Classification &Classification & Differential Differential

DiagnosisDiagnosis of of

Rheumatic Diseases Rheumatic Diseasesby by

Dr. Ibtessam Abd El Dr. Ibtessam Abd El Hamid Hamid

Professor of Internal MedicineProfessor of Internal MedicineRheumatology unit Rheumatology unit Faculty of Medicine Faculty of Medicine

Alexandria UniversityAlexandria University

Classification of rheumatic diseasesClassification of rheumatic diseases

1-Diffuse connective tissue diseases:

a) Rheumatoid arthritisb) Systemic lupus

erythematosusc) Progressive systemic

sclerosisd) Polymyositis/

Dermatomyositise) Vasculitis

1-Diffuse connective tissue diseases:

a) Rheumatoid arthritisb) Systemic lupus

erythematosusc) Progressive systemic

sclerosisd) Polymyositis/

Dermatomyositise) Vasculitis

2-Sero-negative spondyloarthropathies:

a) Ankylosing spondylitis

b) Reiter's syndrome (Reactive arthritis)

c) Psoriatic arthritis

d) Enteropathic arthritis

2-Sero-negative spondyloarthropathies:

a) Ankylosing spondylitis

b) Reiter's syndrome (Reactive arthritis)

c) Psoriatic arthritis

d) Enteropathic arthritis

3-Degenerative joint disease3-Degenerative joint disease (osteoarthritis) (osteoarthritis)

4- Infective arthritis : 4- Infective arthritis :

e.g.e.g.

Septic arthritis Septic arthritis T.B.T.B. Rheumatic feverRheumatic fever Hepatitis B Hepatitis B && C C AIDSAIDS

5-Metabolic and endocrine diseases: (associated with rheumatic disease)

a)Crystal-induced arthropathy (gout and pseudogout)

b)Endocrine diseases (diabetes mellitus, acromegaly, hyperparathyroidism, thyroid diseases)

5-Metabolic and endocrine diseases: (associated with rheumatic disease)

a)Crystal-induced arthropathy (gout and pseudogout)

b)Endocrine diseases (diabetes mellitus, acromegaly, hyperparathyroidism, thyroid diseases)

6- Hematological disorders: Haemoglobinopathies, leukaemia, lymphoma, haemophilia

7-Neoplasms

8-Neuropathic disorders: charcot joint, carpal tunnel syndrome

9-Bone and cartilage disorders: Osteoporosis, osteomalacia

10-Non articular rheumatism: Fibromyalgia , tendinitis , plantar fasciitis

11-Trauma

12- Miscellaneous disorders: Familial Mediterranean fever, Sarcoidosis, Behçet disease

6- Hematological disorders: Haemoglobinopathies, leukaemia, lymphoma, haemophilia

7-Neoplasms

8-Neuropathic disorders: charcot joint, carpal tunnel syndrome

9-Bone and cartilage disorders: Osteoporosis, osteomalacia

10-Non articular rheumatism: Fibromyalgia , tendinitis , plantar fasciitis

11-Trauma

12- Miscellaneous disorders: Familial Mediterranean fever, Sarcoidosis, Behçet disease

Diagnosis of rheumatic diseases:

A) Medical history

B) Physical examination

C) Investigations

Diagnosis of rheumatic diseases:

A) Medical history

B) Physical examination

C) Investigations

A) Medical history

* Demographic considerations: Sex:

RA - SLE > in females. AS - Gout > in males

Age at onset of symptoms Ethnic background: Familial

Mediterranean fever, Behçet.

* History of trauma, infection, drugs, menstruation, fertility and pregnancies

* Chief complaints:• Articular - Periarticular -

Extraarticular

A) Medical history

* Demographic considerations: Sex:

RA - SLE > in females. AS - Gout > in males

Age at onset of symptoms Ethnic background: Familial

Mediterranean fever, Behçet.

* History of trauma, infection, drugs, menstruation, fertility and pregnancies

* Chief complaints:• Articular - Periarticular -

Extraarticular

**

Articular complaints: Onset.

