Dr Amr Mohamed El Kaber Rheumatology amp Rehabilitation MD DD of Monoarthritis Septic arthritis Traumatic Acute gouty attack CPPD Rheumatic fever Hemarthrosis Atypical presentation of polyarticular disease ID: 1039135
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1. Common PresentationsOf Common Rheumatic DiseaseDr. Amr Mohamed El-KaberRheumatology & Rehabilitation MD
2. DD of Monoarthritis:Septic arthritisTraumaticAcute gouty attackCPPDRheumatic feverHemarthrosisAtypical presentation of polyarticular diseaseDD of non-inflammatory arthritis:TraumaOsteoarthritisHemophiliaCharcot arthropathy
3. DD of polyarthritisInfection:Bacterial: N. GonorrheaeStaph. AureusStreptococciBrucellaT.BSyphilisLymeWhipple diseaseViral:Hepatitis C, BHIVRubellaParasitic:Cryptosporidium
4. DD of polyarthritisAutoimmune:Rheumatoid arthritisSLESScPM/DMSpARheumatic feverFMFVasculitisSarcoidosisMetabolic:Chronic gouty arthritisPseudogoutAmyloidosisHaemochromatosis
5. DD of polyarthritisEndocrinal:HypothyroidismAcromegalyDegenerative:Osteoarthritis.Malignancy:PrimarySecondary
6. Acute Rheumatic Fever (ARF)Arthritis (Peripheral)Acute migratory polyarthritis (extremely painful)Affecting large joints (knees, ankles, elbows & wrists)LL > ULAge: child (5-15ys.)Symptoms:FeverExertional dyspnea (carditis)Involuntary movements (chorea)Erythema marginatumSubcutaneous nodulesHistory of URTI. (Group A-β-Hemolytic streptococci)
7. Acute Rheumatic Fever (ARF)Lab:Acute phase reaction: ESR, CRPASOTECG: Prolonged PR intervalRadiology: X-Ray: Non-erosive arthritisEchocardiographyTherapeutic test:Aspirin
8. Rheumatoid arthritis (RA)Arthritis:Polyarthritis (Chronic)Affecting small jointsBilaterally & SymmetricalPattern additiveBoth hands are almost involved sparing DIPMorning Stiffness >1hourErosiveDeformitiesGender:Female > MaleExtra-articular symptomsSubcutaneous nodules
9. Rheumatoid arthritis (RA)Lab:Rheumatoid FactorAnti-CCPAcute phase reaction: ESR, CRPFor follow up (CBC, SGOT, SGPT, creatinine)Radiology: Characteristic X-Ray finding likeJuxta-articular osteopeniaErosionNarrowing joint space
10. Systemic Lupus Erythromatosis SLEArthritis: (peripheral) SymmetricalArthralgia/polyarthritisAge: middle agedGender: Mostly femaleSymptoms:FeverButterfly rashPhotosensitivityAlopeciaOral ulcersHeadacheBehavioral changes, +fitsPuffiness & Lower Limb edema Smoky urineDyspneaChest painPallorEasy fatiguePeripheral vascular manifestations (ischemia, RP, DVT)
11. Systemic Lupus Erythromatosis SLELab:ANAAnti-DS DNAAnti-SmithAnti-Histone (drug induced lupus)Low Complement C3 & C4 Anti-phospholipid profileAcute Phase reaction ESR & CRPCBCAnemiaLeukopenia, lymphopeniaThrombocytopenia Urine analysis (protein & cast)24-hour urinary protein > 500
12. Systemic Lupus Erythromatosis SLERadiology:X-Ray: Non-erosive arthritisChest X-ray (Effusion)Echocardiography (Effusion)Biopsy (Kidney for grading)
13. Ankylosing Spondylitis (AS) Age: young ageGender: Male > FemaleArthritis:Peripheral Joint:Chronic oligoarthritisAffecting large jointAffecting LL > UL, especially HipAxial Joints (Bilateral, Sacroiliac Joint)Inflammatory LBPDuration >3 monthsImproved by exerciseWorsen by restAssociated with morning stiffness
14. Ankylosing Spondylitis (AS) Limitation of:Lumbar spine movementsChest expansionEnthesitisLab:Acute Phase reaction CRPRheumatoid factorHLA-B27Radiology:X-Ray: Erosive arthritisMRI (Bone marrow edema).If with symptoms & signs of IBS (enteropathic arthritis)
