APPROACH TO PATIENTS WITH POLYARTHRALGIA

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Beatrix Brittany Booker
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1 APPROACH TO PATIENTS WITH POLYARTHRALGIA Scott Vogelgesang, MD Division of Immunology University of Iowa No conflicts of interest

DEFINITIONS Arthralgia joint pain with no evidence of inflammation Arthritis joint inflammation (usually with joint pain) Osteoarthritis has

2 DEFINITIONS Arthralgia joint pain with no evidence of inflammation Arthritis joint inflammation (usually with joint pain) Osteoarthritis has no inflammation it s not a great name! Myalgia muscle pain with no evidence of inflammation Myositis muscle inflammation; usually with weakness

3 GENERAL PRINCIPLES History & Physical Exam are Critical Identify urgent situations Monoarticular arthritis with a fever Severe Systemic illness (weight loss, respiratory failure) Identify Inflammatory Conditions AM stiffness > 60 minutes (beware fibromyalgia) Stiffness better with activity, worse with rest Observed joint swelling Exclude fibromyalgia as a cause of pain and evaluate for common causes such as osteoarthritis

4 APPROACH TO PATIENTS WITH MUSCULOSKELETAL COMPLAINTS Complaint > 6 weeks Severe, involving single joint Febrile, acutely ill losing weight systemic symptoms Likelihood of fracture ligament tear dislocation Associated neurologic problem Yes No STOP No Laboratory investigation indicated Yes Condition persistent? Rest painful part, apply heat simple analgesics re-evaluate 2-6 wks Borrowed from Elizabeth Field

5 LABORATORY TESTS: SUPPORT A CLINICAL IMPRESSION General lab evaluation: CBC with differential Chemistry panels Urinalysis Identify occult organ system involvement

6 LABORATORY TESTS: SUPPORT A CLINICAL IMPRESSION ESR Nonspecific UTI, sinusitis can elevate Increases with age Upper Limit Normal Men = Age/2 Women = (Age + 10)/2 CRP Nonspecific Not as affected by age; can be affected by BMI and Diabetes

7 LABORATORY TESTS: SUPPORT A CLINICAL IMPRESSION Beware the Arthritis Panel RF (alone) Rheumatoid Arthritis ANA (alone) Systemic Lupus Erythematosus Elevated Uric Acid (alone) Gout ANCA (alone) Vasculitis

8 INDICATIONS FOR ADDITIONAL TESTING Rheumatoid Factor and/or CCP - Clinical suspicion for Rheumatoid Arthritis Inflammatory Arthritis (symmetrical) of hand/foot joints Present > 6 weeks ANA - Clinical suspicion for SLE, Sjögren's Syndrome or Scleroderma Other antibodies order if Sm/RNP Clinical suspicion for SLE and ANA is positive DsDNA Clinical suspicion for SLE and ANA is positive SSA/SSB Clinical suspicion for SLE or Sjögren's Syndrome SCL-70 Clinical suspicion for diffuse Systemic Sclerosis (Scleroderma)

9 POLYMYALGIA All previous recommendations apply Distinguish Polymyalgia Muscle pain but no weakness from Polymyositis Muscle weakness but no pain Polymyalgia Rheumatica Ages (F > M) w Shoulder, neck > Thigh pain Beware giant cell arteritis (headache, jaw claudication, scalp tenderness, vision) Elevated ESR/CRP; CK not elevated Polymyositis Ages Proximal weakness with no pain CK elevated; ESR/CRP may be normal

10 FIBROMYALGIA Ages (any age) Diffuse musculoskeletal pain (muscle, joint, bone) Sleep abnormalities (awaken feeling tired) Strength (and CK) normal; ESR normal Differential diagnosis Sleep apnea Depression/anxiety Thyroid dysfunction Hyperparathyroidism PMR in a women 60 years

11 INFECTION: HOW NOT TO MISS. Usually monoarticular Patients look sick Knee is most common location Beware Disseminated GC Young, sexually active patient Tenosynovitis Rash (small papules patient may not know) Migratory joint complaints

12 MALIGNANCY: HOW NOT TO MISS In General Night time pain Systemic features X-ray abnormalities Periosteal elevation Focal destructive lesions Osteodsytrophy Dependent pain Periosteal elevation (Xray) Metastatic Disease Usually monoarticular Carcinomatous Polyarthritis Spares PIPs, MCPs Leukemia Children asymmetric polyarticular

13 CASE 25 yo woman has painful, swollen hands x 3 weeks; Difficulty opening jars, fine hand movts; AM stiffness x 45 min; ibuprofen 600 mg TID helps some; ROS: (-) Oral ulcers, chest pain, shortness of breath, rash, GERD, photosensitivity, dry eyes/mouth; FSHx: 5 th Grade Teacher; ETOH (-); Tob (-) PE: Vitals NL; 2+ swelling/pain all MCP/PIP Labs: CBC w NC/NC anemia; Chemistries NL; UA NL;ESR 35 Check ANA? RF? CCP? Diagnosis? Therapy?

14 CASE 73 yo woman has shoulder pain x 3 months & getting worse; no precipitating event; can t sleep; difficult to dress; AM stiffness x 1 hour ROS: (-) fever, chest pain, shortness of breath, headache, jaw pain, scalp tenderness, changes in vision, swollen joints FSHx: Family Hx (-); ETOH (-); Tob (-) Meds: ASA PE: Vitals NL; Uncomfortable in chair; Limited bilateral shoulder ROM; rest (-); Labs: CBC with NC/NC anemia; Chemistry NL; ESR 17 What next? What is her Dx?

15 CASE 40 yo man w low back pain; 10 minutes of morning stiffness; pain gets better with rest; pain present for 3-4 years, but is getting worse. ROS: He notes occasional oral ulcers and irritated eyes (wears contacts), but denies dysuria FSHx: PE Teacher; ETOH (-); Tob (-) PE: Vitals NL; limited back flexion Labs: CBC w NC/NC anemia; Chemistries NL; UA NL;ESR NL Check HLA-B27?..X-rays of back?..diagnosis?..therapy?

16 CASE 38 yo woman w joint pains all over for past 6 months; She reports hand swelling and stiffness; 2 hrs of AM stiffness; Activity makes it worse ROS: (+) fatigue, difficulty with sleep because of pain FSHx: Middle School Teacher; ETOH (-); Tob (-) PE: Vitals NL; Exam NL Labs: CBC NL; Chemistries NL; UA NL;ESR NL Check ESR? CK? Diagnosis? Therapy?

17 TAKE HOME POINTS Labs Support Clinical Impression Occult organ involvement Urgent! Monoarticular with fever Systemically ill Polyarthralgia Look for joint inflammation Exclude fibromyalgia and OA PMR > 60 yrs; proximal pain w ESR/CRP Infection Monoartic. (knee) Sick patient Malignancy Night time pain Systemic features X-ray abnormalities Periosteal elevation Focal destructive lesions

Scott Vogelgesang, MD Division of Rheumatology/Immunology University of Iowa

Scott Vogelgesang, MD Division of Rheumatology/Immunology University of Iowa Basic Concepts ANA DsDNA Sm RNP SSA SSB RF/CCP ESR/CRP ANCA Cases Summary Rheumatology Tests Lie and Mislead! Rheumatology Rally