APPROACH TO THE PATIENT WITH

RHEUMATOLOGICAL DISEASE

It’s in your hand, take action

PRESENTED BY
MAJ MD MOKTER HOSSAIN
TRAINEE IN MEDICINE
GUIDED BY
BRIG GEN M ABDUR RAZZAK
ADVISER SPECIALIST IN MEDICINE AND
RHEUMATOLOGIST
CMH CHITTAGONG
 INDEX SHEET
S/No Subject Page No
1 Introduction
2 Background
3 Presenting problem of musculoskeletal disease
4 Important musculoskeletal symptoms
5 Evaluation of musculoskeletal pain
6 Classification and causes of joint pain
7 Temporal patterns of joint involvement in polyarthritis
8 Distribution of joint involvement in polyarthritis
9 Nature of pain
10 Factors affecting joint pain
11 Chronic multiple regional pain without arthritis
12 Evaluation of symptoms other than joint pain
13 Guidelines for diagnosis of Rheumatological disease
14 Vascuitis
15 Approach to the patient of rheumatological disease
16 History taking and its significance
17 Physical Examination and its evaluation
18 Laboratory studies
19 Principles of management of musculoskeletal disease
20 Conclusion
INTRODUCTION
 Islam says “Human is the best creature of the universe”. Science says ‘Human is the
best creature due to its two special quality. One is well developed brain(Nervous
system) and second one is the best hand grip(well controlled musculoskeletal
system).” And here lies the importance of rheumatology.
 Rheumatic diseases are the most prevalent of chronic painful disorder in the world
today.
 One in four new consultations in general practice are for musculoskeletal symptoms.
 Rheumatological diseases are the most common cause of physical disability in older
people and in one third of physical disability in any ages.

BACKGROUND
 Most musculoskeletal conditions are predominant in women and with advance of age. It
has strong association with genetic and epigenetic susceptibility and influence of
environmental factors and failure of immune tolerance which ultimately land up in
rheumatological disease.
 Pathogenesis involves disturbance of connective tissue turn over, changes in immune
function, inflammation and crystal deposition.
 Outcome of rheumatic disease includes pain and abnormalities of locomotor function
which ultimately land up in physical disability, psychological problem, increased
mortality and morbidity.

PRESENTING PROBLEMS IN MASCULOSKELETAL DISEASE

 Arthritis
 Monoarthritis
 Polyarthritis
 Fracture
 Muscle pain and weakness
 Musculoskeletal pain
o Back pain
o Regional musculoskeletal pain
 o Neck pain
o Shoulder pain
o Elbow pain
o Hand and wrist pain
o Hip pain
o Knee pain
o Ankle pain, Foot pain

IMPORTANT MUSKULOSKELETAL SYMPTOMS

 Pain
 Stiffness
 Weakness
 Swelling
 Deformity
 Abnormal gait
 Systemic symptoms
 weight loss
 weight gain
 Fever
 skin lesion
 Hearing loss,vertigo
 Chest pain
 SOB
 GIT symptoms

Evaluation of musculoskeletal pain

 Joint pain
 Multiple regional pain without arthritis
 Myalgia

CLASSIFICATION OF JOINT PAIN

 According to the cause
o Inflammatory pain
o Noninflammatory pain
  According to the number of joint involvement
o Monoarthritis
o Oligoarthritis
o polyarthritis

CAUSES OF INFLAMMATORY CONDITION

o RA
o Gout
o Seronegative Spondyloarthritis
o Polymyalgia Rheumatica
o Connective tissue disease(Mainly Lupus)
o

CAUSES OF NON INFLAMMATORY CONDITION

 Neck pain and back pain (20%)
 Osteoarthritis
o knee(10%)
o Hip (4%)
 Ostoporosis(15%)
 Regional soft tissue pain(10%)
 Fibromyagia(3%)

