Ongoing joint inflammation = ongoing joint damage
• The earlier treatment is started the better• Rheumatoid arthritis may be a chronic
disease but with good treatment the symptoms need not be…..– Don’t be surprised if you come across
patients on multiple treatments whose arthritis does not seem that bad!
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Seronegative spondyloarthritis
Inflammatory arthritis that can involve the sacroiliac joints and spine. An
entirely different group of diseases to RA.
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Ankylosing spondylitisInflammatory disease of sacroiliac joints and spine. Peripheral joints may also be involved. Uveitis may be associated.
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Psoriatic arthritis
• Single or multiple inflamed joints in association with a personal or family history of psoriasis
Seen in up to 90% of patients
DIP swelling Arthritis Mutilans
Dactylitis
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Reactive arthritisThe body’s response to a prior infection. Usually secondary to gastroenteritis or sexually transmitted infection. Classically a triad of symptoms - sore where you see, sore when you pee, sore in your knee! Previously known more commonly as Reiter’s disease.
Keratoderma blenorrhagicum
Circinatebalanitis
Asymmetrical lower limb arthritis
conjunctivitis
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Inflammatory bowel disease related arthritis
• Seen in association with Crohns and colitis. Asymmetrical sacroiliac joint involvement and peripheral arthritis.
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Connective tissue disease
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scleroderma
lupus
dermatomyositis
vasculitis
Multisystem disease
Granulomatousvasculitis
autoantibodies
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Crystal arthritis
The commonest explanation for joint swelling in general practice
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Agony!destructive
Urate crystals
tophi Podagra – gout at the great toe
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Any questions?
• Everything you ever wanted to know about terminology but were too afraid to ask….
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What is in and what is out…• IN
– Methotrexate– Combination DMARD
treatment– Biologic drugs– Tight control– Musculoskeletal
ultrasound– Anti-CCP testing– Cardiovascular risk– Osteoporosis risk
• OUT– Long-term daily
NSAID– Sequential
monotherapy– Penicillamine, oral
gold, minocycline– Methotrexate and
leflunomidecombination therapy