15. Psoriatic arthritis PsAArthritis:Peripheral:Asymmetrical oligoarthritis > polyarthritisAffecting large > small jointsDIP AffectionAxial:Inflammatory LBPAsymmetrical sacroiliitis Extra-articular manifestation:Sausage digitsPsoriatic skinNail pitting
16. Psoriatic arthritis PsALab: Non SpecificAcute Phase reaction CRPRheumatoid factorRadiology:X-Ray: Erosive arthritis
17. Reactive Arthritis (ReA)Arthritis:Peripheral:Asymmetrical oligoarthritis > polyarthritisAffecting large > small jointsLL > ULDIP AffectionAxial:Inflammatory LBPAsymmetrical sacroiliitis Enthesitis
18. Reactive Arthritis (ReA)Extra-articular manifestation:Conjunctivitis or UveitisUrethritisCircinate BalanitisKeratoderma BlennorragicumMucosal ulcers painlessHistory of infections (GIT or genitourinary)Lab:RF
19. Reactive Arthritis (ReA)Extra-articular manifestation:Conjunctivitis or UveitisUrethritisCircinate BalanitisKeratoderma BlennorragicumMucosal ulcers painlessHistory of infections (GIT or genitourinary)Lab:RF
20. Scleroderma (SSC)Gender: Female > MaleArthritis:Arthralgia / PolyarthritisJoint stiffnessFlexion contractureSkin:Tight skinSclerodactylyTelangiectasiaSubcutaneous calcificationsProgressively repeated attacks ofRPDigital UlcersDigital Gangrene
21. Scleroderma (SSC)GIT:GERDDysphagiaHypomotilityCardiopulmonary:Dyspnea (ILD, PAH)Myocardial, pericardial, or conduction system diseaseCyanosisRenal trouble (Scleroderma renal crisis)Lab:Anti-Nuclear Antibodies (ANA)Anti-topoisomerase I antibodies (anti-Scl-70)Anticentromere antibodiesAnti-RNA Polymerase III antibodies
22. Scleroderma (SSC)Interstitial Lung Disease (ILD):Pulmonary Function Tests (PFT)High Resolution CT ChestPulmonary hypertension (PAH):Transthoracic EchocardiogramRight Heart CatheterizationVascular InvolvementNailfold Capillary MicroscopyGITBarium SwallowUpper Gastrointestinal Endoscopy
23. Polymyositis & DermatomyositisArthralgia > ArthritisMyalgiaProximal muscle weaknessHeliotrope rash on the upper eye lidGottron`s papule over PIP & MCPHeadache & Easy fatigueOral ulcersRPDyspnea & Chest painCardiomyopathyHeart Failure + S & S oAssociated malignancy (lung, stomach, colon & breast)
24. Polymyositis & DermatomyositisLab:Muscle enzyme:CPKAldolaseAST & ALTLDHANAMyositis Specific AntibodiesEMG:MRI for skeletal muscle (edema, degeneration)Biopsy
25. GoutGender: Male > Female (Post-menopausal M=F)Arthritis:Acute intermittent attacksMonoarthritisWith severe pain, redness, swelling1st MTP (podagra), ankle, kneeRisk factor:DMHTNHypothyroidismObeseAtherosclerosis
26. GoutAfter precipitating factor:DiureticAlcoholSurgeryCRDWeight ReductionLab:Joint aspiration and analysis: (Golden standard)Crystals, Cytology, Chemistry, Culture.Serum Uric Acid (may be elevated or normal)24 hour urinary uric acidCBC: Neutrophil leukocytosis& possibly reactive thrombocytosis.ESR: Elevated.
27. Osteoarthritis (OA)Arthralgia / arthritisLarge weight bearing jointWith risk factor e.g. obesePost-menopausal womanPain increasing at usage & night after the daytime usage.+/- Heberden & Bouchard nodes.
28. GoutRadiology:Plain x-ray:Large bony erosions (Punched out lesions – Sclerotic overhang edges)Soft tissue tophiPreserved joint SpacesNo juxta-articular osteopenia.Musculoskeletal ultrasonography (MSK-US)Dual-energy computerized tomography (DECT)Therapeutic testColchicine (dramatic response)
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