Lecture: Warning Signs Of Rheumatic Disease

1 WARNING SIGNS OF RHEUMATIC DISEASE Dr. Llamado (Module 4 / Lecture Date: July 17, 2006) CASE 1: 62 year-old female BMI = 26 (overweight) Hand pain Knee pain worsens after prolonged standing PE: genu varum (bow-legged)

ACR 1987 Classification Criteria for RA 1. Morning stiffness >30 mins 2. arthritis of the 3 or more joints 3. arthritis of hand joints 4. symmetric arthritis 5. rheumatoid nodules extensor surface of elbow

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Dx: OSTEOARTHRITIS Clinical     

Age > 50 y.o. Morning stiffness < 30 mins Crepitus (-) inflammation Bony enlargement or tenderness

Laboratory  ESR < 40 mm/hr  (-) RF  Synovial fluid non-inflammatory Radiography  Osteophytes or new bone formation  Joint space narrowing: asymmetric

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Subchondral cyst or sclerosis : signifies new bone formation; ↑ opacity Malalignment

When looking at x-ray, note for:

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Alignment - straight Bone - radioopaque Cartilage not seen radiographically, look for joint space which will give an idea of the thickness/thinness Compare medial vs. lateral compartment fibula (lateral) if (+) joint space narrowing, compare: Assymetrical in OA

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if (+) white area in tibial plateau: Unnecessary pressure/bone-to-bone contact  stimulus for osteophytes  leading to new bone formation (subchondral sclerosis)

Hand involvement in OA  Refers to bony new growth or bone enlargement  DIP = Heberden’s nodes  PIP = Bouchard’s nodes  X-ray : (-) joint space, (+) osteophytes  (-) tissue swelling.

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Note: In RA, there is an inflammatory cytokine (esp IL-1) reaction  osteoclast stimulation  no new bone formation

Spine involvement in OA  (+) osteophytes  Asymmetric

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poor prognosis marker, If present, must be more aggressive with management Serum rheumatoid factor there may be sero (-) Rf but does not ruleout RA

Subchondral sclerosis at the edge of the vertebral body (radioopacity) OBLIQUE VIEW: done to view the IV joint space o (+) Scotty-dog sign o (+) joint space narrowing o intact cartilage above but narrowing in lower segment Commonly affected: o Weight-bearing joints (hips and knees)

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Lower cervical  Usually C6-C7 Hand (bony enlargement)

CASE 2: 34 year-old female Hand joint pain & swelling for 6 months Muscle aches & pains Anemia (systemic manifestation) Dx: RHEUMATOID ARTHRITIS

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a prognostic factor: the ↑  poorer prognosis radiographic changes

Note: First 4 criteria must be present for at least 6 weeks (Rationale: Viral arthritits may mimic RA but resolves within 6 weeks) Hand involvement

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PIP involvement in early stage Sparing of DIP especially in early stage Soft tissue swelling  synovitis X-ray: bone erosion Deformities Swan neck deformity Buotonnier deformity Mallet finger: flexion of DIP Subluxation of phalanges: prominence of the head of MCPs Problem with grip

Knee x-ray of RA

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Fusion of bones  symmetric narrowing  ankylosis

Spine involvement

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Upper cervical spine are affected  C1-C2 (atlantoaxial joint)

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Look at the distance between 2 bones. If > 5 mm space of atlantoaxial joint  suggestive of subluxation; joint instability

Criteria for Progression of RA Stage 1: Early No destructive changes Osteoporosis on x-ray Stage 2 : Moderate Osteoporosis and slight subchondral bone or cartilage destruction No joint deformities Mobility may be limited Adjacent muscle atrophy Nodules or tenosynovitis may be present Stage 3 : Severe Osteoporosis and erosions Deformity without ankylosis Extensive muscle atrophy Nodules & tenosynovitis Stage 4 : Terminal Fibrous or bony ankylosis (fusion of 2 bones, no flex/ext) Features of Stage 3

CASE 3: 43 year-old male Recurrent monoarthritis Later on becoming polyarthritis Chronic alcoholic beverage drinker Occasional chest discomfort Dx: GOUT 1ST MTP joint : Podagra Most painful type of arthritis Any form of stress can cause change in serum uric acid and precipitate gout Hyperuricemia : (+) tophi Tophaceous or urate nephropathy Can be deposited elsewhere (ears, heart, kidney)

2 Gouty arthritis generalities:  Extremely painful episodes of arthritis

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Intermittent course, usually monoaticular involving the big toe, ankle, knee May later be poly or oligoarticular

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Tendency to abuse NSAIDS (and steroids)  may cause upper GI bleeding

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May be precipitated by stress e.g. surgery & blood transfusion