DIFFERENCE BETWEEN INFLAMMATORY AND MECHANICAL PAIN

Feature Inflammatory Mechanical
Morning Stiffness >1 hour <_30 min
Fatigue Significant Minimal
Activity May improve symptom May worsen
Rest May worsen May improve
Systemic involvement Yes No

Response to steroid yes No

CAUSES OF MONOARTHRITIS
 Infection
o Bacterial
o Tubercular
o Lyme Disease
o Fungal
 Traumatic
o Fracture
o Internal Dearrangement
o Haemochromatosis
 Crystal deposition
Gout(MSUM)
Pseudogout(calcium pyrophosphate dehydrate
Hydroxyapatite Calcium oxalate)
 Others
o OA
o JRA
o Coagulopathy
o FB synovitis
o Pigmented vilonodular sinovitis
o Synovioma
o
CAUSES OF ACUTE POLYARTICULAR SYMPTOMS
 Infection
o Gonococcal
o Lyme
o Acute Rheumatic Fever
o Viral(rubella,HBV,HCV,EBV,HIV)
 Others
o RA
 o JRA
o SLE
o Psoriatic arthritis
o Polyarticular gout
o Sarcoid arthritis
o Serum sickness

CAUSES OF CHRONIC (>6 WEEKS) POLYARTICULARS

SYMPTOMS
 Inflammatory
o RA
o JRA
o SLE
o PSS
o Reiter syndrome
o Polyarticular gout
o Enteropathic
o Sarcoid arthritis
o Vasculitis
o PMR
 Non inflammatory
o OA
o Paget disease of bone
o Fibromyalgia
o Hypermobility syndrome
o Haemochromatosis
TEMPORAL PATTERNS OF JOINT INVOLVEMENT IN
POLYARTHRITIS
 Migratory
o RF,Gonococcal,Lymedisease, SBE, Meningococcal, Viral
 Additive
o Reactive Arthritis
o RA
o SLE
 Intermittent
o Polyarticular gout
o RA
o Sarcoidosis
o Psoriatic Arthritis
o Reiter syndrome

DISTRIBUTION OF JOINT INVOLVEMENT IN POLYARTHRITIS

Disease Joint involved Joint spared

RA Wrist,MCP,PIP,Elbow DIP
,Cervical SI
spine,Hip,Knee,Ankle,Tarsal,MTP Thoracolumber spine
OA 1st CMC,PIP,DIP,axial MCP,Wrist,Elbow,GLenohumeral,
spine,Hip,Knee,1st MTP,Toe IP Tarsal
Gonococcal Knee,Wrist,Ankle,Hand IP Axial spine
Polyarticular 1st MTP,Heel,Ankle,Knee Axial spine
Gout

Pseudogout Knee,wrist,shoulder,ankle,MCP,Hi Axial spine

p,Elbow
Sarcoid Ankle,Knee -
NATURE OF PAIN
 USAGE PAIN

-Worsen on use

-Relieved by rest

 REST PAIN

-worsen after rest/inactivity

-Improved by activity and movement

 NIGHT PAIN

- Mostly at night

- Poorly related to movement

- Unremitting

FACTORS AFFECTING BONE PAIN

Activity Effect
Rest Position Reduces mechanical pain
Stretching Reduces non inflammatory soft tissue pain
Ice pack Reduces acute pain
Warm shower Reduces pain of RA and other inflammatory
condition

Bed rest Reduces PLID Pain but increases pain of AS and

inflammatory condition
Night pain Bone tumour and infection
Postural change(sitting down and Reduces ischemic limb pain but increases
standing) neuropathic pain

FEATURES OF ACTIVE INFLAMMATORY ARTHRITIS

 Duration of morning stiffness>1 hour
 Constitutional symptoms(+)
 Joint swelling
 New joint involvement

