Pearls for Early Arhthritis
UCTD
These parameters are to be used in patients with arthralgia without clinical arthritis and without other diagnosis or other explanation for the arthralgia. History taking:
MCTD Clinical Course Over a 10-year period, 58% of patients are still classified as MCTD. The remaining patients evolve into SSc (17%), SLE (9%), or RA (2.5%) - this is based on Cappeli et al Overlap syndromes most common disease is Sjogren syndrome SjS is the most common disease in overlap syndrome and is seen with RA, SLE, SSc, PM, MCTD, primary biliary cholangitis (PBC), necrotizing vasculitis, autoimmune thyroiditis, chronic active hepatitis, mixed cryoglobulinemia, and hypergammaglobulinemic purpura. Other Overlap syndromes are SSc can be associated with myositis. One specific overlap is characterized by antibody to PM-Scl, a complex of 16 polypeptides located at the site of ribosomal assembly in the nucleolus (hence patients with PM-Scl antibody commonly have a nucleolar pattern ANA on immunofluorescent antibody assay). Limited SSc can be associated with PBC. Limited SSc precedes PBC by an average of 14 years. Antimitochrondrial antibody can be seen in 18% to 27% of limited SSc patients. Many also have SS RA + SLE (Rupus) SLE and IM SSc + ANCA vasculitis Myositis overlap syndrome RA with SSc, SLE, SS, MCTD MCTD PRaSySH : the common diseases of MCTD
RAESEP is the most common clinical features Raynauds Arthritis / Arthralgia Edema of Hands Sclerodactyly Esophagus dysmotility Pulmonary involvement
Ref: UpToDatea 5 major diffuse connective tissue exists - SLE, RA, DM, PM, SSc, Sixth is Sjogren syndrome often mixed with these or can be primary Prominent early symptoms are puffy fingers, easy fatigability, poorly defined myalgias, arthralgias, and raynaud phenomenon. The common diagnostic considerations at this juncture are usually rheumatoid arthritis (RA), SLE, SSc or UCTD. If the patient has swollen hands and/or puffy fingers associated with a high titer speckled antinuclear antibody (ANA), they should be carefully followed for the evolution of overlap features. A high titer of anti-RNP antibodies in such a patient is a powerful predictor of a later evolution to MCTD. Other, less common, early features include severe inflammatory myopathy, acute arthritis, aseptic meningitis, transverse myelitis, digital gangrene, high fever, acute abdomen and trigeminal neuropathy, and sensorineural hearing loss. The major reason for considering MCTD a distinct clinical entity is a frequent observation that high titers of anti-U1 RNP antibodies are associated with several distinctive clinical characteristics. ●Patients with U1 RNP antibodies seldom, i.e., RARELY, develop diffuse proliferative glomerulonephritis, psychosis, or seizures; these abnormalities are a major source of morbidity and mortality in SLE. ●Patients with U1 RNP antibodies nearly always have an early development of the Raynaud phenomenon and a nail fold capillary pattern that is the same as in SSc but that is different from classical SLE. The Raynaud phenomenon only occurs in about 25 percent of patients with classical SLE. ●Patients with U1 RNP antibodies are more likely to develop pulmonary hypertension than patients with classical SLE or SSc. Pulmonary hypertension is the major cause of death in MCTD. ●Patients with U1 RNP antibodies are more likely than SLE patients to test positively for rheumatoid factor or antibodies to a cyclic citrullinated peptide (anti-CCP), and they are also more likely to develop erosive arthritis. ●Patients with a preponderance of immunoglobulin M (IgM) anti-U1 small nuclear ribonucleoprotein (snRNP) antibodies are more likely to have SLE. One study has reported that a combined IgM reactivity for fragments of U1C and U1A of U1 RNP is capable of classifying SLE and MCTD patients with an accuracy of 71.3 percent There are several hierarchies of antibody response in patients who eventually develop MCTD, with each higher level being associated with an increased expression of the MCTD clinical profile: ●Level 1 – Positive ANA ●Level 2 – High titer, speckled ANA pattern ●Level 3 – Anti-U1 RNP antibodies ●Level 4 – Anti-68 kD and A' antibodies U1 RNP consists of ribonucleic acid (RNA) plus three proteins (A', C, and a 68-70 kD protein). The clinical picture of MCTD most closely correlates with the presence of IgG antibodies to the 68 to 70 kD and A' proteins Ref for above: UpToDate Instead of the above pneumonic, alternatively use the clinical features from the SHART or ALARCON-SEGOVIA et al. as that is more clinically meaningful Clinical Course Over a 10-year period, 58% of patients are still classified as MCTD. The remaining patients evolve into SSc (17%), SLE (9%), or RA (2.5%) - this is based on Cappeli et al Rx:
UCTD
Table 2Differential Diagnosis of Migratory Polyarthritis
Ref: doi: 10.1007/s11606-008-0794-7
Additional Pearls CPPD is slightly more subacute in presentation.. When you wake up, muscles that have relaxed goes into spasm, and this causes pain in morning. Spinal Stenosis Pain remains in stopping and standing. Improves on sitting, and bending as spinal space is increased. Going upstair is better, but pain worse in going downstairs. Vascular Claudication Gets better at rest even while standing. Some arthritis do not have swelling. Like Viral arthritis, SLE. Distal muscle myopathy: Only IBM. All including metabolic myopathy, causes proximal weakness Inflammatory eye disease: Seronegative arthritis. ENT: Vasculitis: Elbow: Tophi,and Rheumatic Nodule .Some time wegners present with nodule. Fever in Rheumatology: AOSD, SLE Raynauds: Most important is to have pallor. Cyanosis is common, but if pallor is present, it is very suggestive. Hair Loss: Lupus. Rash: Lupus - Interdigital (between the rash); Dermatomyositis: Over the joint. Where to look for psoriasis Scalp, Peri-umblical area, Gluteal / Natal cleft, palms, sole, nail changes, knee externsor surface Lupus Peringo: around nose or ear (Sarcoidosis) Circinate balanitis: Reactive arthritis Keratoderma Blenorrhegicum: Reactive arthritits. Pyoderma gangrenous: IBD , Scar: Paper thin scar due to loss of subcutaneous bed Zagged boarders: Common in cryoglobinemic vasculitits. Nailfold Infarct: Rheumatoid Vasculitits. Eye: Uveitits:
Epi-scleritis: Red, usually not much pain, vision not affected. Acute Angle Closure Glaucoma: Emergency, needs to see opthal right away Rheum examination (look, feel, move) anatomy inflammation Function: Complication/stability of joint Antatomic position: 0 - 45 degree. except: Hand and leg Move: Active, passive, stability, Marginal erosion: at the end of the cartilage, beginning of the bone. Seen in synovitis. Gout erosions Not always around the joint, but anywhere in the joint. So, they defy the rule of synovitis causing erosion. |
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