Approach to the Achy Patient joint x-rays Questions: Management of - PDF document

Notes • The talk went 41 minutes. • Drop the x-rays in evaluation of RA • Could add symptoms of inflammatory back pain & SI Approach to the Achy Patient joint x-rays • Questions: – Management of fibromyalgia Andrew J. Gross, MD – How do you investigate other diseases in Fibromyalgia Rheumatology Clinic Chief patients. (include lab tests slide) Associate Clinical Professor – ANA reflex testing – how useful are the highly specific University of California, San Francisco antibodies like Scl-70 and dsDNA Ab – Peri-menopausal achiness Clinical Case #1 Disclosures • None • 52 year old woman with 5 months of joint pain. Initially she had pain in her hands. Over time, she developed pain in her shoulders, knees and feet. Ibuprofen has been helpful for the pain. • Review of systems is notable for moderately severe fatigue, and occasional sharp chest pains. She also reports symptoms of Raynaud’s phenomenon. • Past medical, family and social history are unremarkable. 1

Clinical Case #1 Let me just pull out my “tricorder” • General physical examination is unremarkable. • On musculoskeletal exam, you are uncertain if there are any swollen joints. Many joints are tender, particularly her PIP and MCP joints, her wrists and knees. What is the diagnosis? Approach to Arthritis Differential Diagnosis (clinical clues) Inflammatory Non-Inflammatory • age • Autoimmune • Osteoarthritis • gender – Lupus/Scleroderma • Endocrine • family history – Rheumatoid Arthritis – Thyroid Disease • onset of disease (acute/chronic) – Spondyloarthritis – Diabetes • pattern of joint involvement • Crystal Disease – Calcium metabolism (& presence of enthesitis) • Infectious • Overuse – Viral • Somatic/Fibromyalgia – Chronic bacterial – Hypermobility • Neoplastic 2

All of the following conditions commonly involve Pattern of Joint Involvement PIP & MCP joints, wrists and knees EXCEPT: All of the following conditions commonly involve A. Osteoarthritis PIP & MCP joints, wrists and knees EXCEPT: B. Rheumatoid A. Osteoarthritis Arthritis B. Rheumatoid Arthritis C. SLE C. SLE D. CPPD disease D. CPPD disease (“pseudogout”) (“pseudogout”) E. Parvovirus B19 induced arthritis E. Parvovirus B19 induced arthritis Pattern of Joint Involvement ¡ Pattern of Joint Involvement All of the following conditions commonly involve All of the following conditions PIP & MCP joints, wrists and knees EXCEPT: commonly involve PIP & MCP joints, wrists and knees A. Osteoarthritis EXCEPT: B. Rheumatoid Arthritis C. SLE A. Osteoarthritis D. CPPD disease (“pseudogout”) B. Rheumatoid Arthritis E. Parvovirus B19 induced arthritis C. SLE D. CPPD (“pseudogout”) E. Parvovirus B19 arthritis 3

Approach to Arthritis Approach to Arthritis (clinical clues) (clinical clues) • age • age • gender • gender Lupus/MCTD/ Lupus/MCTD/ • family history • family history scleroderma scleroderma • onset of disease (acute/chronic) • onset of disease (acute/chronic) Rheumatoid Rheumatoid • pattern of joint involvement • pattern of joint involvement Arthritis Arthritis (& presence of enthesitis) (& presence of enthesitis) Psoriatic Psoriatic • extra-articular manifestations Arthritis Arthritis • diagnostic testing Clinical Case #1 Clinical Case #1 Re-examination Re-examination of the skin is of the skin is remarkable for remarkable for mild erythema mild erythema of her fingers, of her fingers, particularly particularly between the between the knuckles. knuckles. What is the diagnosis? What is the diagnosis? Photo courtesy of Maria Dall’era 4

All of the following could cause this All of the following could cause this appearance EXCEPT: ¡ appearance EXCEPT: A. Dermatomyositis 1. Dermatomyositis B. Psoriasis 2. Psoriasis C. Lupus 3. Lupus D. Granuloma Annulare 4. Granuloma Annulare E. Eczema 5. Eczema All of the following could cause this Tip appearance EXCEPT: A. Dermatomyositis B. Psoriasis • To help diagnose Inflammatory Arthritis C. Lupus Search for extra-articular CLINICAL D. Granuloma Annulare CLUES E. Eczema 5

