Diagnos(c

Approach in Arthri(s Pa(ents

Lita Diah
Rheumatology Division
Internal Medicine Department
 Introduc(on
•  “arthri(s” : inflammatory process in a joint.
•  It can be caused by
ü infec(ous agents ( Sep(c Arthri(s )
ü microcrystals that lead to the degranula(on of
neutrophils (microcrystalline arthri(s)
ü an immunological reac(on to remote infec(ous
agents (reac(ve arthri(s)
ü it can be of unknown cause, the case in most
inflammatory joint diseases.
Arthri(s
 Introduc(on
•  the inflammatory process results local
produc(on of inflammatory mediators
•  a great poten(al for damaging ar(cular car(lage,
bone and periar(cular soJ (ssue.
•  Proinflammatory cytokines, IL-1, TNFα, s(mulate
bone and car(lage cells
•  Proteoly(c enzymes released by ac(vated
leucocytes and synoviocytes contribute directly
to joint destruc(on.
 Introduc(on
•  symmetrical loss of joint space
•  the subchondral bone loses
•  the subchondral sclerosis
•  muscular atrophy
•  articular instability, subluxations
•  articular deviations.
•  periarthritis
•  peripheral nerve compression

 Basic Principle in Arthri(s

1.  Take a relevant history and perform a focused

examination
2.  Recognize diagnostic patterns of joint involvement
3.  Be able to apply a screening history and
examination as part of a general systemic inquiry on
all patients
 Basic Principle in Arthri(s
•  Is the problem acute or chronic?
•  Is it an ar(cular or extra-ar(cular problem?
•  Is it a mono or oligo/poly arthri(s?
•  Are there features of joint inflamma(on?
•  Are there extra-ar(cular features?
•  Is the arthri(s part of a more generalised
complaint?
Inflammatory Vs. Noninflammatory
Ar(cular Vs. Periar(cular
Number of involved joints
•  Monoarthri5s: involvement of one joint.
•  Oligoarthri5s: involvement of 2-5 joints.
•  Polyarthri5s: involvement of 6 or more joints.
Symmetry of joint involvement
•  Symmetric arthri5s: characterized by involvement of
the same joints on each side of the body. This
symmetry is typical of RA and SLE.
•  Asymmetric arthri5s: characteris(c of
spondyloarthropathies (e.g., psoria(c arthri(s, and
reac(ve arthri(s)
Distribu5on of affected joints
•  The distal inter-phalangeal (DIP) joints of the fingers are
usually involved in psoria(c arthri(s, gout, or osteoarthri(s
but are usually spared in RA.
•  Joints of the lumbar spine are typically involved in ankylosing
spondyli(s but are spared in RA.
Dis5nc5ve types of musculoskeletal involvement
•  Spondyloarthropathy involves entheses, leading to:
– heel pain (inflamma(on at the inser(ons of the Achilles
tendon and/or plantar fascia),
– dactyli(s (sausage digits),
– tendni(s
– back pain (sacroilii(s and vertebral disc inser(ons).
Extra-ar5cular manifesta5ons
•  Cons5tu5onal symptoms suggest an underlying systemic
disorder and are not expected in degenera(ve joint
•  Skin lesions may be present of rheuma(c diseases, e.g., SLE,
dermatomyosi(s, scleroderma, psoriasis
•  Ocular symptoms or signs
– Episcleri5s and scleri5s: RA or Wegener granulomatosis,
– Anterior uvei5s with spondyloarthropathies
– iridocycli5s with juvenile Idiopathis Arthri(s
– Conjunc5vi5s may be caused by reac(ve arthri(s.

 Review of Organs System
Manifestation Disease

Rash SLE, vasculitis, PsA, dermatomyositis, JRA, lyme disease

Eye involvement Sjogren’s syndrome, RA, spondyloarthropathy, temporalis

arteritis, Behcet’s disease, Wargener granulomatous,SLE

Oral ulcer SLE, enteropathic arthritis, Behcet’s disease

Raynaud’s phen. Scleroderma, SLE, RA, MCTD

Pleuritis/pericarditis SLE, RA, MCTD,AS

CNS involvement SLE, vasculitis, lyme disease,antiphospolipid syndrome

GI involvement Enteropathic arthritis, polymyositis, scleroderma 13

Grouping of Arthri(s Pa(ents
Akut Kronik

Monoarthri5s akut Monoarthri(s kronik

Oligoarthri5s akut Oligoarthri(s kronik

Polyarthri5s akut Polyarthri(s kronik

 Acute Monoarthri(s.
loca(ons. Relevant
extra-ar(cular
manifesta(ons: fever,
infected wounds,
recent infec(ons, kidney
stones.