• Abrupt onset: symptoms develop over minutes to hours. e.g. trauma-infection-gout/pseudogout

• Insidious onset: symptoms develop over weeks to months. e.g. RA-OA

Duration

• Acute < 6 weeks

• Chronic > 6 weeks Temporal patterns of joint involvement:

• Migratory: (inflammation persists for only a few days in each joint) Acute rheumatic fever - gonococcal infection

• Additive or simultaneous: Symptoms begin in certain joints and persist with subsequent involvement of other joints.

• Intermittent (episodic): intervening periods free of joint symptoms e.g. gout, pseudogout

Articular complaints: Onset.

• Abrupt onset: symptoms develop over minutes to hours. e.g. trauma-infection-gout/pseudogout

• Insidious onset: symptoms develop over weeks to months. e.g. RA-OA

Duration

• Acute < 6 weeks

• Chronic > 6 weeks Temporal patterns of joint involvement:

• Migratory: (inflammation persists for only a few days in each joint) Acute rheumatic fever - gonococcal infection

• Additive or simultaneous: Symptoms begin in certain joints and persist with subsequent involvement of other joints.

• Intermittent (episodic): intervening periods free of joint symptoms e.g. gout, pseudogout

n of involved joints• Monoarthritis: involvement of one joint.• Oligo-or pauciarthritis: involvement of 2-4

joints.• Polyarthritis: involvement of 5 or more

joints.

Symmetry of joint involvement• Symmetric arthritis: involvement of same

joints on each side of the body (RA, SLE & other CT diseases)

• Asymmetric arthritis psoriatic arthritis, reactive arthritis (Reiter's syndrome)

Distribution of affected joints:• DIP joints of fingers usually spared in RA

and usually involved in psoriatic arthritis, gout or OA

• Lumbar spine: typically involved in AS & spared in RA

n of involved joints• Monoarthritis: involvement of one joint.• Oligo-or pauciarthritis: involvement of 2-4

joints.• Polyarthritis: involvement of 5 or more

joints.

Symmetry of joint involvement• Symmetric arthritis: involvement of same

joints on each side of the body (RA, SLE & other CT diseases)

• Asymmetric arthritis psoriatic arthritis, reactive arthritis (Reiter's syndrome)

Distribution of affected joints:• DIP joints of fingers usually spared in RA

and usually involved in psoriatic arthritis, gout or OA

• Lumbar spine: typically involved in AS & spared in RA

Distinctive types of musculoskeletal involvement:

•RA synovitis

•Spondyloathropathy involves joints & entheses (heel pain) dactylitis (sausage digits), tendinitis

& back pain.

•Gout & infection may involve joints, tendon, sheaths & bursae.

Distinctive types of musculoskeletal involvement:

•RA synovitis

•Spondyloathropathy involves joints & entheses (heel pain) dactylitis (sausage digits), tendinitis

& back pain.

•Gout & infection may involve joints, tendon, sheaths & bursae.

Peri-articular involvement:

Tendinitis – Bursitis – Fasciitis

Peri-articular involvement:

Tendinitis – Bursitis – Fasciitis

Extra-articular manifestations:

*Constitutional symptoms (fatigue-malaise-wt loss) suggest an underlying systemic disorder SLE, RA but not OA.

*Systemic involvement:pleurisy & pericarditis (SLE, RA)oral or genital ulcers (Behçet, Reiter, SLE)urethral or vaginal discharge (reactive)photosensitivity, hair loss (SLE)diarrhea (reactive arthritis)dysphagia & Raynaud's (Systemic sclerosis)conjunctivitis (Reiter)scleritis & episcleritis & Sjogren (RA) - uveitis (AS)skin lesions (SLE, Dermatomyosits, psoriasis, Henoch-Schonlein Purpura ….)

Extra-articular manifestations:

*Constitutional symptoms (fatigue-malaise-wt loss) suggest an underlying systemic disorder SLE, RA but not OA.

*Systemic involvement:pleurisy & pericarditis (SLE, RA)oral or genital ulcers (Behçet, Reiter, SLE)urethral or vaginal discharge (reactive)photosensitivity, hair loss (SLE)diarrhea (reactive arthritis)dysphagia & Raynaud's (Systemic sclerosis)conjunctivitis (Reiter)scleritis & episcleritis & Sjogren (RA) - uveitis (AS)skin lesions (SLE, Dermatomyosits, psoriasis, Henoch-Schonlein Purpura ….)

