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Note the pattern of joint involvement (monoarticular or polyarticular), immediate and more recent history, family history and drug use.
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Enquire whether the joint pain is acute or insidious and confined to specific joints or fleeting as in rheumatic fever.
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A systematic examination of the affected joint or joints should look for signs of inflammation, deformity, swelling and limitation of movement.
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Searching for associated systemic disease such as connective tissue disorders and infection demands examination of the chest, heart and abdomen.
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FBE
ESR & CRP
Uric acid
Urine analysis
Joint X-rays
Synovial fluid analysis and culture Red flag pointers for polyarthritis
RA factor
Autoantibodies (ANA, dsDNA, ENA), anti-CCP antibody (for RA)
Other tests according to findings of tests for infection (e.g. specific serology, blood culture)
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Explanation: patient education and reassurance that arthritis is not the crippling disease perceived by most patients. Consider CBT.
Rest: during an active bout of inflammatory activity only.
Exercise: a graduated exercise program is essential to maintain joint function. Aim for a good balance of relative rest with sensible exercise.
Heat: recommended is heat packs, a hot water bottle, warm bath or electric blanket to soothe pain and stiffness. Advise against getting too cold.
Diet: if overweight it is important to reduce weight to ideal level.
Physiotherapy: referral should be made for specific purposes such as exercises and supervision of a hydrotherapy program.
Occupational therapy: refer for advice on aids in the home.
Simple analgesics (regularly for pain): paracetamol is the basic analgesic (avoid opioids such as codeine or dextroproproxyphene preparations and aspirin if recent history of dyspepsia or peptic ulceration).
NSAIDs and aspirin: the first-line drugs for more persistent pain or where there is evidence of inflammation. The risk versus benefit equation always has to be weighed carefully. As a rule, NSAIDs (e.g. ibuprofen) should be used sparingly if possible. Aim for short courses of 14–20 d. The COX2 specific inhibitors should be considered where there is an indication for an NSAID but the risk of NSAID-induced ulceration and bleeding is high.
Consider duloxetine for some people when pain relief is inadequate.
Intrarticular corticosteroids: as a rule IA corticosteroids are not recommended but occasionally can be very effective for an inflammatory episode of distressing pain (e.g. a flare-up in an osteoarthritic knee).
Referral for surgical intervention: for debilitating and intractable pain or disability. Examples include OA of hip, knee, shoulder, first CMC joint of thumb and first MTP joint.
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ESR usu. raised according to active disease
Anaemia (normochromic and normocytic) may be present
Rheumatoid factor— +ve in ~70–80%, not specific
Anti-cyclic citrinullated peptide AB test—specific
X-ray changes
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Management principles
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Give patient education, support and appropriate reassurance. The diagnosis generally has distressful implications so the patient and family require careful explanation and support. It should be pointed out that the majority of patients have little or no long-term problems. Refer to rheumatologist for shared care—this referral is very important to outcome.
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Rest and splinting: this is necessary where practical for any acute flare-up of arthritis.
Exercise: it is important to have regular exercise esp. walking and swimming. Hydrotherapy in heated pools.
Referral to physiotherapists and occupational therapists: expertise in exercise supervision, physical therapy and advice regarding coping in the home and work is important.
Joint movement: each affected joint should be put daily through a full range of motion to keep it mobile and reduce stiffness.
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Pharmaceutical agents
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simple analgesics (e.g. paracetamol)
NSAIDs (use with caution)
glucocorticoids: prednisolone 5–10 mg (o)/d (max 15 mg/d)
Consider: in severe disease or failure of other agents
DMARDs, e.g. hydroxychloroquine
gold compounds (IM or orally)
D-penicillamine
sulfasalazine
immunosuppressive agents, e.g. methotrexate (the ‘backbone’ of therapy), azathioprine, cyclophosphamide, leflunomide, ciclosporin
fish body oil (Omega-3)
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Standard initial drug therapy RA
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Consider (if remission not achieved with methotrexate): addition of a biological DMARD, e.g. adalimumab, entanercept, anakinra, golimumab.
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Connective tissue disorders
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The main CTDs have the common feature of arthritis or arthralgia. They include SLE, scleroderma, polymyositis and Sjögren syndrome. Other common features include vasculitis and multisystem involvement. They are autoimmune diseases and should be referred for shared care.
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Systemic lupus erythematosus (SLE)
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Arthritis is the commonest clinical feature of SLE (over 90%). It is a symmetrical polyarthritis involving mainly small and medium joints, esp. the proximal interphalangeal and carpal joints of the hand.
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The initial presentation is similar to rheumatoid arthritis. If suspected, test ANA and, if +ve, DNA and ENA Antibodies (Abs).
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DxT: polyarthritis + fatigue + skin lesions → SLE
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ESR—proportional to disease activity
Antinuclear antibodies—+ve in at least 95%
ds DNA Abs → 95% specific for SLE but present in only 60%
ENA Abs, esp. Sm—highly specific
Rheumatoid factor—+ve in 50%
LE test—inefficient and not used
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Mild—NSAIDs/aspirin (for arthralgia)
Moderate—low-dose antimalarials (e.g. hydroxychloroquine)—up to 6 mg/kg once/d for 3 mths, then 200 mg/d long term
Moderate to severe—corticosteroids (mainstay drug); immunosuppressive drugs (e.g. azathioprine, methotrexate + folic acid); bDMARDs useful for severe arthralgia
Consider fish body oil 0.2 mg/kg (o) daily (usually 2.7 g)
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This can present as a polyarthritis affecting the fingers of the hand in 25% of patients, esp. in the early stages. Scleroderma mainly affects the skin, presenting with Raynaud phenomenon in over 85%.