Acute attack of gout  Associated with change in serum uric acid level (either increase or decrease)  Taking of Allopurinol within 24-48 hours of attack of gout to decrease hyperuricemia may prolong attacks due to the sudden drop. Initiate Allopurinol only when the attack of gout has subsided

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If the patient is not on allopurinol, do not introduce; If the patient is already on allopurinol, don’t stop immediately

X-ray:

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(+) tophaceous erosion: far from joint, can deposit into the bone, as compared to RA where erosions are near the junction areas

43 year-old male Back pain, > 4 months Morning stiffness PE: (-) lumbar lordosis DX: ANKYLOSING SPONDYLITIS

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Bridging syndesmophytes (ossification) Early changes: squaring of the vertebral body X-ray: Bamboo spine deformity

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Duration > 3 months Associated with morning stiffness Decreased stiffness with exercise  impt treatment modality

CASE 5 53 year-old male asymmetric arthritis “Dandruff” nail changes Dx: PSORIATIC ARTHRITIS  Mgt: aggressive due to destructive course

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Nail-pitting changes  early changes  check for scalp (dandruff along the hair line) Scalp changes follow hairline

Hand deformity  X-ray of DIP : fusion of bone  Pencil-in-cup deformity

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Telescoping digit  redundant skin, retractable

Hip Fracture

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16%: die within 1-2 years due to fracture, embolism, surgical complications

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80%: loss of independence permanently

Far Eastern Osteoporosis Study, 1996  Total interviews: 2412 females (Phils 600)

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Dx: OSTEOPOROSIS 

Silent disease

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Often asymptomatic until fractures occurs Early diagnosis & treatment are essential

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Awareness of osteoporosis: considerably lower among Asian women than among women in Europe Only about 66% of Asian women surveyed are aware of the disease compared to 90% of European women Asian women regard it mainly as a function of aging and not a disease Repeat study: no change in awareness level

 Peak bone mass: achieved by 35 years old, after 35 yo, physiologic bone loss Vertebral fracture Assess the following

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Vertebral height Anterior, midPosterior • Reduction in at least >20% considered as vertebral compression fracture

Deformities 1. Normal 2. Concave: decrease in midvertebral height

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Wedge: anterior part Crush: all (ant-post-mid) parts of the vertebra

Bone densitometry = assesses bone mineral density T-score: Px score vs. normal young sex-matched : assesses how much bone was lost from the time px had his or her peak-bone mass Z-score: Px score vs. normal age-matched & sex matched : if < -2 = maybe secondary bone loss WHO Criteria (Vertebrae and hip) T-score > -1 : Normal -1 to -2.5 : Osteopenia -2.5 and below : Osteoporosis < -2.5 + fracture : Severe osteoporosis Warning signs of Serious Rheumatic Disease  Persistent or worsening pains

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Pains unrelieved by regular intake of NSAIDs or other potent analgesics

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“Nerve pain” (tingling, burning, electric current-like sensation), vascular pain (claudications), bone pains Accompanied by fever, weight loss, pallor, etc.

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Elderly patients

CASE 6 68 year-old female Chronic back pain Loss of height PE: Dowager’s hump (C4 compression)

Protuberant lower abdomen with early satiety, bloating & nausea (increased risk of function at other areas e.g. hip)

Vertebral fracture associated with other fractures as well

Mgt: Infliximab earliler prevention of LOM better

Characteristics of Back Pain  Onset before 40 years  Onset is insidious

Thinning and breakdown of trabeculae

Spinal osteoporosis: Clinical Features  (-) early warning symptoms  Height loss  Dorsal kyphosis  Paraspinal muscle pain  Restrictive lung disease

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CASE 4:

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Examples: Infection, Malignancy, Vasculitis (impaired vascular supply)

CASE 7 25 year-old male Chronic fever, cough, back pains

3 ESR 120 mm/ 1st hour Draining sinuses (usually due to TB) Recent paraparesis Dx: POTT’S DISEASE 

Anterior wedging of the spine

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Abscesses (usually continuous; rare presentations: skip lesions  problem for surgery)

Treatment of Septic Arthritis

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TB and Bacterial type of arthritis

60 year-old male Heavy smoker Progressive peripheral swelling of right shoulder Not relieved by NSAIDs and potent analgesics X-ray: Lytic lesions, destroyed humoral head Dx: PULMONARY MALIGNANCY with BONE METASTASIS

CASE 10 73 year-old male Bone pains and weight-loss Elevated acid phosphatase

Dx: SEPTIC ARTHRITIS

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Direct invasion of joint space by a variety of microorganism such as bacteria, mycobacteria and fungi

VS. Reactive arthritis: occurs after an infection outside the joint; thus sterile arthritis Organisms  Staphylococcus aureus most common; adult & children > 2 years of age  Neisseria gonorrhea: the most frequent pathogen (75%) of cases among young sexually active individuals

