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Undifferentiated / Early Peripheral Arthritis




  • 4 important questions to answer are: 
    • Articular vs Extra-articular 
    • Acute vs Chronic
    • Inflammatory arthritis vs Non-inflammatory arthritis
      • History: Morning stiffness, and Constitutional Symptoms
      • Physical Exam: Soft-tissue swelling, erythema, warmth, synovitis vs bony enlargement 
      • Lab: ESR, CRP, Anemia of Chronic Disease, Albumin 
      • Imaging Study: Symmetrical Joint-space narrowing, periarticular osteopenia, erosions vs asymmetric joint-space narrowing, osteophytes, sub-chondral sclerosis 
      • Synovial Fluid: Total WBC, Neutrophil % 
    • Number of joints / Symmetry 
  • Migratory Polyarthritis 
    • VRICCS - PM 
    • V: Vasculitides 
    • R: RA 
    • I: Infectious cause 
      • Post-infectious: Strep, Chalymadia, Shigella, Salmonella, Campylobacter, Yersinia (Diarrhea, Pyrangitis, Bronchitis, Urethritis / UTI)
      • Rheumatic Fever: 
    • C: Crystal Induced arthritis 
    • C: Connective tissues syndromes?
    • S: Spondyloarthropathies (PsA)
    • Paraneoplastic syndromes 
    • Malignancies 

Table 2

Differential Diagnosis of Migratory Polyarthritis

Palindromic rheumatoid arthritis
Crystal induced arthropathy
Reactive arthritis
Autoimmune disease (e.g., SLE, rheumatic fever)
Infectious polyarthritis (e.g., Lyme disease, chlamydia)

            Ref: doi: 10.1007/s11606-008-0794-7
Pearls for Early Arhthritis 
  • During a 9-month follow-up period, RA developed in more than half (57%) of the ACPA+ arthralgia patients according to the 2010 American College of Rheumatology/European League against Rheumatism (ACR/EULAR) classification criteria. Importantly, the magnitude of subclinical inflammation detected by MRI did not accurately predict those at risk for imminent RA; rather, the best predictors of progression included a greater number of joints involved and seropositivity for ACPA and/or RF KF 1168 
  • Patience, Humility and Close observation are the keys 
    • Do not overtreat - you may be treating patients who does not have disease thinking it is working, or going up on the treatment ladder with no response to treatment despite lack of clear diagnosis 
    • Ask for help with folks with experience 
    • Treat if it affects the quality of life - carpenter, hairdresser with an understanding if there is no improvement, we will likely cut back and we are treating as a suspect - if treating looking for treatment response to 1/3rd in 3 months might be a good way to assess success (Janet Pope Podcast) - HCQ might be the one to use for treatment 
    • Clear/honest documentation will be of help: 
      • RA suspect, RF-, ACPA positive, family hx positive 
      • Lupus suspect, ANA positive, hx of pericarditis 15 yrs back etc. 

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:
  • Anterior uveitits (anterior to lens)
    • Red eye, pain, blurry vision
    • Causes:
  • Posterior uveitits 
    • Non-red, painless, but blurry vision
    • Causes: 
Scleritits: Red, Painful, Affects vision
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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