How would you frame the DDx of joint pain?
Acute vs. chronic
Inflammatory vs. mechanical
Polyarthritis vs. oligoarthritis vs. monoarthritis
What are the patterns of joint pain?
A 14 YO girl has had pain in her fingers & wrists & this has made her clarinet performances more difficult over the last couple months. She has also had tactile fevers, fatigue, mouth sores & erythema of her cheeks for the last month. She thinks her hair is thinning & she has lost 5 lb in 2 wks. She has missed the last week of school.
She is tired appearing. Her eyes seem puffy. There is trace pitting edema of her ankles.
What is your top differential?
Systemic Lupus Erythematosus (SLE)
Depression/Chronic Pain Syndrome
How does this present?
What questions should you ask?
- Fatigue, weight loss, missing school, diffuse pain
- Recent stressors? Disinterest in usual activities? Difficulty sleeping?
EBV Infection
How does this present?
What questions should you ask?
- Fatigue, diffuse pain
- Sick contacts? Swollen LN? Sore throat?
Rheumatoid Arthritis
How does this present?
What questions should you ask?
- Multiple joint pain, fatigue
- Persistent swelling/stiffness of joints?
Psoriatic Arthritis
How does this present?
What questions should you ask?
- Multiple joint pain
- Persistent swelling/stiffness of joints?
- Rash?
- Nail abnormalities?
- FHx of psoriasis?
Inflammatory Bowel Disease
How does this present?
What questions should you ask?
- Multiple joint pain, mouth sores, weight loss, fatigue, hair loss
- Abdominal pain? Diarrhea? Bloody stools?
Systemic Lupus Erythematosus
How does this present?
What questions should you ask?
- Multiple joint pain, mouth sores, facial rash, fatigue, weight loss, hair loss, missing school
- Has facial rash been persistent?
- Photosensitive rashes?
- Leg swelling?
Common Variable Immune Deficiency
How does this present?
What questions should you ask?
- Multiple joint pain, fatigue, weight loss
- History of sinopulmonary infections?
What laboratory tests would you do for these?
- SLE
- EBV
- Hypothyroidism
- Rheumatoid arthritis
- IBD
- CVID
- SLE
- CBC, Cr, UA, ANA, anti-dsDNA, anti-Smith Ab
- EBV
- Monospot, EBV titers
- Hypothyroidism - TSH
- Rheumatoid arthritis
- RF, CCP, hand X-rays
- IBD
- CBC, ESR, CRP, stool guiaic
- CVID
- Immunoglobulin panel, vaccine titers
What are the two main categories of symptoms in Systemic Lupus Erythematosus?
- Mucocutaneous manifestations
- “-itis”
What are the mucocutaneous manifestations in SLE?
- Oral ulcers - hard palate
- Malar rash - crosses nasal bridge, spares nasolabial folds
- Rashes often photosensitive
What are the “-itis”-es of SLE?
- CNS inflammation
- Cerebritis (seizures, psychosis)
- Transverse myelitis
- Nephritis
- Arthritis
- Small joints
- Hands & wrists
- Serositis
- Pericarditis
- Pleuritis
What are the laboratory abnormalities seen in SLE?
-
Auto Ab
- ANA (sensitive but not specific)
- anti-dsDNA, anti-Smith (specific but not sensitive)
- Coombs
-
Cytopenia
- Leukopenia, lymphopenia
- AIHA, ITP
- Low complement
If our patient with SLE had normal urine but platelets consistently <20K, what would you treat her with?
- Steroids
- IVIG
- Rituximab
- Belimumab - not typically used for thrombocytopenia, but a related B-cell therapy
What is the pathophysiology of SLE nephritis?
How is this manifested in the lab abnormalities?
Type III Hypersensitivity
- (Auto)Ab + (Auto)Ag = immune complex (IC)
- IC deposit in tissues
- Deposited IC elicits inflammation including PMN infiltration
- Inflammation results in tissue damage
- Labs
- Immunofluorescence for IgG stains dermal-epidermal junction
- Lupus Band
A 14 YO girl has had pain in her fingers & wrists and this has made her clarinet performances more difficult over the last couple months. She has also had fatigue & mouth sores. On exam you see scaling on the extensor surfaces & nail pitting.
What is the most likely diagnosis?
Psoriatic Arthritis
What are the patterns of joint involvement in Psoriatic Arthritis?
- DIP predominant arthritis
- Oligoarticular (typically large joints)
- Polyarticular
- Axial involvement (uncommon)
What are some other presenting characteristics of Psoriatic Arthritis?
What is the genetic association?
- Enthesitis
- Dactylitis (“sausage digits”)
- Can be associated w/ HLA-B27
- Arthritis can precede onset of psoriasis
How does Psoriatic Arthritis present on the skin?
What is the Auspitz sign? Koebner phenomenon?
How does this correlate with arthritis severity?
- Lesions
- Well-demarcated erythematous lesions w/ silvery scale
- Auspitz sign - bleeding w/ peeling of scale
- Koebner phenomenon - rash at sites of trauma
- Most common distribution w/ plaque psoriasis - extensor surfaces of elbows & knees
- Severity does not correlated with arthritis severity
- Nail pitting increases the risk of arthritis
How is Psoriatic Arthritis treated?
