Rheumatology: With Kartik Rangaraj MD

Rheumatology
With Kartik Rangaraj MD
Nailah Rahmah, nailahrahmah1997@gmail.com

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Overview

Rheumatic Diseases
Historically, the diseases within the field of Rheumatologists also treat:

rheumatology have been called collagen- • Osteoarthritis (OA)
vascular diseases (a now antiquated term).
• Crystalline arthropathies (gout/pseudogout)
Within this, several subsets exist: • Septic arthritis
• Connective Tissue Diseases
(CTDs; i. e., lupus)
• Seronegative Spondylarthropathies CTDs Vasculitis SN SpA

(SN SpA; i. e., ankylosing spondylitis)
• Vasculitides (i
Most CTDs can cause vasculitis,
not vice versa

Rheumatic Diseases
Rheumatologic diseases affect the extracellular components of tissues in almost every organ.
• Joints (arthralgias, arthritis)
• Skin (rash)
• Nerves/muscle (neuritis, myositis)
• Kidneys (nephritis)
• Lung, heart, gut, brain

Lecture Outline
Non-Autoimmune Arthritis Vasculitis
• Osteoarthritis (OA) • Large vessel • ANCA-associated
• Crystalline arthropathies (gout/pseudogout) • Medium vessel • Non-ANCA-associated
• Septic arthritis • Small vessel
Seronegative Spondylarthropathies
• ankylosing spondylitis (AS) We will break each condition down into these sections:
• Reactive arthritis 1. Definition
• Psoriatic arthritis (PsA) 2. Pathogenesis
• Inflammatory bowel disease-associated arthritis 3. Signs & symptoms
4. Diagnosis
Connective Tissue Diseases
5. Treatment
• Rheumatoid arthritis (RA)
• Systemic Lupus Erythematosus (SLE)
• Scleroderma/ phenomena
• Syndrome (SS)
• Inflammatory myositis
(polymyositis/dermatomyositis)

Rheumatic Diseases
Non-Autoimmune Arthritis
With Kartik Rangaraj MD

Osteoarthritis

Approach to Arthritis
Joint pain is a common symptom in rheumatic disease.
This is how rheumatologists approach this issue:
Arthritis vs. arthralgias

• Arthritis joint-centered (articular) pain
• Arthralgias sensation of joint pain but pain around joint (periarticular)
Acute vs. chronic (  6 weeks)

• Symmetrical vs. asymmetric
Forms basis of how to
• Monoarticular vs. polyarticular describe arthritis
• Inflammatory vs. noninflammatory
AM stiffness > 1 2 hrs: key feature of systemic inflammatory (read: autoimmune) arthritis!

Osteoarthritis
Osteoarthritis is a chronic, asymmetric, noninflammatory,

degenerative arthritis (wear-and-tear arthritis) associated with
articular cartilage damage and formation of new bone at joint
surfaces and margins.
Definition It commonly affects joints that are subject to repetitive use and
weight-bearing joints:
• Small joints of the fingers (CMC of thumb, DIP, PIP)
• Knees
• Hips
• Spine

Osteoarthritis
• Very complex orchestration of biomechanical, biochemical,

and cytokine-mediated changes
• Obesity, which increases the work-load on weight-bearing joints

and increases the risk for OA
• Incidences of OA increases with age

Pathogenesis
• In contrast to RA, pain in OA worsens with use
• Classically, DIP and PIP joints (

respectively) are involved; clinically, CMC of thumb is usually first
hand joint involved
• OA frequently involves the knees, spine, and hips

Signs & symptoms • Crepitus of affected joints

Osteoarthritis
Marshall M, Jonsson H, Helgadottir GP, Reliability of Assessing Hand Osteoarthritis on Digital Photographs /
detailedresult.php?img=PMC4153954_acr0066-0828-f1&query=osteoarthritis+of+the+hand&it=xg&lic=by&req=4&npos=1, cropped, CC BY 3.0
Osteoarthritis
Shah N, Mini-subvastus approach for total knee arthroplasty in obese patients., https://openi.nlm.nih.gov/detailedresult.php?img=PMC2911930_IJOrtho-
44-292-g001&query=osteoarthritis+of+the+knee&it=xg&lic=by&req=4&npos=32, cropped, CC BY 2.0
Osteoarthritis
• ESR is normal.
• Rheumatoid factor is not present.
• X-rays reveal subchondral sclerosis and osteophyte formation