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Crystal-induced, rheumatoid, noninfectious inflammatory arthritis: o 30,000-50,000 cells/uL

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Mycobacterial or Fungal infection o 10,000 – 30,000 cells/uL o with 50-70% neutrophils

Mycobacterial Arthritis  1% of all cases of TB and 10% extrapulmonary manifestation

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Most common presentation: chronic granulomatous monoarthritis PONCET DISEASE o reactive symmetric form of arthritis that affects patients with visceral or disseminated TB

Dx: HYPERTROPHIC OSTEOARTHROPATHY

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Clubbing of digits

Hypertrophic Osteoarthropathy  characterized by clubbing, excessive proliferation of the skin, joint effusion and periosteal bone elevation in the distal extremities (pachydermoperiostosis)  9times more common in men  pain, when present, is deep-seated; may range from burning pain in fingertips to an incapacitating bone pain more prominent in LE and aggravated by dependency of the limbs o Due to periostitis (new bone formation) X-ray:

periostitis (+) pulmonary malignancy

CASE 12 54 year-old female Bone pains Back pain Anemia, azotemia Weight loss Skull x-ray: well-circumscribed lytic lesions Bone obscureness (cannot see outline) Dx: MULTIPLE MYELOMA Low Back Pain

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X-ray: PHEMISTER TRIAD

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Spine lesions  blastic, lytic lesions  prostatic metastasis

63 year-old female 50 pack-year smoking history Distal clubbing

involves hip, knee and ankle Peripheral erosion at points of synovial attachment, periarticular component, Periarticular osteopenia, Joint space narrowing Treatment is the same for TB pulmonary disease (69 months)

Blastic  new bone formation

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Aerobic gram (-) : 20% in immunocompromised 20-25%

Synovial fluid examination  (N): < 180/uL cells (predominance of mononuclear cells)  Acute bacterial o 100,000 cells/uL o (25,000-250,000 with 90% neutrophils)

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Dx: PROSTATIC MALIGNANCY with BLASTIC and LYTIC LESION

Streptococcus spp. : 20%

Affected Joint Distribution in Adults and Children with Non-Gonococcal Bacterial Arthritis % Cases Adult Children Knee 55 40 Hip 11 >8 Ankle 8 14 Shoulder 8 4 Wrist 7 3 Elbow 6 11 Others 5 3

Draining of fluid Joint immobilization (during acute phase only)

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CASE 8 40 year-old male Alcoholic DM Type 2 Recent arthrotomy for TB arthritis 2 weeks post-op developed non-healing wound or persistent effusion

Appropriate antibiotics

More common in Female > male Increasing frequency with increasing age Some statistics: o Most episodes are not incapacitating o > 50% improve after a week o >90% are better after 8 weeks o 7-10% continue to experience symptoms for longer than 6 months

Etiology

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Mechanical in 90% i.e. Overuse of normal anatomic structures e.g. trauma, Deformity (Scoliosis)

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10%

Manifestation of Systemic Illness

Clinical Evaluation  most source of LBP are disorders of muscles, fascia and ligaments which cannot be (nor need be) specifically identified  however, the clinician must be alert to the red flags of LBP which portend a more serious underlying cause which requires early diagnosis and treatment Red Flags of LBP  Persistent progressive pain especially on recumbency  Saddle anesthesia with or without bladder and bowel symptoms

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Accompanying fever, weight loss, anemia Bone and nerve pains (signs of neuropathy)

Classification  Mechanical

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Medical o Infection Bacterial – acute Tuberculosis and fungal – indolent Fever, weight loss, pain is persistent, present at rest, exacerbated by motion o Tumor or malignancy Fever, weight loss, pallor Pain with recumbency or at night & disturbs sleep Pain has gradual onset but persistent in character and increasing in intensity Pain not relieved with rest or application of heat, localized tenderness Signs of hypercalcemia

Cancer Pain: NEUROPATHIC PAIN:  during the day, the stimulus is masked by other sensation; during nighttime, this is the only stimulus present thus “exacerbation” Assessment of cancer pain

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Assessment: vital first step in cancer pain management Pain: always subjective; patient self-report of pain is the gold standard for assessment

Some Pittfalls in Rheumatology  Present polyarthritis may have started as intermittent monoarthritis of gout

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(referred pain) Knee pain in a perfectly-looking knee may be coming from hip (referred pain)

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A rash is not a rash if you do not look for it

SUMMARY

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Most rheumatic diseases are diagnosed by history and PE, occasionally with the use of basic laboratory tests Analgesics and anti-inflammatory drugs are a mainstay of therapy in most rheumatic diseases Therapy is highly individualized even in patients with the same rheumatic disease Recognition of a serious rheumatic disorder may be more important than making an actual diagnosis Jobern Hipol/Faye delos Santos/Trina FC USTMedB’08