B) Physical examinationB) Physical examination

In clinical roundsIn clinical rounds

DD- acute and chronic mono and polyarthritis

Acute monoarthritis Inflammatory

Septic arthritis. Gout and Pseudogout Reiter Atypical presentation of RA , SLE ,

AS, RF

Non inflammatory Trauma and internal derangement Hemarthrosis ( trauma –

hemophilia- anticoagulants)

DD- acute and chronic mono and polyarthritis

Acute monoarthritis Inflammatory

Septic arthritis. Gout and Pseudogout Reiter Atypical presentation of RA , SLE ,

AS, RF

Non inflammatory Trauma and internal derangement Hemarthrosis ( trauma –

hemophilia- anticoagulants)

Investigations for acute monoarthritis

Synovial fluid analysis: The single most useful test CBC leucocytosis infection

ESR and CRP non specific may suggest inflammatory process

Serum uric acid: unreliable- may be elevated in acute inflammatory conditions not related to gout-

may be acutely diminished in true gout attack-aspirin taken as analgesics may lower serum uric

acid Radiograph of joint & contra lateral joint (for

comparison) frequently normal, may diagnose fracture or pseudogout

ANA and RF Cultures of blood, urine or other possible sites of

infection important in septic arthritis Serum prothrombin & partial thromboplastin time

coagulation disorders and patients on anticoagulants

Investigations for acute monoarthritis

Synovial fluid analysis: The single most useful test CBC leucocytosis infection

ESR and CRP non specific may suggest inflammatory process

Serum uric acid: unreliable- may be elevated in acute inflammatory conditions not related to gout-

may be acutely diminished in true gout attack-aspirin taken as analgesics may lower serum uric

acid Radiograph of joint & contra lateral joint (for

comparison) frequently normal, may diagnose fracture or pseudogout

ANA and RF Cultures of blood, urine or other possible sites of

infection important in septic arthritis Serum prothrombin & partial thromboplastin time

coagulation disorders and patients on anticoagulants

Chronic monoarthritis Inflammatory

Chronic infectious arthritis (mycobacterial TB fungal)

Gout and pseudogout Atypical presentation of RA & sero

- ve spondyloarthropathy

Noninflammatory Osteoarthritis Hemarthrosis Charcot joint

Chronic monoarthritis Inflammatory

Chronic infectious arthritis (mycobacterial TB fungal)

Gout and pseudogout Atypical presentation of RA & sero

- ve spondyloarthropathy

Noninflammatory Osteoarthritis Hemarthrosis Charcot joint

Investigations for chronic mono arthritis :

1.X-ray of affected joint & contralateral joint mycobacterial. & fungal infection-characteristic

features of osteoarthritis 2.Synovial fluid if possible (inflammatory #

noninflammatory) cultures (mycobacterial or fungal infection)

3.ESR & CRP non specific inflammatory process4.X-ray of SI joints spondylo arthritis

5.RF & ANA6.X-ray chest - Tuberculin test : TB

7.MRI: early inflammatory changes, destruction of periarticular bone

8.Arthroscopy visualization of structure , internal derangement, synovial biopsy

9.Synovial biopsy, microscopic evaluation & culture synovial tisse diagnosis of tumors,

fungal & mycobacterial affection

Investigations for chronic mono arthritis :

1.X-ray of affected joint & contralateral joint mycobacterial. & fungal infection-characteristic

features of osteoarthritis 2.Synovial fluid if possible (inflammatory #

noninflammatory) cultures (mycobacterial or fungal infection)

3.ESR & CRP non specific inflammatory process4.X-ray of SI joints spondylo arthritis

5.RF & ANA6.X-ray chest - Tuberculin test : TB

7.MRI: early inflammatory changes, destruction of periarticular bone

8.Arthroscopy visualization of structure , internal derangement, synovial biopsy

9.Synovial biopsy, microscopic evaluation & culture synovial tisse diagnosis of tumors,

fungal & mycobacterial affection

Acute polyarthritis

Rheumatic fever Gonococcal arthritis –meningococcal Viral arthritis (eg., hepatitis B&C infection, rubella,