(bone spurs).
•
• Osteophytes of the DIPs: nodes

Definition

Osteoarthritis
• Acetaminophen (Tylenol) and NSAIDs are the mainstay of

therapy.
• Weight loss, physical therapy, and supports
• Orthopedic surgery for joint replacement
• No role for PO steroids
• Can inject intraarticular steroids (very limited relief) or

Treatment hyaluronic acid

Gout & Calcium Pyrophosphate
Deposition Disease (CPPD)

Gout
Gout is an acute, inflammatory, monoarticular, asymmetric arthritis

due to deposition of monosodium urate crystals intraarticularly.
Definition

Gout
Phagocytosis of urate crystals by neutrophils causes release of

inflammatory mediators via activation of the inflammasome
worry, the inflammasome will not be on your boards).
Hyperuricemia (uric acid > 7 mg/dl) is a risk factor for the development
of gout.
Pathogenesis Disorders of uric acid metabolism involve one of the following:

• Overproduction or under-excretion
• Under-excretion much more common (90 % of gout pts)
Associated with chronic kidney disease (CKDs), HTN, DM2,

dyslipidemias, obesity, and transplant pts (especially cardiac, related
to cyclosporine).

Gout
Cardinal symptom: sudden onset of pain

• Pain is very severe
stand the weight of a bed sheet on the affected joint)
• The joint is inflamed (tender, red, hot, & swollen)
• Most common joint affected: 1st MTP joint

• This is so characteristic of gout that it has
Signs & symptoms its own name: podagra

Gout
Tophi (subdermal urate crystal

deposition) may be found.
• Particularly along the pinna of ear,
elbows
Recurrent episodes of gout can lead

to a chronic arthritis.
• Each subsequent flare involves
Signs & symptoms more joints than prior flare
Roddy E, Revisiting the pathogenesis of podagra: why does gout target the foot?, https://openi.nlm.nih.gov/detailedresult.php?img=PMC3117776_1757-
1146-4-13-2&query=Gout&it=xg&lic=by&req=4&npos=4, resized, CC BY 2.0
Gout Tophi
F.l.t.r.: Inani K, Mernissi F, [Gouty tophus]., https://openi.nlm.nih.gov/detailedresult.php?img=PMC4189869_PAMJ-17-250-g001&query=Gout+%26ndash%3B

+Tophi&it=xg&lic=by&req=4&npos=41, resized, CC BY 2.0; Michael McCullough, Gouty Tophi in the Helix of the Ear, https://flic.kr/p/9a2MrM, croped, CC BY 2.0
Gout
• Analysis of the synovial fluid obtained by arthrocentesis
• Synovial fluid analysis reveal -

crystals
• MSU crystals are negatively birefringent under
polarized light.
Diagnosis
Although hyperuricemia is a risk factor for gout, uric acid levels are
neither diagnostic nor reliable during acute gouty attacks.
• Normal uric acid levels are seen during flares as most of it is in
immeasurable crystal form!
• Only 10 % of hyperuricemic pts ever develop gout

Gout
Acute gouty attack
• NSAIDs (e.g. indomethacin)
• Colchicine for patients who cannot tolerate NSAIDs

• Colchicine causes diarrhea as one of its major side
effects; also remember myopathy and pancytopenia
as important side effects for exam purposes.
• Oral steroids (e.g., prednisone) for patients who cannot tolerate

Treatment NSAIDs or colchicine (advanced CKDs)

Gout
Chronic gouty attacks
• Allopurinol and febuxostat can be used for patients with

hyperuricemia who are overproducers based on serum uric
acid level.
• Goal: serum uric acid < 6 mg/ml
• If urinary uric acid > 1000 mg/day, pts at risk for acute
obstructive uropathy
• Should not be started until several weeks after an acute gouty

attack.
Treatment • Need dose adjustment for chronic kidney disease.

