Reactive Arthritis

Reactive Arthritis
Presentation by: Walter Eisenhauer MMS, PA-C

Reactive Arthritis

* Also known as Reiter’s syndrome
o Named after Hans Reiter, a German Physician in 1916
o Symptoms of Arthritis, Conjunctivitis, Non Gonococcal Urethritis following bouts of bloody dysentery
o > 75% HLA B27 positive
* Secondary immune reaction, in susceptible individuals, to primary infection:
o Yersinia
o Campylobacter
o Shigella
o Salmonella
o Chlamydia
* Classified as a seronegative spondyloarthropathy
* Occurs 2-4 weeks after inciting infection
* Most responsible organisms have an affinity for mucous membranes
* Terms Reactive Arthritis & Reiter’s Syndrome Synonamous
* First manifestation usually non gonococcal Urethritis
o occurs in both venereal and non venereal forms of the disease
o Mucopurulent discharge
o Dysuria
o Prostatitis
o Epididymitis
* Females
o Dysuria
o Vaginal discharge
o Purulent cervicitis
* Conjunctivitis
o follows urethritis by several days
o Sx often mild and transient
o acute anterior Uveitis possible
* Articular symptoms typically appear last
* additive
* oligoarticular
* lower limbs most common
* Keratoderma blennorrhagicum
* Circinate Balanitis

Glossitis/ Mucocutaneous Lesions
* Aortic Valve involvement 1-2% of cases
* Amyloidosis
* Neurologic complications
o peripheral neuropathies
o encephalopathy
o transverse myelitis

* Clinical course
o Normally limited course running 3-12 months
o 15% with prolonged relapsing arthritis
+ ? Relapse
+ ?Reinfection
o Ankylosing Spondylitis in 10% of cases
o Relation to HIV- probably due to increased risk of concurrent infection not HIV as initiator
* Laboratory findings
o Normochromic, normocytic anemia
o Leukocytosis
o Acute phase reactants:
+ ESR
+ C-reactive Protein
* HLA-B27 positive 75%
* Synovial fluid- highly inflammatory
* Sterile cultures- negative gram stain
* X-Ray reveals periostitis with eventual new bone growth
* Treatment:
Idiopathic Inflammatory Bowel Disease
Whipple’s Disease
Ankylosing Spondylitis
Ankylosing Spondylitis
Clinical Picture
Syndosmophytes
Patient Instructions

* No cure but can be well managed
* Education of patients =increased compliance
* Early diagnosis important
* NSAIDS Vocational support
* Exercise Screen first degree relatives
* Surgical measures
Treatment

Reactive Arthritis.ppt

Read more...

Rheumatologic Examination

Rheumatologic Examination
Presentation by:Walter Eisenhauer MMS PA-C

Approach to Disorders of the Joints
* Etiologies of Joint Pain
+ Traumatic
+ Infectious
+ Degenerative
+ Metabolic
+ Immunologic
+ Neoplastic

Diagnosis

* Based on
+ History
+ Physical
+ Lab
+ X-ray
* Origination of Joint Symptoms
+ Synovium Cartilage Periarticular structures
+ Inflammatory Non-inflammatory

History

* Duration of Joint Symptoms
* Rapidity of Development
* Self Limited Symptoms Vs Persistent
* Number and Location of Affected Joints
* Pattern of Affected Joints
+ Symmetric
+ Asymmetric
* Sequence of Joint Involvement
+ Additive
+ Migratory
* Pain at Rest/Following Exercise
* Gelling
* Precipitating Events-Illness
* Morning Stiffness
* Symmetric Distribution of inflammatory changes-RA
* Weight Bearing Joints After Exercise-DJD
* Migratory-Rheumatic Fever
* Additive-RA
* Persistent Low Back Pain in Young Man-Ankylosing Spondylitis
* Acute Inflammation-Infection/Crystal Deposition Disease
* Chills/High Fever
* Constitutional Sx-RA/Neoplasm/infections
* Medications-Pronestyl Induced Lupus


Past Medical History

* Hepatitis
* Rubella, Mumps, Parvovirus
* Reynauds
* Iritis-Ankylosing Spondylitis
* Inflammatory Bowel Disease

Social History

* Sexual Practices
* Work
* S/S Depression-Anxiety
* Stress
* Diet-CA++/Purines

Physical Examination

* Skin
+ Nodules on extensor surfaces
+ Psoriatic Rashes
+ Nails
+ Signs of Vasculitis
+ Mucocutaneous lesions of Reiters Syndrome
+ Eye Dryness

Examination of the Joints

* Examine even Unaffected Joints
* Examine Peri-Articular Surfaces
+ Atrophy Effusions Erythema
+ Palpation
* Establish Range of Motion
* Palpate Exact Location of Tenderness
* Temperature
* Assess Muscle Strength/Tone
* History will help guide complementary exams:
+ Risk for CA and Assoc Wt Loss-Examine high risk systems
+ Abdomen/Bowel Sx- Examine abdomen
+ Fever-Cardiac
+ Pulmonary Sx-Lung