HIV) Bacterial endocarditis (infective endocarditis) Polyarticular gout & pseudogout Rheumatoid arthritis Systemic lupus erythematosus (other diffuse CT-

diseases) Sero -ve spondylo arthritis Familial Mediterranean Fever

Acute polyarthritis

Rheumatic fever Gonococcal arthritis –meningococcal Viral arthritis (eg., hepatitis B&C infection, rubella,

HIV) Bacterial endocarditis (infective endocarditis) Polyarticular gout & pseudogout Rheumatoid arthritis Systemic lupus erythematosus (other diffuse CT-

diseases) Sero -ve spondylo arthritis Familial Mediterranean Fever

Investigations for acute polyarthritis

CBC ESR,C-reactive protein-ASO titer

RF, anti-CCP ANA, other auto antibodies HBsAg-HCV antibodies

HLA-B27, if compatible with spondyloarthritis Synovial fluid analysis to rule out crystalline

arthropathy X-rays of involved and contra-lateral joints-

ultrasound-CT scan-MRI Culture of cervix, rectum, throat, and skin lesions

when indicated. ECG – Echocardiography ( Rheumatic Fever )

Investigations for acute polyarthritis

CBC ESR,C-reactive protein-ASO titer

RF, anti-CCP ANA, other auto antibodies HBsAg-HCV antibodies

HLA-B27, if compatible with spondyloarthritis Synovial fluid analysis to rule out crystalline

arthropathy X-rays of involved and contra-lateral joints-

ultrasound-CT scan-MRI Culture of cervix, rectum, throat, and skin lesions

when indicated. ECG – Echocardiography ( Rheumatic Fever )

Chronic polyarthritis Inflammatory :

Rheumatoid arthritis Systemic lupus erythematosus &

other diffuse CT diseases Sero -ve spondyloarthropathies gout

Non – inflammatory Osteoarthritis

Chronic polyarthritis Inflammatory :

Rheumatoid arthritis Systemic lupus erythematosus &

other diffuse CT diseases Sero -ve spondyloarthropathies gout

Non – inflammatory Osteoarthritis

Investigations for chronic polyarthritis

CBCESR , C-reactive proteinTest for RF, anti-CCPANA, other autoantibodies Creatinine kinase , aldolase, EMG (myositis)HLA-B27, if compatible with spondyloarthritisHCV Ab - HIV Ab assayThyroid function tests, if appropriateX-rays of involved and contralateral joints-ultrasound-CT scan-MRI-Bone scan

Chest X-raySynovial fluid analysis

Investigations for chronic polyarthritis

CBCESR , C-reactive proteinTest for RF, anti-CCPANA, other autoantibodies Creatinine kinase , aldolase, EMG (myositis)HLA-B27, if compatible with spondyloarthritisHCV Ab - HIV Ab assayThyroid function tests, if appropriateX-rays of involved and contralateral joints-ultrasound-CT scan-MRI-Bone scan

Chest X-raySynovial fluid analysis

Investigations (contd.)

Special procedures, when appropriate:• Serum complement• Creatinine clearance• Coagulation screening• Esophageal motility studies• Contrast studies of the gastrointestinal

tract• Biopsy of subcutaneous nodules, tophi,

or synovium

Investigations (contd.)

Special procedures, when appropriate:• Serum complement• Creatinine clearance• Coagulation screening• Esophageal motility studies• Contrast studies of the gastrointestinal

tract• Biopsy of subcutaneous nodules, tophi,

or synovium

Examination of joint fluid Examination of joint fluid Measure Normal Group I

Noninflammatory

Group II

Inflammatory

Group III

Septic

Volume (ml)(knee)

Clarity

Color

Viscosity

WBC/l

Polymorphonuclear

leukocytes(%)

Culture

<3.5

Transparent

Yellow

High

<200

<25%

Negative

Often <3.5

Transparent

Yellow

High

200 to 2000

< 25%

Negative

Often > 3.5

Translucent-opaque

Yellow or white

low

2000 to 100,000

50% or more

Negative

Often > 3.5

Opaque

Yellow to green

Variable

>100,000

75% or more

Often positive

Thank You