Gout
What if maxed out on allopurinol and still have high uric acid?
• Uricosuric drugs (furosemide, probenecid, sulfinpyrazone)

increase urinary uric acid excretion.
• Uricase treatment
• Anakinra (IL-1 antagonist)
Treatment

Calcium Pyrophosphate Deposition Disease
Pseudogout is an acute, inflammatory, symmetric arthritis due to

deposition of calcium pyrophosphate crystals intraarticularly.
Definition

• Deposition associated with high calcium and phosphate

concentrations
• Most commonly seen in large joints; mainly affects older patients
• See chondrocalcinosis in menisci of knees, pubic symphysis, and
wrists
• Associated with osteoarthritis and metabolic disorders that alter
calcium metabolism:
Pathogenesis • Hyperparathyroidism • Hypophosphatasia
• Hemochromatosis •
• Hypothyroidism
• Hypomagnesemia

• Patients typically present with acute symmetric arthritis.
• These episodes are usually triggered by surgery

(secondary to volume shifts) or severe illness.
• Chronic disease mimics osteoarthritis (pseudo-OA) or

rheumatoid arthritis (pseudo-RA).
Signs & symptoms

• Calcium pyrophosphate crystals appear

rhomboid-shaped and are positively
birefringent under polarized light.
• Soft tissue calcification

(chondrocalcinosis) can be seen
Diagnosis on X-rays.
Taokinesis ,CC0 1.0

• Acute flares treated similarly to gout

• NSAIDs, steroids
• Treatment of underlying disorder is most important.
Treatment

Septic Arthritis

Septic Arthritis
Serious (read: medical emergency!) acute, inflammatory,

asymmetric, monoarticular arthritis caused by bacterial
infection of joint space.
Why is this a medical emergency?

It can take only hours for the infection to destroy the
cartilage within the joint to the point that the joint is permanently
damaged.
Definition

Septic Arthritis
Usually there is a nidus of infection:
• In diabetics, skin infection secondary to neuropathic changes
• In drug users, direct inoculation of blood Look for

endocarditis!
• In young adults, look for Gonococcus!
• In sickle cell pts, look for Salmonella and Staph!

Pathogenesis
• In trauma pts, look for Staph epidermidis!
• Obviously, immunosuppressed pts have every reason to

develop septic arthritis.

Septic Arthritis
High risk of seeding joints with bacteria:

• Pts with underlying joint disease (esp. rheumatoid arthritics, pts
with prosthetic joints)
The two main group of organisms causing septic arthritis are:

• Gonococcus (Neisseria gonorrhoeae)
• Nongonococcal
• Staphylococcal infection (most common S. aureus)
• Group A beta-hemolytic strep

Pathogenesis

Septic Arthritis
• Acute, abrupt onset of monoarticular joint pain with redness,

swelling and warmth; associated with fevers/chills
• Mimics gouty arthritis
• Both septic and gouty arthritis can occur at the same time!
Signs & symptoms

Septic Arthritis
Depending on bug, severity of symptoms vary:
• Nongonococcal (S. aureus) most aggressive in severity of pain
quickness of onset)
• Think gonococcal if arthritis is migratory and monoarticular in
nature
• Young sexually active patients with acute monoarthritis
considered to have GC arthritis until proven otherwise
• Slower onset of symptoms, usually over several days
Signs & symptoms • Patients may have symptoms of genital infection with
gonococcus
• If asymptomatic, can see periarthritis-dermatitis syndrome
• Patients may develop a pustular rash due to
disseminated GC infection
• Seen more in N. meningitidis
Septic Arthritis
Gonococcal arthritis
• Positive sexual history
• Cultures of cervix/urethra/pharynx/rectum as appropriate

• Remember: gonococcus is hard to culture, so if
inappropriately performed by lab, these results
can be negative.
• Joint aspiration necessary.

