Aspectos relativos à ODR

FIGURE 42.1:

FIGURE 42.1: Swelling of wrist and metacarpophalangeal joints, radial deviation of wrist with ulnar deviation of digits in rheumatoid arthritis

Joint Pain ¹⁵³

FIGURE 42.2:

FIGURE 42.2: Halux varus deformity, widening of the forefeet with cock-up great toes in rheumatoid arthritis

FIGURE 42.3:

FIGURE 42.3: Fusiform swelling of entire left middle finger (dactylitis or sausage digit) – often a clinical clue in reactive arthritis

154 Pearls in Medicine for Students

• Monoarticular flare of polyarticular rheumatic diseases (e.g.

rheumatoid arthritis, SLE, psoriasis, reactive arthritis)

• Charcot joint (neuropathic joint from diabetes, leprosy, syringomyelia or tabes dorsalis)

• Villonodular synovitis

• Haemophiliac joint (e.g. knee), acute leukaemias, Henoch-Schö nlein purpura

Note: As any delay in the treatment of septic arthritis would lead to joint destruction, it is prudent to start antibiotic therapy empirically before laboratory reports give a definitive diagnosis. Urgent synovial

fluid examination is mandatory in acute monoarthritis for:

• Crystals (under polarised light microscopy)

• Pathogens (Gram staining and microbial culture)

• WBC (> 2000/mm³ is diagnostic of inflammatory joint disease)

* Cha rco t’s joi nt a nd v illo nod ula r si nov iti s giv e ris e to chr oni c monoarthritis.

POLYARTHRITIS POLYARTHRITIS

• Rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA)

• SLE and other connective tissue diseases

FIGURE 42.4:

FIGURE 42.4: Painful and swollen knee (monoarthritis) in a patient of haemophilia

Joint Pain ¹⁵⁵

• Psoriatic arthritis

• Ankylosing spondylitis

• Palindromic rheumatism

• Rheumatic fever, SBE, Lyme arthritis

• Reactive arthritis

• Crystal-induced arthritis (e.g. gout)

• Drug hypersensitivity (e.g. surum sickness)

• HIV, hepatitis B, Parvovirus B19, chikungunya or rubella infection

• Miscellaneous–generalised osteoarthritis, lymphoma, leukaemia, sarcoidosis, Behcet’s disease, spondyloarthropathies, Whipple’s disease, Henoch-Schonlein purpura, neuropathic joint, HPOA

(hypertrophic pulmonary osteoarthropathy), relapsing polychondritis, malignancy, post-streptococcal reactive arthritis, amyloidosis.

FEW TERMINOLOGY FEW TERMINOLOGY

• Arthralgia–only pain in the joints

• Arthritis–pain + swelling in the joints

• Monoarthritis–affection of single joint

• Oligo– or pauciarticular arthritis–affection of 2-4 joints

• Polyarthritis–affection of 5 or more joints

The anatomical basis of pain in musculoskeletal system could be:

Joint:

• Synovium–synovitis

• Joint capsule–capsulitis Periarticular soft tissue:

• Bursa–bursitis

• Tendon sheath–tenosynovitis

• Tendon–tendonitis

• Insertion of tendon, ligament–enthesitis Bone

DURATION OF JOINT PAIN DURATION OF JOINT PAIN

• Acute (< 6 weeks)

• Chronic (> 6 weeks).

PATTERN OF INVOLVEMENT PATTERN OF INVOLVEMENT

• Axial (spine, sacroiliac, anterior chest wall, shoulder and hip joint)

156 Pearls in Medicine for Students

• Appendicular (peripheral joints)

* Shoulder and hip joints are known as root joints.

CLINICAL PARAMETERS OF ‘INFLAMMATORY’ JOINT DISEASES CLINICAL PARAMETERS OF ‘INFLAMMATORY’ JOINT DISEASES

• Significant early morning stiffness (usually > 30 minutes)

• Symptomatic improvement on gentle use of joint

• Spontaneously up-and-down course (i.e. ‘spontaneous flare’)

• Constitutional symptoms (e.g. fatigue,^↓ appetite,^↓ body weight, low-grade fever, night sweats).

COMMON LABORATORY INVESTIGATIONS PERFORMED IN COMMON LABORATORY INVESTIGATIONS PERFORMED IN JOINT DISEASES

JOINT DISEASES

1. Acute phase rea ctants (confirm inflammatory nature of the dise ase).

• ESR

• Platelet count

• Albumin-globulin ratio

• C-reactive protein (CRP)

• Alkaline phosphatase.

2. Rheumatoid factor (RF).

3. Anti-nuclear antibody (ANA) and its subsets, e.g. ds DNA, anti-RNP etc.

4. Complement C₃ and C₄.

5. Antibodies to cyclic citrullinated peptide (anti-CCP) to diagnose early rheumatoid arthritis.

6. Anti-streptolysin ‘O’ antibody (ASO) titre.

7. Anti-neutrophil cytoplasmic antibody (ANCA, i.e. c- or p-ANC A).

8. Synovial fluid analysis.

9. Serum uric acid level.

10. Others: HLA-B 27 screening, synovial biopsy.

PATIENTS COMPLAINING OF STIFF/PAINFUL MUSCLES PATIENTS COMPLAINING OF STIFF/PAINFUL MUSCLES

1. Strenuous exercise (H/O unaccustomed exercise 24-48 hr before).

2. Ankylosing spondylitis (young, low backache, progressive loss of spinal movement).

3. Polymyositis/dermatomyositis (proximal muscle weakness+).

4. Polymyalgia rheumatica (elderly, fatigue, painful proximal muscle).

5. Fibromyalgia (females with specific tender points all over the body, anxiety+, depression+).

Joint Pain ¹⁵⁷ 6. Rheumatoid arthritis (middle aged female, morning stiffness in active

disease, MCP and PIP joints involved in hands).

