Classification of Rheumatic Diseases
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Transcript of Classification of Rheumatic Diseases
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