1.
DIAGNOSTIC STRATEGY IN RHEUMATOLOGY
BACKGROUND
MAIN SYNDROMES
Joint syndrome
Inflammatory arthritis
Osteoarthritis
The main reason the patients address to the rheumatologist is joint
pain. The first thing we have to do is to identify the source of pain
is it articular or not? The joint pain has the following characteristics:
it is present in all degrees/movements of the joint
the intensity is similar in active and passive mobilization,
causing limited range of motion
it is localized (normally alongside the margins of the joints)
the presence of crepitus, heat, swelling or effusion are
additional clues to confirm a the joint involvement
The pattern of the pain, initially can discriminate between a
degenerative disorder versus an inflammatory one.
The pain can
be: mechanical or inflammatory.
In the mechanical model the pain augments during mobilization and
usually its intensity is increased at the end of the day. The pain is
reduced at rest, and the patient will confess the presence of a pain
free position. Stiffness appears after rest (2-3) and dont last,
ceasing in a few minutes (< 15).
The inflammatory pattern is characterized by pain at rest, usually
during the night and early morning, morning stiffness that last
minutes (>30) to hours. The intensity decreases during and after
exercise.
In chronic conditions the pains pattern might be mixed: mechanical
and inflammatory.
The onset of the pain is important. In inflammatory model the onset
is quick hours to week, as for the mechanical pain the patient will
confirm an increasing of the pain over the years the onset is
insidious, chronic.
It is not mandatory in inflammatory pattern to associate all the
Celsius signs. Redness might be lacking in 50% of the patients with
septic arthritis and can be present in gout and psoriatic arthritis.
The articular swelling is a sign of an inflamed, engorged synovium. It
is firm, uniform spindle shape (due to the limitation imposed by the
capsule), globular in superficial joints and has a rubbery consistency.
Effusion may be associated.
Patterns of inflammatory joint disease
When evaluating a patient we are evaluating a patient with articular
involvement we must consider the following:
1. number of joints involve
monoarthritis: one single joint involved
oligoarthritis: 2 to 4 joints involved
polyarthritis: 5 or more joints involved
2. the type of the onset
acute: onset in hours or days
chronic: onset over weeks or months
3. the site affected
proximal: arthritis mainly involves large joints, i.e,
proximal to the wrist or ankle, and the spine
distal: the arthritis mainly involves the small joints of
the hands and feet, with or without the wrist and ankle
4. the evolution of pain
symmetrical: affects approximately the same joint
groups of each side of the body
asymmetrical: there is no relationship between the
joints involved on either side of the body
persistent: once it has set, the arthritis persists over
the time
recurrent: episodes or crisis of arthritis separated by
symptom-free intervals
additive: the affected joints are added progressively
migratory: the inflammatory process flits from one
joint to another
5. the association with other manifestations
systemic manifestations
inflammatory low back pain
Monoarthritis
Acute monoarthritis. It is mandatory to exclude a sepsis when
dealing
with
inflammatory
monoarthritis.
Classically
it
is
characterized by rapid onset, redness and swelling in a single joint.
Aspiration or/and biopsy of synovial fluid is required in order to
confirm the diagnosis.
Gout is the most common cause of acute monoarthritis. The sudden
onset, at night involves the first metatarsophalangeal joint. The joint
is typically swollen, bright red, hot and extremely tender. Systemic
symptoms such fever and malaise could be present. The pattern of
pain is recurrent. In time other joints are affected, the pattern
becoming polyarticular.
The following disorders can start as monoarthritis:
reactive arthritis
post-traumatic synovitis
pseudo-gout
bacterial endocarditis
psoriatic arthritis
Chronic monoarthritis (weeks to months)
synovial biopsy is required for diagnosis
infections are the common causes (brucella, mycobacterium,
Lyme disease, others),
crystal induced arthritis
juvenile idiopathic arthritis
reactive arthritis
seronegative spondyloarhropathy
sarcoidosis
Differential diagnosis with non-inflammatory conditions:
osteoarthritis,
recurrent hidrarthrosis
osteonecrosis
reflex sympathetic dystrophy
neuropathic (Carchots) joints
tumors - villonodular synovitis
Polyarthritis
Chronic symmetrical additive peripheral polyarthritis
common affected small joints of the hands and feet
no inflammatory low back pain
rheumatoid arthritis
connective tissue diseases:
systemic lupus
primary Sjgrens syndrome
polymyositis
mixed connective tissue disease
psoriatic arthritis
chondrocalcinosis
gout
viral arthritis
Chronic, asymmetrical oligo/polyarthritis
asymmetrical arthritis, affecting proximal or distal joints
common, but not mandatory dactilitis
psoriatic arthritis
hand osteoarthritis
seronegative spondylarthropathies:
ankylosing spondylitis,
inflammatory bowel disease
chronic sarcoid arthropathy
Proximal oligoarthritis
seronegative spondylarthropathies
rheumatoid arthritis
juvenile idiopathic arthritis
Polyarthritis with systemic manifestations
connective
tissue
diseases
eg.
systemic
lupus
erythematosus (+ photosensitivity, livedo reticularis, alopecia,
ulcers etc.)