7. Myxoed ema ( middle aged female, obese, hoars e voi ce, co ld intolerance, muscle weakness+).

DRUGS

DRUGS PRODUCING ARTHRALGIA/ARTHRITIPRODUCING ARTHRALGIA/ARTHRITI SS

• Sulphonamides

• Acute rheumatic fever

• Ankylosing spondylitis

• SBE

• Rheumatoid arthritis

• SLE (Libman-Sacks endocarditis)

• Atrial myxoma

• Relapsing polychondritis B. Subcutaneous nodules—

• Rheumatoid arthritis

• Gout

• Acute rheumatic fever

• Sarcoidosis

158 Pearls in Medicine for Students

• Disseminated idiopathic sketelal hyperostosis (DISH).

COMMON CAUSES OF POLYARTHRITIS IN HANDS COMMON CAUSES OF POLYARTHRITIS IN HANDS 1. Rheumatoid arthritis (MCP, PIP).

2. Nodal osteoarthritis (DIP but spares MCP).

3. Psoriatic arthritis (commonly DIP).

4. Chronic tophaceous gout (MCP, IPs).

5. SLE (Jaccoud’s arthritis; MCP joints commonly).

6. Viral arthritides (all joints).

D/D OF ACUTE MONOARTHRITIS PRESENTIN

D/D OF ACUTE MONOARTHRITIS PRESENTING AS ‘RED HOT JOINT’G AS ‘RED HOT JOINT’

A. Infections (septic arthritis) : bacterial (non-gono coccal/gonococcal), viral.

B. Crystal-induced: gout, pseudogout.

C. Acute exacerbation of rheumatoid arthritis, reactive arthritis, psoriatic arthritis and palindromic rheumatism (monoarticular RA lasting 24-48 hours).

D. Haemophilia.

E. Traumatic.

DISEASE COURSE OF POLYARTHRITIS DISEASE COURSE OF POLYARTHRITIS

Intermittent: gout, palindromic RA A. Progressive: classical RA

Migratory (as the inflammation of one joint is subsided, other tend to become affected, i.e. usually one joint is affected at a time for about 3 days): rheumatic arthritis, SLE, drug reaction/serum sickness, arthritis following gonoccocal or meningococcal septicaemia, viral arthritis (Lyme arthritis, chikungunya), following inflammatory bowel disease/Whipple’s disease, ‘seroconversion’ in AIDS,

septicaemia, sarcoidosis, following intestinal by-pass surgery Additive: RA, ankylosing spondylitis, reactive arthritis.

B.

→

→

→

→

Joint Pain ¹⁵⁹ AGE AND SEX RELATED ARTHRITIS

AGE AND SEX RELATED ARTHRITIS A. Age:

• Children : Rheumatic arthritis, JIA, haemophilia, trauma

• Adolescents : Rh eu ma ti c ar th ri tis , sp on dy lo arthr op at hy , trauma, JIA, post-streptococcal reactive arthritis

• Young : Trauma, gonococcal

• Adults : Spondyloarthropathy, reactive arthritis, psoriasis, SLE, gout

• Middle age : RA, gout, osteoarthritis, scleroderma B. Sex:

Arthritis predominant in males are:

• Gout

• Ankylosing spondylitis

• Reiter’s syndrome (i.e. reactive arthritis)

• Polyarteritis nodosa

* Other arthritides are dominant in females.

ARTHRITIS AFFECTING DISTAL INTERPHALANGEAL (DIP) ARTHRITIS AFFECTING DISTAL INTERPHALANGEAL (DIP) JOINTS

JOINTS

• Osteoarthritis

• Psoriatic arthritis

• Scleroderma

• Sarcoidosis

• Gout

• Septic arthritis.

JACCOUD’S ARTHRITIS JACCOUD’S ARTHRITIS

Ulnar deviation of MCP joints due to subluxation may develop from,

• Rheumatic arthritis

• SLE

• Sjögren’s syndrome.

–––– o ––––

160 Pearls in Medicine for Students

AETIOLOGY AETIOLOGY

1. Venous diseases: Varicose ulcer, DVT, deep venous obstruction from pelvic growth, incompetent valves.

2. Arterial insufficiency: Atherosclerosis, Buerger’s disease, vasculitis.

3. Small vessel diseases: Diabetes mellitus, vasculitis.

4. Neuropathy: Diabete s mellitu s, lepro sy, tab es dors alis, s yringo -myelia.

5. Haemorrhagelogical: Sickle cell disea se, hereditary spherocytosis, thalassaemia major, cryoglobulinaemia, immune complex diseases, cold agglutinin disease, macroglobulinaemia.

6. Tumour: Squamous cell carcinoma, Kaposi’s sarcoma, malignant melanoma, basal cell carcinoma, mycosis fungoides, metastasis

43

43 .. .... .... .... .... .... .... .... .... .... .... ....

CHAPTER CHAPTER

In document FUTURE LAW, Vol. II (página 185-190)