Causes of chronic multiple regional pain without arthritis

o Fibromyalgia
o Joint hypermobility
o Seronegative spondyloarthritis
o Osteomalacia
o Polymyalgia rheumatica
o Polymyositis
o DISH(Diffuse idiopathic skeletal hyperostosis)
o Endocrine cause---Primary hyperparathyroidism, hypothyroidism, Addison disease
o Parkinson’s disease
o Drugs like retinoid, statins
EVALUATION OF OTHER MUSCULOSKELETAL SYMPTOMS
OTHER THAN PAIN
 Stiffness
o Subjective feeling of inability to move freely
o Duration and severity of early morning stiffness that can be worn off-
suggest degree of inflammation
 Weakness
o Consider primary or secondary muscular abnormality
 Swelling
o Fluid
o Soft tissue
o Bone
 Deformity
o Bone or joint
 Weight loss
o RA
o SLE
o Systemic vasculitis
o Occult malignancy
o Infection
 Weight gain
o SLE with Nephrotic syndrome
o Hypothyroidism
 Fever with chills
o Infectious arthritis
 Periodic fever
o Familial Mediterranean fever
o Still’s disease
 Rash,photosensitivity and Hair loss
 o SLE
 Skin Nodule
o RA, Topheous gout
 Raynaud’s Phenomenon
o MCTD, PSS, SLE,
 Skin lesion
o psoriasis, Bruising vasculitic rash
 Prolonged headache
o Temporal Arteritis
 Sicca syndrome
o Sjogren’s synd, SLE
 Hearing loss, vertigo
o WG & PAN
 Nasal bridge swelling
o WG & Relapsing Polychondritis
 Neurologic Complaints
o RA, SLE, & other CT disease, systemic vasculitis, cervical & lumber OA
 Pleuritic pain
o SLE, drug induced lupus & MCTD
o Serong SpA
 SOB
o Rheumatoid lung disease, scleroderma, MCTD (ILD)

 IBS
o Associated with Fibromyalgia
 Esophageal symptom
o Scleroderma (CREST synd)
 Oral/Genital ulcer
o SLE, Behcet’s synd
 Lower GI Symptom
o IBD with Arthropathy
 Urethral discharge
o ReA, Gono Arthritis
 Balanitis
 o ReA
 Vaginal dryness
o Sjogren’s synd

GUIDELINES FOR DIAGNOSIS OF RHEUMATOID DISEASE

RHEUMATOID ARTHRITIS DIAGNOSTIC CRITERIA

(AS PER ACR AND EULAR-2010)

1.Joint Involvement(0-5)

Number of joint Score

One large joint 0
2-10 large joint 1
1-3 small joint 2
4-10 small joint 3
>10 joint where at least 1 small joint 5

2.Serology(0-3)

Antibody Result Score

RF and anti CCP Both negative 0
RF and anti CCP Low positive(<3 times of upper limit 2
of normal)
RF and anti CCP High positive 3

3.Acute Phase Reactants(0-1)

Acute phase protein Result Score

CRP,ESR Normal 0
CRP,ESR Abnormal 1

4.Duration of Symptoms(0-1)
 Duration in weeks Score
<6 0
>6 1

Interpretation:Total score ≥6 is indicative of definite RA

DIAGNOSTIC CRITERIA FOR SLE

 Malar rash
 Photosensitivity
 Oral or nasopharyngeal ulcer
 Arthritis involving >2 peripheral joints
 Serositis- Pleura/Pericardium
 Renal involvement
 Neurological manifestation- Seizure/Psychosis
 Haematological disorder
 Leucopenia < 4000/µl
 Lymphopenia<1500/µl
 Thrombocytopenia <100000/µl
 Immunological marker
 ANA/Antiphospholipid Ab/Anti ds DNA Ab/Anti sm Ab.


INTERPRETATION: 4 or more criteria should be present either serially or simultaneously for

diagnosis.