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DxT: finger discomfort + arthralgia + GORD (± skin tightness) → scleroderma
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Investigations (no specific diagnostic tests)
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ESR may be raised
Antinuclear Abs → 90% +ve
Rheumatoid factor—+ve in 30%
Antinucleolar and anticentromere Abs—specific
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Analgesics and NSAIDs for pain
Avoid vasospasm (no smoking, β blockers, ergotamine)
CCBs as for Raynaud
D-penicillamine for skin or systemic involvement
Proton-pump inhibitors for GORD
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Polymyositis and dermatomyositis
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Arthralgia and arthritis occur in ~50% of patients and may be the presenting feature before the major feature of muscle weakness and wasting of the proximal muscles of the shoulder and pelvic girdles appear. The small joints of the hand are usually affected and it may resemble rheumatoid arthritis. Polymyositis + associated rash = dermatomyositis.
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Sjögren syndrome (SS)
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SS is the dry eyes (kerato conjunctivitis sicca) in absence of any other autoimmune disease.
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DxT: dry eyes + dry mouth + arthralgia → Sjögren syndrome
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Diagnosis: +ve ENA. Ro (SSA). La (SS-B) Abs
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Treatment: symptomatic for sicca; hydroxychloroquine or steroids for arthritis
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Arthritis, which can be acute, chronic or asymptomatic, is caused by a variety of crystal deposits in joints. The three main types of crystal arthritis are monosodium urate (gout) (see Gout), calcium pyrophosphate dihydrate and calcium phosphate (usually hydroxyapatite).
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The spondyloarthropathies
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The spondyloarthropathies are a group of disorders with common characteristics affecting the spondyles (vertebrae) of the spine. Apart from back pain this group tends to present with oligoarthropathy in younger patients (see The spondyloarthritides).
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The group includes: ankylosing spondylitis; reactive arthritis; inflammatory bowel disease (enteropathic arthritis); psoriatic arthritis; juvenile chronic arthritis; unclassified spondyloarthritis—partial features only.
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Ankylosing spondylitis
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This usually presents with inflammatory back pain (sacroiliac joints and spine) and stiffness in young adults and 20% present with peripheral joint involvement before the onset of back pain. It usually affects the girdle joints (hips and shoulders), knees or ankles.
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Key clinical features
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Insidious onset of discomfort
Age less than 40 yrs
Low back pain persisting for >3 mths
Associated morning stiffness >30 mins
Improvement with exercise or NSAIDs, not relieved by rest
Sacroiliitis
Limitation of lumbar spinal motion in sagittal and frontal planes
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This is a form of reactive arthropathy in which non-septic arthritis and often sacroiliitis develop after an acute infection with specific venereal or dysenteric organisms.
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Reiter syndrome = NSU + conjunctivitis ± iritis + arthritis
Reactive arthritis = similar syndrome without ocular or mucocutaneous lesions
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Enteropathic arthritis
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Inflammatory bowel disease (ulcerative colitis, Crohn disease and Whipple disease) may be associated with peripheral arthritis and sacroiliitis.
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Like Reiter syndrome, this can develop a condition indistinguishable from ankylosing spondylitis. It is therefore important to look beyond the skin condition of psoriasis, for ~5% will develop psoriatic arthropathy.
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Management principles of spondyloarthropathies
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Identify the most active elements of the disease and treat accordingly.
Provide patient and family education with appropriate reassurance.
Refer for physiotherapy for exercises, postural exercises and hydrotherapy.
Pharmacological agents:
– NSAIDs (e.g. indomethacin 75–200 mg/d) to control pain, stiffness and synovitis
– sulfasalazine (if NSAIDs ineffective)
– intra-articular corticosteroids for severe monoarthritis and intralesional corticosteroids for enthesopathy
– immunosuppressive agents, e.g. methotrexate, for severe cases
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Viral polyarthritis is common. Features are acute onset, symmetric inflammation of hands and feet, rash for about 24 hours. Viral causes include influenza, parvovirus, rubella, hepatitis B and C, varicella. Usually settles quickly. Treat with NSAIDs if necessary.
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Lyme disease and lyme like disease
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Lyme disease (known as Lyme borreliosis) is caused by a spirochete, Borrelia burgdorferi, and transmitted by Ixodes ticks, in particular the deer tick. It is not endemic in Australia and is usually seen in travellers from affected regions.
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Diagnostic serology should be considered for patients with a history of tick bites, typical rash (a doughnut-shaped red rash ~6 cm in diameter) at the bite site, heart disorders (esp. arrhythmias), unusual joint arthralgia or CNS disease (usually large joints, e.g. knees).
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After removing the tick (see Tick bites), treatment is with penicillin, tetracycline or cephalosporins (e.g. doxycycline 100 mg bd for 21 d).
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The vasculitides or vasculitis syndromes are a heterogeneous group of disorders involving inflammation and necrosis of blood vessels, the clinical effects and classification depending on the size of the vessels involved.
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More common causes are the small vessel vasculitis effects associated with many important diseases such as rheumatoid arthritis, SLE, infective endocarditis, Henoch–Schonlein purpura and Hepatitis B. Skin lesions and arthritis are usually associated with these disorders.
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The major vasculitides are:
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Note: If a CTD or vasculitide is suspected always dipstick urine (+ blood and albumin), micro-urine and check BP. If +ve indicates kidney disease and need for referral.