Classification of Joints

* Synarthrosis-No Movement
+ Suture-Cranial
+ Synchondrosis-Epiphysis/Diaphysis
* Amphiarthrosis-Slight movement
* Diarthrosis-Synovial
* Ball and Socket Saddle-Thumb Carpal/MC
* Hinge Gliding-intervertebral
* Pivot-Atlantoaxial
* Condyloid-Wrist

Examination

* Waiting Room Diagnosis
* Inspect Gait
* Ability to Disrobe etc- good eval of ROM
* Inspect Muscles
* Goniometer for ROM

Motor Examination

* S.I.T.S.
+ Size-measure all major muscle groups
* upper/lower arms
* upper/lower legs
* Inspect for Involuntary Movements
* Evaluate Tone
* Strength Testing
+ 0-4 grading

Motor Strength Testing

* 0- No Movement
* 1-Slight Contraction
* 2-Full Range of Motion/No Gravity
* 3-Full Range of Motion/Gravity
* 4- Some resistance
* 5- Full Resistance

Examination of the Upper Extremities

* Shoulder
+ Inspect
* Contour
* Girdle
* Clavicles
* Scapulae
* Muscles-SITT/Biceps/Deltoid/Traps
* AC Joint
* Bicipital Groove
* Shoulder Shrug-Inspect for symmetry
* Abduction-180
* Adduction-50
* Internal Rotation(behind small of back)-90
* External Rotation(behind neck)-90

Elbow
Fibromyalgia Syndrome
Rheumatologic Examination.ppt

Read more...

Diagnostic Testing Rheumatologic and Connective Tissue Diseases

Diagnostic Testing Rheumatologic and Connective Tissue Diseases

Is it a rheumatologic or connective tissue disorder?

* The distinction between rheumatologic and connective tissue (collagen vascular) diseases is unclear.
* There is much overlap in disease presentation and laboratory testing
* In each, the body’s own proteins are recognized as foreign, and AUTO-antibodies produced


Case #1

Rheumatoid Arthritis Lab Work-up

* CBC (with diff)
* Sedimentation rate
* Rheumatoid Factor (RF)
* 40-60% have anemia of chronic disease; (suspect infection); mild WBC

Erythrocyte Sedimentation Rate (ESR)

* Nonspecific test for inflammatory process
* anticoagulated blood in calibrated tube; rate of sedimentation of RBCs in 1 hour
* normal <15m;<20f; add 10 past age 60
* Rate of sedimentation increases with
o increased fibrinogen 2 inflammatory process (occurs wi 12-24 hours)
o acute/chronic infection; tissue necrosis; tissue infarction; well established malignancy; rheumatoid/collagen diseases; abnormal serum proteins; pregnancy; obesity; anemia

Sedimentation Rate Uses

* An aid in detection and diagnosis of inflammatory condition (or to exclude)
* A means of following the activity, clinical course, or therapy of inflammatory diseases
* To demonstrate or confirm occult organic disease

Rheumatoid Factor (RF)

* RA and related diseases associated with increased immunoglobulins (autoantibodies):
o IgG variety antibodies
o IgM variety antibodies
o IgA variety antibodies
* RF is an IgM antibody directed against IgG
* Present in the sera of 75% of patients with Rheumatoid Arthritis
* Higher titer of RF are commonly associated with severe RA
* High titers also seen in syphyllis, sarcoid; infective endocarditis; TB; leprosy; parasitic infections; old age
* Presence of RF does NOT rule in RA
* Absence of RF does NOT rule out RA
* If the pretest probability of RA is high, the presence of RF is supportive of the diagnosis.
* If the pretest probability of RA is high, the absence of RF should not change your clinical diagnosis
* Order if symmetrical polyarthritis of uncertain origin
* There is no need to repeat RF testing once it is positive

Case #2

Systemic Lupus Erythematosus Lab Work-up
Antibodies in SLE
Antinuclear Antibody
(ANA)
ANA: peripheral pattern
ANA: solid/diffuse pattern
ANA: speckled pattern
Anti-nDNA Antibody
Anti-Sm Antibody

Case #3
Mixed Connective Tissue Disease Lab Work-up
Anti-RNP (ribonucleoprotein) Antibody
Case #4
Anti-RO/SSA and Anti-LA/SSB
Complement Levels
(C3, C4, CH50)
INFLAMMATION
Complement Activation Pathways
Complement Testing
HLA-B27 Antigen in Ankylosing Spondylitis
Case #5
Joint Aspirate Analysis
INFECTION

Diagnostic Testing Rheumatologic and Connective Tissue Diseases.ppt

Read more...