WHO classification for Lupus Nephritis

Grade Histological change

1 No histological change
2 Proliferative changes confined to mesangium.
3 Proliferative changes in 10-50% of glomeruli

4 Proliferative glomerulonephritis >50% of glomeruli

5 Membranous changes of proliferation
6 End stage scar glomeruli
DIAGNOSTIC CRITERIA FOR ANKYLOSING SPONDILITIS
(Modified NEW YORK Criteria):

The presence of definite radiographic sacroilitis ( on X- Ray) plus one of the

following criteria is sufficient for diagnosis of Ankylosing Spondilitis.

1. History of back pain( improved by exercise not relieved by rest) > 3 months
2. Limitation of motion of lumber spine
3. Limited chest expansion.

DIAGNOSTIC CRITERIA FOR AXIAL SPONDYLOARTHRITIS:

 Imaging – Sacroilitis ( only on MRI)
 History
o Back Pain> 3 months which fulfills 4 out of following 5 criterias-
 Improved by exercise
 Not relieved by rest
 Insidious onset
 Night pain
 Age at onset <40 yrs.
o Good response to NSAIDs
o Family history
o History of IBD.
 Clinical Examination:
o Arthritis
o Enthesitis.
o Uveitis.
o Dactilitis
o Psoriasis
4.Investigations:

-HLA B27-Positive

-CRP-Elevated

INTERPRETATION:

 Sacroilitis on MRI plus one feature from history, clinical examination or

investigation is diagnostic.
OR
 HLA B27 positive plus 2 or more clinical feature in absence of sacroilitis is
diagnostic.

DIAGNOSTIC CRITERIA FOR PSORIATIC ARTHRITIS:

( CASPAR CRITERIA)
Patient must have inflammatory pain (joint/spine/entheseal) along with 3 0r more criteria out
of following 5 criteria:

 Evidence of current Psoriasis or personal/family history of Psoriasis.

 Typical psoriatic nail dystrophy ( onycholysis,pitting, hyperkeratosis.)
 Negative RF.
 Either current dactilitis or history of dactilitis recorded by rheumatologist.
 Radiology: Juxtra articular new bone formation in hand or foot.
 APPROACH TO THE PATIENT OF RHEUMATOLOGICAL
DISEASE
HISTORY TAKING
AIM: The goal of history are to find clues whether pain is inflammatory ,determine
how and when the pain started and what makes the pain worse or better, establish its
temporal pattern and confirm whether there are constitutional symptoms.

Particulars of patient:

Age and Sex :Rheumatological disease has strong association with age ,sex ,genetic
factor, epigenetic factor, environmental factor .

Disease Age Female:Ma Genetic Epigenetic or environment factor

le association or trigger
RA - 3:1 HLA DR4 Infection
(50-75%, In -periodental
Caucassian), -GIT pathogen
HLA DR1 in -EBV,CMV;
Indians, Smoking,
DW15 in Post partum
japanese Breast feeding

SLE 20-30 9:1

yr
Reactive Young 1:15 H/O Bacilary dysentery or
arthritis age chlamydial urethritis 2-4 weeks
before
Fibromyalgi Advanc 10:1 Psychological distress,
a e with Injury,assault, low income
age,7%
in
woman
 aged
over 70
yrs
SS 30-50 4:1
20-30 1:3 HLA B27 Klebsiella
IL -23
AS
Septic Preexisting joint disease(RA)
arthritis DM, immunosuppression,i/v drug
abuse,old age
Psoriatic 25-40 Psorias(7-20%)
arthritis yrs

Enteropath
ic arthritis IBD
Takayasu 25-30 8:1
disease
Kawasaki Childre In Japanese
disease n<5 yr
PAN 40-50 1:2

CHIEF COMPLAINTS AND HISTORY OF PRESENT ILLNESS

Evaluation of pain and stiffness

 Mechanical or inflammatory
 Acute or Symmetrical
 Mono or Polyarthritis
 Temporal patterns of joint involvement in polyarthritis
 Duration of morning stiffness
 Involvement of axial skeleton
 Involve of hand joint
 Bony deformity
 muscle wasting
 Rash or nail changes
 any systemic symptoms like fever,weight loss or gain ete

