The Evaluation of the Patient in Rheumatology

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The Evaluation of the Patient in Rheumatology

• Emilio B. González, MD
• Professor and Director
• Division of Rheumatology
• Department of Medicine

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Joint and Muscle Aches and Pains - Evaluation

• Articular vs. non-articular. For example,
  shoulder pain due to bursitis-tendinitis is
  extra-articular, not true arthritis. Also,
  referred pain needs to be considered
• Inflammatory vs. non-inflammatory
• Monoarticular vs. polyarticular pattern of joint
  involvement
• Patients age and sex fibromyalgia in young
  females, polymyalgia rheumatica (PMR) in older
  patients, gout is rare in premenopausal females,
  ankylosing spondylitis typically seen in young
  males

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Basic Principles

• Polyarticular multiple joints. Example RA
• Mono-articular one joint. Example septic joint
  or acute gout
• Pauci - or oligo-articular a few joints.
  Example reactive arthritis (Reiters Sx)
• The pattern of joint involvement is
  important!

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More Basic Principles

• Arthralgias presence of joint pain only
• Arthritis pain swelling and/or redness, and
  warmth
• Since pain is a subjective complaint, the
  presence of joint swelling (arthritis) adds
  objective evidence for the presence of
  inflammation!

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Inflammation What To Look For

• Clinical
• Stiffness
• Joint swelling
• Fever, malaise, fatigue
• Weight loss
• Lymphadenopathy

• Laboratory
• ? Sedimentation rate (ESR)
• ? C-reactive protein (CRP)
• Anemia
• Thrombocytosis
• Abnormal serum protein
• electrophoresis polyclonal
• hypergamaglobulinemia

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Joint and Muscle Aches and Pains A
Complete Evaluation

• Systemic signs and symptoms
• Fever, Raynauds, livedo reticularis, digital
  ischemia, muscle weakness, nodules, skin rashes
• Abnormal labs
• ? WBC or cytopenias, elevated ESR, positive
  serologies, CPK and TSH levels, SPEP, renal and
  hepatic function abnormalities

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Examples of Systemic Inflammatory vs.
Non-Inflammatory Disorders

• Inflammatory
• Rheumatoid Arthritis RA)
• Systemic lupus
• erythematosus (SLE)
• Viral infections, e.g., hep
• C and B, Parvovirus
• Bacterial infections, e.g.,
• septic joints

• Non-inflammatory
• Osteoarthritis (OA)
• Fibromyalgia
• Depression
• Chronic pain syndromes
• Bursitis-tendinitis (local
• inflammation, not systemic)
• Avascular osteonecrosis

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Case No. 1

• A 25 year old female with a 6-week history of
  polyarthritis. There is symmetrical involvement
  of the small joint of the hands and feet
• Most likely diagnosis?
• Differential diagnosis?

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The Autoimmune or Connective Tissue Diseases
All Are Inflammatory

• Inflammatory polyarthritis with autoantibodies
• Rheumatoid arthritis (RA) Importance ?
  destructive potential
• MCTD (mixed connective tissue disease)
• Scleroderma
• Lupus
• Sjögren's syndrome
• Differential diagnosis viral infections such as
  hepatitis C and parvovirus B19, among others

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Polyarticular Involvement!
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Rheumatoid arthritis (RA) vs. Osteoarthritis (OA)

• RA
• Systemic inflammation
• Polyarticular
• Hand PIPs, MCPs, and
• wrists
• X-rays marginal
• erosions, soft tissue
• swelling, osteopenia
• Extra-articular features

• OA
• Local inflammation
• Selected joints hands
• and weight-bearing
• Hands PIPs, DIPs, and 1st
• CMC (base of thumbs)
• X-rays sclerosis and
• osteophytes
• No extra-articular features

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Case No. 2

• A 25 year old homeless male with chronic
  oligoarticular arthritis. It is cold outside and
  he shows up in the UTMB ER
• There is involvement of two toes, right ankle,
  and left knee. He has a skin rash at the bottom
  of his feet
• What other information?
• Differential diagnosis

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Would anybody like to see the rash?
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Case No. 3

• A 40 year old male with a long history of low
  back pain and recent monoarthritis in the right
  knee. There is morning stiffness
• Diagnostic possibilities?

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Seronegative HLA-B27-positive Spondyloarthropathie
s

• Ankylosing spondylitis
• Enteropathic arthritis Crohns disease and
  ulcerative colitis
• Psoriatic arthritis and psoriatic spondylitis
• Reactive arthritis (Reiters syndrome)
• Characteristics
• Asymmetric oligoarthritis Sacroiliitis and
  spondylitis

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Case No. 4

• A 25 year old female with acute polyarthritis of
  a few days duration. You are called to the ER to
  evaluate her. There is involvement of lateral
  right wrist and she can hardly move this joint
  because of intense pain the right knee is
  swollen, and also the left lateral ankle. Her
  temp is 39 degrees Celsius
• Other information?
• Likely diagnosis?

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If you could ask her only one question, what
would it be?
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Infectious Arthritis

• Viral hepatitis C and B, Parvovirus B19, etc
• Septic DGI (disseminated gonococcal infection),
  
• staph or strep in previously damaged, RA
  joints, or
• prosthetic joints
• Lyme disease Rare in the Southern US
• Rheumatic fever Rare to uncommon
• Polymicrobial
• AFB and fungal
• Pseudomonas and staph in immunocompromised
• hosts such as HIV patients and drug abusers
  
• Other salmonella infection in sickle cell
  disease, etc

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Case No. 5

• A 65 year old male with acute arthritis in the
  left knee. He is hospitalized and 4 days post-op
  after an elective cholecystectomy
• Alternative clinical scenario he could have
  been admitted a few days ago for an acute MI
• Other information? Tap?
• Diagnostic possibilities?

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Case No. 6

• A 55 year old female with chronic monoarthritis
  in the right knee
• Other information?
• Diagnostic possibilities?
• X-rays?

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CPPD Whats in a Name?

• Pseudogout acute inflammatory arthritis that
  clinically mimics gout
• CPPD calcium pyrophosphate crystal
• Chondrocalcinosis x-ray appearance of cartilage
  calcification. Many patients are completely
  asymptomatic

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Crystal-Induced Arthritis

• Gout Monosodium urate (MSU)
• CPPD Calcium pyrophosphate deposition disease
• Other calcium salts Hydroxyapatite crystals,
  typically in patients with CRI, ESRD, Milwaukee
  shoulder, etc

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Diagnostic Approach to Patient with Arthritis

• Age, sex
• Mono- or polyarthritis
• Pattern of joint involvement
• Acute or chronic
• Associated Features
• Fever, eye, skin, mucous membrane, bowel, axial
  skeleton
• Selected laboratory tests

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Overall Assessment

• A given patient may have a lot of complaints
  including pain however, if there is no objective
  evidence of inflammation, e.g., no joint
  swelling, and the lab tests are all cold normal,
  e.g., CBC, ESR, CRP, TSH, hep C, including x-rays
  ? the patient likely does not have an
  inflammatory process to explain her/his symptoms.
  
• If only one joint is involved, exclude a local
  orthopedic lesion, e.g. ACL tear, or if it is the
  shoulder, obtain a CXR to exclude intrathoracic
  pathology with pain radiating to the shoulder
  joint.
• If labs all normal, and with polyarthralgias or
  with generalized pain, look for fibromyalgia or
  other related disorders, depression, psychogenic
  rheumatism, chronic pain syndromes, etc.

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• FIN
• Questions?