Stills disease
reactive arthritis
Acute oligo -or polyarthritis
oligo- or polyarthritis
fever
recent infection
reactive arthritis
systemic lupus erythematosus
dermatomyositis
Behcets disease
rheumatoid arthritis
Inflammatory low back pain
specific for seronegative spondylarthropathies:
ankylosing spondylitis
psoriatic arthritis
Reiters syndrome,
spondylitis of inflammatory bowel disease
Behets disease
infectious or aseptic discitis
Patterns of degenerative joint disease
ageing related
most common sites: hip, knee, spine
no specific cause primary osteoarthritis
nodal osteoarthritis typical osteoarthritis
Regional Syndromes
a unique muscle area is affected
the pain can be:
periarticular (eg. shoulders, elbows). Pain is more increased in
active motion compare to passive one. Also, it is exacerbated
in certain positions that induce compression of the structure
(rotator cuff tendonitis). Passive movement is not limited,
because the structure involved remains at rest during passive
motion.
articular (forefeet, knees) pain at motion (active or passive).
Passive motion is limited due to swelling or structural damage.
The joint is tender accompanied by crepitus, swelling, effusion
and articular heat.
neurogenic compression or irritation of nerve roots or
peripheral nerves. Pain is described as a sensation of burning,
numbness, electric shock, tingling.
reffered symptoms are felt at distance from their anatomical
origin.
Generalized pain syndrome
pain is diffuse, migratory, worse after exercise
the specific disorder is fibromyalgia
other conditions: rheumatoid arthritis, systemic
lupus
erythematosus, Sjgrens syndrome, polymyalgia rheumatica,
ankylosing
spondylitis,
polymyositis,
hypothyroidism,
hypoparathyroidism,polyneuropathy
Neck/Low back pain
pain has a mechanical rhythm with certain exception (see table one)
pain can be reffered
lymphadenopathy, thyroiditis and meningitis represent important non-rheumatic causes of
neck pain.
The
possibility of referred pain, from the heart, lung apex and shoulder must be kept in mind.
RED FLAGS
Back pain with inflammatory
Sacroiliitis
rhythm
Localized pain
Nocturnal pain
Visceral or constitutional
Spondylodiscitis
Metastases
Osteoporotic fracture
symptoms
Neurogenic pain
Onset before age 30 or after 50
Referred pain
Pain at movement in all
Interspinous ligamentitis
directions
History of neoplasm
Risk or evidence of osteoporosis
Neurological manifestations
Table 1. Low back pain - alarm signals
Bone syndrome
The pain is:
deep,
diffuse,
continuous pain
unrelated to movement
most common affected: proximal limbs, pelvis, spine
metastatic tumors
metabolic bone disease
Osteoporosis syndrome
related with the osteoporosis risk factors:
smoking
alcohol
sedentary life style
family history of osteoporosis
history of fractures
late menarche
early menopaise
hyperparathyroidism
liver disease
malabsortion
Muscle syndrome
typically characterized by: proximal muscle weakness and
atrophy
most common
inclusion-body myositis
pay attention at patietnts drugs intake: glucocorticoids,
statins, fibrates, colchicine, cyclosporine
always perform a neurological exam to exclude non-
disorders:
polymyositis,
dermatomyositis,
inflammatory disorders such as: myasthenia gravis, spinal
muscle atrophies, storage diseases, myotonic diseases
Systemic syndrome
The autoimmune inflammatory diseases are associating extraarticular manifestations.
Some of them are common, nonspecific
those are the constitutional manifestations (fever, weight loss,
severe fatigue) others are specific (eg. serositis SLE, muscular
weakness myositis etc.).
Paediatric syndromes
Children are not just little adults.
The enquiry is similar with the adults one. The physical exam is
different from the adult patients. The child can be uncooperative
and shy. The majority of symptoms in children are confined to a
single joint area and are caused by minor deformities, growth
abnormalities
or
trauma.
Generalized
pain
is
also
relatively
common. The musculoskeletal symptoms and signs associated with
major rheumatic or systemic conditions are less common.
TAKE HOME MESSAGES
Out rule all the malignancies and TB diagnosis before considering a
rheumatologic disorder
References:
1. West S, Rheumatology Secrets second edition, ed. Hanley
Belfus, 2002, 695: 12-22
2. Bijlisma WJJ, Eular Compendium on Rheumatic Diseases, BMJ
Publishing Group, 2009, 824: 1-12