Diagnosis

Septic Arthritis
Non-gonococcal arthritis
• Aspiration of joint fluid will reveal large numbers of WBCs and

Gram stain & cultures will likely be positive; they also need to
be analyzed for crystals.
• If patient received antibiotics prior to aspiration, this can
create a false negative culture.
• Blood cultures
Diagnosis

Septic Arthritis
Gonococcal arthritis
• IV ceftriaxone, followed by oral antibiotics
Non-gonococcal arthritis
• IV drugs with Gram (+) coverage (vancomycin)
• Non-GC arthritis require drainage:

Treatment • Needle aspiration vs. open surgical drainage (ortho consult)

This document is a property of: Nailah Rahmah
Note: This document is copyright protected. It may not be copied, reproduced, used, or
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Rheumatology

With Kartik Rangaraj MD

Nailah Rahmah, nailahrahmah1997@gmail.com

Nailah Rahmah, nailahrahmah1997@gmail.com

Historically, the diseases within the field of Rheumatologists also treat:

• Seronegative Spondylarthropathies CTDs Vasculitis SN SpA

Nailah Rahmah, nailahrahmah1997@gmail.com

• Nerves/muscle (neuritis, myositis)

• Lung, heart, gut, brain

Nailah Rahmah, nailahrahmah1997@gmail.com

Nailah Rahmah, nailahrahmah1997@gmail.com

With Kartik Rangaraj MD

Nailah Rahmah, nailahrahmah1997@gmail.com

Nailah Rahmah, nailahrahmah1997@gmail.com

Arthritis vs. arthralgias

• Arthralgias sensation of joint pain but pain around joint (periarticular)

Acute vs. chronic (  6 weeks)

Nailah Rahmah, nailahrahmah1997@gmail.com

Osteoarthritis is a chronic, asymmetric, noninflammatory,

Nailah Rahmah, nailahrahmah1997@gmail.com

• Very complex orchestration of biomechanical, biochemical,

• Obesity, which increases the work-load on weight-bearing joints

• Incidences of OA increases with age

• In contrast to RA, pain in OA worsens with use

• Classically, DIP and PIP joints (

• OA frequently involves the knees, spine, and hips

Nailah Rahmah, nailahrahmah1997@gmail.com

• Rheumatoid factor is not present.

• X-rays reveal subchondral sclerosis and osteophyte formation

• Osteophytes of the DIPs: nodes

Nailah Rahmah, nailahrahmah1997@gmail.com

• Acetaminophen (Tylenol) and NSAIDs are the mainstay of

• Weight loss, physical therapy, and supports

• Orthopedic surgery for joint replacement

• No role for PO steroids

• Can inject intraarticular steroids (very limited relief) or

Nailah Rahmah, nailahrahmah1997@gmail.com

Nailah Rahmah, nailahrahmah1997@gmail.com

Gout is an acute, inflammatory, monoarticular, asymmetric arthritis

Nailah Rahmah, nailahrahmah1997@gmail.com

Phagocytosis of urate crystals by neutrophils causes release of

Pathogenesis Disorders of uric acid metabolism involve one of the following:

Associated with chronic kidney disease (CKDs), HTN, DM2,

Nailah Rahmah, nailahrahmah1997@gmail.com

Cardinal symptom: sudden onset of pain

• The joint is inflamed (tender, red, hot, & swollen)

• Most common joint affected: 1st MTP joint

Nailah Rahmah, nailahrahmah1997@gmail.com

Tophi (subdermal urate crystal

Recurrent episodes of gout can lead

F.l.t.r.: Inani K, Mernissi F, [Gouty tophus]., https://openi.nlm.nih.gov/detailedresult.php?img=PMC4189869_PAMJ-17-250-g001&query=Gout+%26ndash%3B

• Synovial fluid analysis reveal -

• Only 10 % of hyperuricemic pts ever develop gout

Nailah Rahmah, nailahrahmah1997@gmail.com

Acute gouty attack

• NSAIDs (e.g. indomethacin)

• Colchicine for patients who cannot tolerate NSAIDs

• Oral steroids (e.g., prednisone) for patients who cannot tolerate

Nailah Rahmah, nailahrahmah1997@gmail.com

Chronic gouty attacks

• Allopurinol and febuxostat can be used for patients with

• Should not be started until several weeks after an acute gouty

Treatment • Need dose adjustment for chronic kidney disease.