Arthritis

Unit 22. Arthuritis  Stiffness of the joints caused by too many nights at the round table  Most common disease in Canada.

Objectives: 1. To know the rheumatic diseases and their presentation. 2. To know the laboratory tests to order in rheumatic diseases 3. To interpret the results from these laboratory investigations.

Types of rheumatic disease:    

Tendonitis Fibrositis Osteoarthritis Systemic inflammatory rheumatic diseases

Arthritis society 1994 (Canadian numbers):     

Osteoarthritis Fibromyalgia Rheumatoid arthritis Gouty arthritis Ankylosing spondylitis  Systemic lupus erythematosus.

 3,000,000  820,000  290,000  280,000  30,000  15,000

Some autoimmune diseases:  Rheumatoid arthritis  Systemic lupus erythematosus  Reiter's syndrome  Rheumatic fever

 Myasthenia gravis  Multiple sclerosis  Graves (thyroid) disease  Insulin dependant diabetes mellitus.  Psoriasis.

Some systemic signs of arthritis  Scleritis :Sjogren’s syndrome.  Spine: cervical cord compression  Lungs: fibrosis, nodules, effusions  Splenomegaly: Felty’s syndrome  Bursitis. Oedema at joints. Carpal tunnel syndrome.  Vasculitis. Leg ulcers: Felty’s syndrome  Kidneys: amyloid. Neuropathies…………..

Questions to ask are:  Onset  Characteristics  Pattern of joint involvement  Course  Therapy  Extra articular features  Ability to function

Osteoarthritis:  Most common arthritis  Degenerative  Secondary:  Haemochromatosis.  Wilson’s disease  Acromegaly  Serum keratan sulphate – a marker of predisposition to OA. Research, not proven useful.

Fibromyalgia (myofascial pain, Fibrositis, psychic rheumatoid):       

1-2% of population Female to male 9:1 30-50 years Cause unknown, pain sensitive Tender nodules and points. DDx: difficult. Low serotonin in CSF, high neurotransmitter substance P in CSF, low somatomedin C.

Systemic inflammatory rheumatic diseases:  Autoimmune: Rheumatoid arthritis, Systemic Lupus Erythematosis, Sjogren’s syndrome, polymyositis dermatomyositis, systemic sclerosis  Seronegative spondylarthropathies: Ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis  Crystals: gout and pseudogout.

Systemic inflammatory rheumatic diseases (continued):  Vasculitides: Wegener’s granulomatosis. Polyarteritis nodosa, polymyalgia rheumatica.  Infections: Neisseria gonorrhoea, rheumatic fever.

Rheumatoid arthritis:  1-2% of the populations.  Chronic inflammatory  Women 20-40 years of age, mostly  Disrupted Collagen.  Rheumatoid factor (RF) antibodies against the Fc fragment of IgM.

Prevalence of rheumatoid factor in non rheumatic diseases: Sub acute bacterial endocarditis Waldenstrom’s macroglobulinaemia Infectious hepatitis Cirrhosis of the liver Pulmonary interstitial disease Cytomegalovirus. Epstein Barr virus (Kissing disease)

approx 40% 30 25 25 25 20 20

Rheumatoid arthritis:  Complete blood count:  Haemoglobin decreased  Leukocytes decreased  Platelets increased  ESR, viscosity, CRP  Cryoglobulins  Rheumatoid factor, ANA

Systemic lupus erythematosus:  Women:men 8:1  13-40 years  Attacks skin, brain, heart, lungs, joints, muscle, kidney.  14 symptoms, need 4 for the diagnosis  Antinuclear antibodies (ANA) indirect immunofluorescence patterns.

Antinuclear antibodies: >1:320 Systemic lupus erythematosus

96%

Drug induced systemic lupus erythematosus

100

Scleroderma

97

Sjogren’s syndrome

90

Polymyositis

78

Dermatomyositis.

78

Systemic Lupus Erythematosus:  CBC: Hb, wbc, lymphocytes decreased  ESR increased  Anti Sm antibodies  Antidouble stranded DNA  Serum C3, C4, total complement decreased  Rheumatoid factor in 20%

Sjogren’s syndrome:  Chronic autoimmune disease  Lymphatic infiltration of lachrymal and salivary glands.  Dry eyes and mouth  90% are female > 50 years of age  50% also have rheumatoid arthritis  2/100,000.

Reiter’s syndrome (reactive arthritis):  HLA B 27  Arthritis  Sacroillitis  Extraarticular inflammations.  Affects muscles, tendons, eyes, gastrointestinal tract, genitourinary tract, digits, vertebrae, keratoderma……

Scleroderma: Limited:  Calcinosis  Raynaud’s  Esophageal  Sclerodactyl  Telangiectasia  Pulmonary HT  Benign  Seropositive.

Diffuse:  Widespread skin  Proximal to trunk  Visceral disease: kidneys, lungs, heart.  Malignant  Seropositive.

Scleroderma:  Hb decreased  Wbc normal  Platelets increased  ESR increased  Anti-Scl-70  Anticentromere  Rheumatoid factor in 30%

Ankylosing spondylitis:        

Possibly a RA variant. Male 1-2% of population Back and sacroiliac pain Tendon insertion pain Pulmonary fibrosis Aortic disease Unwell.

Ankylosing spondylitis:  RF negative  HLA B27 positive  Anaemia  Renal failure, amyloidosis – nephrotic syndrome  Iritis

Tests of inflammation:  Complete blood count  Erythrocyte sedimentation rate ESR  Plasma viscosity  Serum C reactive protein.

Specialty arthritis tests  ANA  Individual nuclear antigens    

Anti DNA, histones Extractable nuclear antigens Anti RNA, anti Smith Anti cardiolipin etc.

 Antineutrophil cytoplasmic antibodies ANCA

Specialty tests  Cryoglobulins – Raynaud’s phenomenon.  HLA typing  

RA associated with HLA-DR4 Ankylosing spondylitis with HLA-B27.

Rose Wolff 20 year old woman intermittent pain in hands feet  Face red on cheeks.  Serum ANA  Put on steroids.  2 years later her ankles and abdomen started swelling.  Her joints are normal.

Rose Wolff:  ESR 100 mm/h (1-20)  Serum albumin 20 g/L (35-50)  Serum protein 35 g/L (60-80)  Serum creatinine 130 umol/L (40-120)  Serum cholesterol 7.2 mmol/L (3.9-6.2)  Serum complement C3 0.4 g/L (0.5-1.2)  C4 0.06 g/L (0.1-0.5)

Rose Wolff:  Serum CH50 <30 umol/L (60-160)  Urinalysis protein ++++ (0)  Urine protein 7 g/d (<150mg/d)  Serum ANA 1:2500 (negative)  Serum Anti DNA positive (negative)  Anticardiolipin antibodies 24 GLP (0-20)

Ruth Arthur, 33 year old woman has morning stiffness  Joints stiff, swollen, symmetrical.  Serum RF positive (negative)  When pregnant her symptoms lessened.

Rumourtism: A morbid craving for gossip.