- NSAIDs (arthritis only)
- Methotrexate
- Anti-TNF medications (etanercept, adalimumab, infliximab)
- Costimulation blockade (CTLA-4 Ig, abatacept)
- Anti-IL17 (secukinamab)
- Anti-IL12/23 (ustekinumab)
- JAK/STAT inhibitors (tofacitinib)
- PDE-4 inhibitors (apremilast)
14 YO female presents w/ a 2 wk history of very painful joints, initially her R knee, then her L wrist, and now her L ankle. She has had hives, and is fatigued. She has had mild dsypnea w/ ambulation. She is tachycardic & has a II/VI holosystolic murmur at the apex radiating to the axilla. Her joint exam is normal except for severe pain w/ ROM of the L ankle w/ mild swelling. She has an urticarial-like rash on her trunk. She had a sore throat about a month ago.
What is the Problem List?
What is the Leading DDx?
- Problem List
- Migratory polyarthritis
- Urticarial rash
- Murmur radiating to axilla (mitral valve)
- History of sore throat
- Leading DDx: acute rheumatic fever
14 YO female presents w/ a 2 wk history of swelling & stiffness intitially her L knee then progressed to also involve her L wrist, then both wrists w/ stiffness of her fingers. She has had fever, rash & is fatigued. She has swelling, warmth, erythema, tenderness & severe pain w/ ROM of her R knee, L wrist & L ankle. She has small pustules on her hands. She had a sore throat about 1 mo ago.
What is the Problem List?
What is the Leading DDx?
- Problem List
- Additive polyarthritis (very painful & erythematous)
- Fever
- Pustular rash
- History of sore throat
- Sexually active
- Leading DDx: gonococcal arthritis
14 YO female who presents w/ a 1 wk history with very painful swollen knees & fingers. She has also had a blotchy rash on her arms & legs. About 2 wks ago, she had a fever & red cheeks. Her little brother was also sick with fever & red cheeks. Her exam reveals swelling & stiffness of her knees & PIPs. She has a lacy erythematous rash on her arms & legs.
What is the Problem List?
What is the Leading DDx?
- Problem List
- Acute polyarthritis
- Lacy rash in stocking/glove distribution
- History of febrile illness
- Sick contact w/ fever & slapped cheek rash (5th’s disease)
- Leading DDx: Parvovirus
Mr. J is a 54 YO man w/ obesity & recently diagnosed HTN who complains of L knee pain. The pain is so severe he became nauseated & vomited 2X this morning. He feels sweaty & wife reports “color was not good”. He seemed to be breathing rapidly. In the past he has complained of intermittent knee pain in both kenes & feet at night. He just retruned from hunting large game in South Africa & attended his college reunion at Yale 4 months ago.
On exam his skin is cool & clammy. On joint exam he has Hebreden’s nodes, squaring of the base of the thumb, non-tender nodules at olecranon bursa on the R, large warm effusion w/ some patchy redness over L knee.
What diagnostic tests should be performed?
What is the likely diagnosis?
- Aspiration of joint, CBC, basic metabolic panel, pulse oximetry, imaging not necessary
- Synovial fluid analysis
- Axis of polarization aligned w/ yellow crystals
- DDx: Gout
What is the pathophysiology of Gout?
What is the treatment principle of acute gout?
What is the treatment principle of recurrent gout?
What are the treatment options?
-
Acute gout: reduce inflammation
- Colchicine
- NSAIDs
- Steroids
-
Recurrent gout: reduce uric acid levels
- Allopurinol
- Febuxistat
- Probenacid
What if the synovial fluid looked like this?
Calcium Pyrophosphate Deposition Disease (CPPD)
What is CPPD?
- Common form of arthritis
- Affects elderly patients preferentially
- Clinically heterogenous presentation
- Can look like gout, OA or RA
- Difficult to treat
- Lab: blue perpendicular cystals
- Hallmark: Chondrocalcinosis
What if the synovial fluid looked like this?
Septic arthritis
- Monoinflammatory arthritis that is otherwise unexplained
- This is a medical urgency
- Joint needs to be drained
- Etiology is typically from hematogenous spread
- Wks of antibiotics are typically necessary
If the synovial fluid was inflammatory but gram stain was negative, what would the possibilities be?
-
Gonococcal arthritis
- Wrists & knees
- Sexually active, W > M
- Extremely sensitive to therapy
- Dissemination to skin
- Hard to recover from joints
-
Lyme arthritis
- Tick form
- Not very common
- Secondary & tertiary phase
- Erythema migrans
-
Fungus
- Immunocompromised patients
- Mycobacteria
What if the synovial fluid looked like this?
Osteoarthritis
- Normal looking, non-inflammatory
- Loss of articular cartilage
- Bones sclerotic
- Osteophytes
What is knee osteoarthritis?
How does it present?
Treatment?
- The most common form of arthritis in adults
- “non-inflammatory”
- Can still cause severe pain
- Treatment is symptomatic