Objectives. Joint Pain. Case 1. Rheumatology for the Primary MD (Not just your grandmother s disease) 12/4/2010
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1 Objectives Rheumatology for the Primary MD (Not just your grandmother s disease) Identify when it is appropriate to refer for rheumatologic evaluation Autoimmune/ Inflammatory v. noninflammatory disease R. Krishna Chaganti Assistant Clinical Professor Div. of Rheumatology UCSF Useful preliminary tests Less useful tests INFLAMMATORY (Autoimmune) Rheumatoid Arthritis Seronegative Spondyloarthropathies Connective Tissue Diseases SLE MCTD Inflammatory Myopathies Vasculitis Joint Pain NON-INFLAMMATORY Osteoarthritis Mechanical Injury Tendon Muscle Bursitis Neuropathic Crystal-Diseases Gout CPPDD (Pseudogout) Case 1 65 year old man c/o pain in both hands Began 6 months ago Hard to make a fist Takes several hours in a.m. to loosen up Fingers are swollen 1
2 Most likely diagnosis: 1. Osteoarthritis 2. Rheumatoid Arthritis 3. Diabetic cheiropathy 4. Gout 69% 27% 1% 3% Inflammatory* Joint Pain Pain worse after rest Improves with activity Constitutional symptoms Exam: joint swelling Atypical joint involvement Glenohumeral Elbow Labs: ESR, CRP * Autoimmune Case 1 65 year old man c/o pain in both hands Began 6 months ago Hard to make a fist Takes several hours in am to loosen up Fingers are swollen A) Osteoarthritis B) Rheumatoid Arthritis C) Diabetic Cheiropathy D) Gout 2
3 Rheumatoid Arthritis 30 cases/100,000 Peak onset: y 6 weeks: AM stiffness > 1 hour, 3 swollen joints (at least one wrist, MCP, PIP) Bilateral Subcutaneous nodules Labs: RF, anti-ccp Ab Rheumatoid Arthritis Symmetric Spares DIP joints Anemia of chronic disease X-ray: Erosions (Late) Peri-articular osteopenia (Early) RA RA: Erosions 3
4 Early RA RA: Extra-articular Useful Tests: Pre-Referral ESR CRP CBC RF anti-ccp LFTs Hepatitis B and C X-rays (bilateral) 4
5 Case 2 32 year old man with 4-5 months of low back pain Wakes him at night Active (runner) Most likely diagnosis 1. Lumbar Strain 2. Scheurmann s disease 3. Ankylosing Spondylitis 4. Hypermobility Syndrome 82% Heel pain (changed his sneakers) Fatigue (increased workout intensity) 9% 7% 2% Inflammatory Back Pain Case 2 Inflammatory Insidious onset Improves with exercise Worse with rest Wakes people up at night Onset < 40y 30 min AM stiffness Alternating buttock pain (Sacroiliac joint pain) Mechanical Acute Worse with exercise Improves with rest <30 min AM stiffness 26 year old man with low back pain x several months Wakes him at night Active (runner) Heel pain (changed his sneakers) Fatigue (increased workout intensity) A) Lumbar Strain B) Scheurmann s disease (juvenile thoracolumbar kyphosis) C) Ankylosing Spondylitis D) Hypermobility Syndrome 5
6 Ankylosing Spondylitis Ankylosing Spondylitis 2-5% prevalence Increased in HLA-B27 (+) Dx criteria: Onset < 40 years old Insidious onset Improves with exercise Worse with rest Wakes people up at night Ankylosing Spondylitis Ankylosing Spondylitis 6
7 Seronegative* Spondyloarthropathies Ankylosing Spondylitis Psoriatic Arthritis IBD-associated arthritis Reactive Arthritis * RF, anti-ccp and ANA negative Psoriatic Arthritis Psoriatic Arthritis 7
8 Case 3: 60 year old woman Several weeks of difficulty combing her hair, putting a shirt on over her head Hard to sit for long periods of time Fatigued Possible Diagnoses 1. Bilateral Rotator Cuff Tendonitis and trochanteric bursitis 2. Cervical Spine Osteoarthritis 3. Polymyalgia Rheumatica 4. Hypothyroidism 97% 1% 2% 1% Polymyalgia Rheumatica (PMR) Age > 50, average age= 70 AM stiffness, shoulder and hip Painful joints, especially shoulder > hip Synovitis, bursitis Swelling, tenosynovitis Muscle tenderness Subjective weakness Systemic Sxs: malaise Lab: ESR > 40 PMR: Differential Dx RA RS3PE (Remitting Seronegative Symmetric Synovitis with Pitting Edema) Bursitis/tendinitis Spondyloarthropathy CPPDD (Pseudogout) Hypothyroidism Fibromyalgia Malignancy Inflammatory Myositis Parkinson s Disease Depression 8
9 Giant Cell Arteritis Anti-Nuclear Antibody Testing (ANA) 50% of GCA patients have PMR symptoms. PMR pt with refractory Sx consider GCA Vision loss Diplopia SLE and ANA ANA testing Different Methods Immunofluroscence ELISA Be suspicious if no ANA pattern reported (+) ANA does not = SLE SLE /100,000; Women > Men Clinical diagnosis: Mucocutaneous Arthritis Serositis Renal Neurologic Hematologic (+) ANA 9
10 SLE: Cutaneous manifestations SLE: Discoid Photosensitive rash Spares nasolabial folds Easily confused with: Rosacea Polymorphous Light Eruption Flushing of Pregnancy SLE: Septal perforation Summary Refer when symptoms suggest inflammatory joint or back pain Useful Tests: ESR* C-reactive protein CBC RF Bilateral x-rays *Age-adjustment 10
11 Summary Less useful: HLA-B27 (clinical suspicion) ANA and subserologies of ANA anti-ccp Thank You 11
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