PAST MEDICAL HISTORY

  History of IBD
 Bacilary dysentery or Chlamydial urethritis
 History of bleeding disorder or Haemoglobinopathy
 History of Trauma or I/V drug abuse
 History of Sore throat
 History of co-morbid condition or immune suppression
 History of PUD or Bronchial Asthma or CKD
 History of HBV

PERSONAL HISTORY

 Smoking
o Prohibited in ILD
o Trigger in RA
 Alcohol
o precludes use of MTX

DRUG HISTORY

Condition Responsible drug

Drug Induced SLE Hydralazine
-INH
-Procainamide
-Quinidine
-Arthritis Quinolone can induce
-Tendinitis
-Skin rash
Gout Diuretic,low dose ASPIRIN
Arthralgia pyrezinamide

PHYSICAL EXAMINATION

GENERAL EXAMINATION

SIGN DISEASE

Acutely ill Viral arthritis

Anemia Acute leukemia and SLE
Fever Viral arthritis ,acute leukemia,SLE or JRA
Lymphadenopathy acute leukemia,SLE,JRA,sarcoidosis
Erythema nodosum Sarcoidosis,enteropathic arthritis,
Psoriatic nail changes ie Psoriasis
Pitting,onycholysis,
Hyperkeratis
Maculopapular rash or salmon rash JRA
Oral ulceration SLE or RA
Butterfly rash,alopecia SLE
Livedo reticularis
Palpable purpura,Livedo reticularis Vasculitis
Gray or brown pigmentation of skin Haemochromatosis
Bony tenderness Acute leukemia
Bleeding manifestation Leukemia,SLE
Keratoderma blenorrhagica,Carcinate Reactive Arthritis
balanitis
Thickening,taut,shiny skin Systemic sclerosis
Helitrope rash on eye lid,upper Dermatomyositis
chest,external aspect of joint
And
Gottron papule overlying extensor aspect of
MCP,IP Joints of hand

GAIT

 Ask the patient to walk for few steps and then come back
 Look for painful expression or limp
 AS causes gross flexion deformity of axial spine with flexion contracture of Hip and kness

EXAMINATION OF HAND

 Swan neck deformity,Z deformity of thumb,boutoniere deformity in RA

 Muscle wasting and dupuytrens contracture
 psoriatic nail change
 inability yo unbutton cloth,pain in hand grip,characteristic pincer movement
 Heberdens node(DIP) and Bouchard nodule(PIP)
 Gouty tophus

Examination of Spine:

 Test for flexion,extension and lateral flexion

  Look for kyphosis,scoliosis and localized deformity

Regional exam difference between Joint & Periarticular lesion

Sign Joint periarticular

Stress pain Present in all tight pack Present in direction of
position (several use of ligament, tendon
directions) or enthesis (mainly on
direction)

Swelling Capsular pattern Localized, periarticular

Creps Coarse or fine Fine

Difference between Jt inflam & Jt damage

Stiffness +++ _
Warmth + _
Stress pain + _

Soft tissue swelling + +_

Effusion +++ +++
Crepitus - +
Deformity - +

EXAMINATION OF SI JOINTS

 Evidence of Sacroilitis
 Schober test
 Evidence of enthesitis

EXAMINATION OF LEG

 Erythema nodosum
 Livedo reticularis

EXAMINATION OF RESPIRATORY SYSTEM

 Pleural effusion(SLE,JRA,sarcoidosis)
  ILD
 Pulmonary fibrosis

ABDOMINAL EXAMINATION

 Hepatosplenomegaly in SLE,JRA,Sarcoidosis
 Ascitis in SLE

PRECORDIAL EXAMINATION

 Pericarditis in SLE,amyloidosis,JRA
 AR,MR

LABORATORY FINDINGS
• Lab tests should be guided by the history & physical exam. Panel or Bundle tests should
be discouraged