Acute monoarthri(s,
undergo an urgent
arthrocentesis to
examine the synovial fluid,
For analysis, culture, gram
stain and search crystal

Radiologic : can be
misleading, erosion, fracture,
degenera(v
Acute oligoarthri(s
 Acute Oligoarthri(s
Infeksi Disseminated gonococcal infec5on a
Nongonococcal sep5c arthri5s
Bacterial endocardi5s b
Viral c
Post infeksi Reac(ve arthri(s b
Rheuma(c fever (poststreptococcal
arthri(s)
Spondyloarthropathy Reac(ve arthri(s b
Ankylosing spondyli(s b
Psoria(c arthri(s b
Inflammatory bowel disease b
Gout dan pseudogout
Systemic autoimmune disease rheumatoid arthri(s, systemic lupus
erythematosus,adult-onset S(ll disease,
relapsing polychondri(s,
Asymmetric, Inflammatory
Oligoarthri(s
 Acute oligoarthri(s
•  Urinalysis
•  Haematology - FBC, ESR, clobng Radiology :
•  Biochemistry - LFTs, urate, CRP
•  Immunology Can be mis leading
•  Microbiology Degenera(v joint
–  blood/urine/stool/urethral/ erosion
sputum cultures
–  Serology
•  Synovial fluid
§  volume/viscosity/cellularity
§  polarised light microscopy
(crystals)
§  gram stain/culture
Acute Polyarthri(s
 Acute Polyarthri(s
Common
Acute viral infec5ons
Early disseminated Lyme disease
Rheumatoid arthri5s
Systemic lupus erythematosus
Uncommon or rare
Paraneoplas5c polyarthri5s
RemiSng seronega5ve symmetric polyarthri5s with piSng edema
Acute sarcoidosis, usually with erythema nodosum and hilar
adenopathy
Adult-onset S5ll disease
Secondary syphilis
Systemic autoimmune diseases and vasculi5des
Whipple disease
Viral Arthri(des - Parvovirus
Acute Polyarthri(s - Psoria(c
 Acute Polyarthri(s
Screening tests for acute polyarthritis
•  Blood cultures
•  Antistreptolysin O titer
•  Parvovirus B-19 immunoglobulin G and
immunoglobulin M levels
•  ANA test,HIV test, a rubella titer, anti CCP,
and ANCA
•  Radiologic : cannot helpfull

Differen(al Diagnosis of
Chronic Inflammatory Monoarthri(s

Infection Sarcoidosis
Nongonococcal septic arthritis
Gonococcal Uncommon or rare
Mycobacterial FMF
Fungal Amyloidosis
Viral Pigmented villonodular synovitis
Crystal-induced arthritis
Gout Non-inflammatory
Pseudogut
Osteoarthritis
Monoarticular presentation of oligoarthritis Internal derangements (eg,torn,meniscus)
or polyarthritis Chondromalacia patella
Osteonecrosis
Spondyloarthropathies Neıropathic (charcot) arthropathy
Rheumatoid arthritis
Lupus and other systemic autoimmune
diseases.
 Chronic monoarthri(s
•  LABORATORY EVALUATION
•  A cri(cal step is to determine whether the monoarthri(s is
inflammatory, preferably by analyzing synovial fluid.
•  Synovial fluid should be sent for culture (bacterial,
mycobacterial, and fungal), WBC count, and gram stain and
examined for crystals by polarized light microscopy.
•  Culture synovial and biopsy
•  Radiology/imaging, very useful
 CHRONIC OLIGOARTHRITIS
Common inflammatory causes Common non-inflammatory causes
Spondyloartropa5es Osteoarthri5s
Reac5ve arthri5s Uncommon-rare non inflammatory
Ankylosing spondyli5s Hypotyroidism
Psoria5c arthri5s amyloidosis
Inflammatory bowel disease

Uncommon-rare inflammatory arthri5s

Subacute bacterial endocardi5s
Sarcoidosis
Behçet disease
Celiac disease
Arthri5s of axial skeleton
 Features of Spondyloarthropathies (1)

Dactylitis Trigger finger

Entesi5s

Tendinitis Plantar pedis

30
 CHRONIC OLIGOARTHRITIS
•  Laboratory evalua(on
•  Synovial fluid analysis- culture- crystals
•  RF-dd(x) of RA
•  HLA B 27- limited value
Radiographs and Imaging studies-considerable value
Evidence of sacroili(s indicates a spondyloarthropaty and narrow
dd(x)

Erosions of RA and Gout
 CHRONIC POLYARTHRITIS
Inflammatory –Common Inflammatory- uncommon

Rheumatoid arthritis Vasculitiitis

SLE Sjögren’s syndrome
spondyloartropaties (especiaally Psoriatic Viral infections other than hepatitis C
art)
Gout
Chronic hepatitis C infection Non inflammatory
Drug induced lupus syndrome
Osteoarthritis
Inflammatory-Uncommon Hemachromatosis

Paraneoplastic polyarthritis
Remitting seronegative symmetric
polyarthritis with pitting edema (RS3PE)
Adult onset still disease
 CLINICAL PRESENTATION
• Pattern of joints affected with psoriatic arthritis is different than those with rheumatoid
arthritis.

Rheumatoid arthritis Psoriatic arthritis

The high frequency of distal joint involvement in psoriatic arthritis
compared to rheumatoid arthritis.
 Clinical Pearl:
Arthri(s of the DIP joint

Psoriatic Arthritis (inflammatory) OA (non-inflammatory)

 CHRONIC POLYARTHRITIS
•  Laboratory evalua(on
•  If arthrosentesis is feasible- joint aspira(on-
cell count and crystals
•  CBC
•  RFT
•  Urine analysis
•  ESR_CRP
•  RF-ANA- hepa((s B and C serology
 Take Home Massage
•  Arthri(s must be defined as inflammatory or
non inflammatory
•  Remember about basic principle arthri(s
•  Chronic arthri(s leading joint destruc(on and
disability
•  Inflammatory arthri(s must be referred to get
appropriate therapy
Thank You