Classification Criteria for Clinical Case #1 – Alternative Scenario Systemic Lupus Erythematosus • General physical examination is unremarkable. • Rashes (~85%) • Glomerulonephritis • On musculoskeletal exam, you are unsure if there are (50-70%) – Malar rash any swollen joints. Many joints are tender, particularly – Discoid rash (scarring) • CNS disease (25-35%) her PIP and MCP joints, her wrists and knees. – Photosensitive (seizures, chorea, stroke) • Skin exam is unremarkable • Hematologic disorder • Oral/nasal ulcers (painless) Leukopenia, Lymphopenia, • Arthritis (80-90%) Thrombocytopenia, AIHA (usually small joints) In the absence of clinical clues • Immunologic disorder Are there diagnostic tests that will • Serositis (~45%) dsDNA, Sm, APL Antibodies help identify the diagnosis? • Antinuclear antibodies Any combination of 4 or more of 11 criteria, well-documented at any time during a patient's history, makes it likely that the patient has SLE (95% specificity; 75% sensitivity) Tan EM, et al, Arthritis Rheum 1982 Anti-Nuclear Antibody (ANA)? How does an ANA test help me to determine if the patient has “a rheum thing” (like SLE)? 6

How will an ANA test help me to determine if How will an ANA test help me to determine if the patient has “a rheum thing” (like SLE)? the patient has “a rheum thing” (like SLE)? ¡ A. ANA ¡presence ¡suggests ¡ A. Although an ANA is not specific for any particular disease ¡is ¡present ¡ autoimmune disease, the presence of the ANA does B. ANA ¡suggests ¡will ¡ suggest the patient has a connective tissue disease. develop ¡disease ¡ B. A positive ANA indicates the patient has a defect in tolerance mechanisms and will develop an C. ANA ¡pa7ern ¡is ¡diagnos8c ¡ autoimmune disease. D. Tes8ng ¡for ¡addi8onal ¡ C. By examining the pattern of the ANA, you can autoan8bodies ¡is ¡helpful ¡ determine the diagnosis. D. Testing for additional autoantibodies can increase the specificity of testing. ANA is highly sensitive for Lupus & How will an ANA test help me to determine if Somewhat sensitive for other the patient has “a rheum thing” (like SLE)? autoimmune conditions A. ANA ¡presence ¡suggests ¡ • SLE 95-99% • Thyroid disease 30-50% disease ¡is ¡present ¡ • Systemic Sclerosis • Multiple Sclerosis 25% B. ANA ¡suggests ¡will ¡ (Scleroderma) 60-80% • ITP 10-30% develop ¡disease ¡ • Sjögrens 40-70% • Infectious diseases & C. ANA ¡pa7ern ¡is ¡ malignancies - varies widely • Polymyositis & Dermatomyositis 30-80% diagnos8c ¡ D. Tes8ng ¡for ¡addi8onal ¡ • Rheumatoid Arthritis 30-50% autoan8bodies ¡is ¡ helpful ¡ Kavanaugh A, et al, Arch Pathol Lab Med 2000 7

People without Autoimmune Disease can ANA Frequencies have a positive ANA 100% 50% 0% • Fibromyalgia 15-25% • Relatives of SLE Pts 5-25% • Healthy People Healthy Rheumatoid  >1:40 20-30% Scleroderma Fibromyalgia Arthritis &  >1:80 10-12% Lupus Thyroid Disease  >1:160 5%  >1:320 3% 1° relatives of SLE Pts Kavanaugh A, et al, Arch Pathol Lab Med 2000 Kavanaugh A, et al, Arch Pathol Lab Med 2000, PMID 10629135 Among 100,000 American Women How will an ANA test help me to determine if Who has a positive ANA? the patient has “a rheum thing” (like SLE)? Condition Number ANA+ Calculated with Prevalence of a. Although an ANA is not specific for any particular condition ANA+ people autoimmune disease, the presence of the ANA does per 100,000 per 100,000 suggest the patient has a connective tissue disease. Women with SLE 50 99% ~50 b. A positive ANA indicates the patient has a defect in Patients w/ Autoimmune Thyroid Dz 250 40% ~100 tolerance mechanisms and will develop an Women with Fibromyalgia 3500 20% ~700 autoimmune disease. c. By examining the pattern of the ANA, you can Healthy women with ANA ≥ 1:160 -- 5% ~5,000 determine the diagnosis. d. Testing for additional autoantibodies can increase ANA is not really helpful to screen for the specificity of testing. autoimmune disease Data extrapolated from Kavanaugh A, et al, Arch Pathol Lab Med 2000 & Tan EM, et al, Arthritis Rheum 1997 8

Speckled Nucleolar Disease Suspicion: Scleroderma Raynaud ’ s Phenomenon How about the ANA 1. Ischemia Pattern? 2. Cyanosis 3. Hyperemia Cytoplasmic Centromere Disease Suspicion: Scleroderma Disease Suspicion: Scleroderma Raynaud ’ s Phenomenon Raynaud ’ s Phenomenon TIP: Features of Raynauds ’ Phenomenon that are predictive of CTD Women with ANA 1:160 in Primary Healthy • Presence of ANA Raynaud ’ s: Women: 15% 5% ∴ 1 in 133 women have Primary Raynaud ’ s & Positive ANA 1 in 5,000 women have Scleroderma http://www.skincosmos.com/img/raynauds_cold_hands.jpg 9