• Lab test for monoarthritis

o X-ray of the Jt + MRI

o Synovial fluid analysis – Inflam Vs noninflam, bloody synovial effusion –
Haemarthosis, pigmented villonodular synovitis, synovial chondromatosis and
synovioma.
o Culture – septic, TB, fungal; crystal (uric acid, CPPD).
• Other tests
 ESR, CRP
 X-ray of SI Jt, L/S spine
 CXR-PTB, Sarcoidosis
 MT – TB (+), Sarcoid (0)
 Serologic test for lyme disease, RA, ANA, HLA-B27
 S. Uric Acid
 Arthroscopy
 Synovial Bx
 Bone scan-AVN, stress fracture, osteomyelitis
 Blood C/S, Urine C/S, sample from other possible primary sites
  PT, APTT-anti coagulant or coagulation disorder

INVESTIGATION IN POLYARTICULAR SYMPTOMS

 CBC

 ESR

 ANA, anti ds DNA , complement

 RF- +ve in 75% of RA ,Anti-CCP

 Liver enzymes

 S. Creatinine

 Urinalysis

 Serum uric acid

 TSH

 S. Iron

 HLA-B27

 Radiographic + MRI

 Synovial fluid analysis

 CPK, EMG, Muscle Biopsy, Skin Bx

CONDITION ASSOCIATED WITH POSITIVE RF

RA with nodules & extra-articular -100%

manifestation
RA (over all) - 70%
Sjogren’s synd - 90%
PBC - 50%
SBE - 40%
SLE - 30%
TB - 15%
 Old Age (>65 yrs) - 20%

CONDITION ASSOCIATED WITH POSITIVE ANA

CONDITION FREQUENCY
SLE 100%
SS 60-80%
SJOGREN SYNDROME 40-70%
DM,PM 30-80%
MCTD 100%
AUTOIMMUNE HEPATITIS VARIABLE

ANA IS NOT DIAGNOSTIC FOR FOL CONDITION

RA - 30-50%

Autoimmune thyroid disease - 30-50%

Malignancy - Variable

Infectious disease - variable

5% of healthy indl

Conditions associated with antibodies to extractable nuclear Antigens

Antibody Disease association

Anticentromere Ab CREAST(Sentivity 60%,
Specificity 98%)
Anti histone Ab Drug induced Lupus
Anti Jo-1 Ab PM,DM
Anti Ro Ab SLE(35-60%),
Sjogren(40-80%)
Anti La Ab Sjogren,SLE
Anti RNP MCTD
SLE
Principles of management of musculoskeletal disorders:
Aim

• Educate the patient

• Control pain

• Optimise function

Modify the disease process where possible

Factors to be considered

• The person’s daily activity requirements, and work recreational aspirations

• Risk factors and associations of the MSK condition (e.g obesity, muscle weakness, non-
restorative sleep)

• The person’s perceptions and knowledge of their condition

• Medications and coping strategies already tried by the patient

• Comorbid disease and its therapy

• The availability, cost and logistics of appropriate evidence-based interventions.

Core  Reduction of adverse mechanical

 Education factors
 Exercise - Pacing of activities
- Aerobic conditioning - Appropriate footwear
- Strengthening  Weight reduction if obese
 Simple Analgesia

Other option  Corticosteriods

 Other analgesic drugs  Local injections
- Oral NSAIDs  Physical treatments
- Topical agents - Heat , Cold, aids,
- Opioid analgesics appliances
- Amitriptyline  Surgery
• Slow-acting  Coping strategies
- Antriheumatic drugs
CONCLUSION

• In Rheumatology, we often treat what we find. Diagnosis is less important than specific
clinical abnormalities.

• Symptomatic & target oriented treatment is practiced in most Rheumatic patient.

• At the beginning of chronic Rheumatic illness, the correct diagnosis may not be possible

• It may take yrs for a case of Raynaud’s phenomenon to evolve into other features of
scleroderma

• MCTD/overlap synd may eventually evolve into well defined entity eg SLE, PSS, DM/PM.