Disclosures • None Rheumatology vs Ortho: How Do You Tell? Andrew J. Gross, MD Rheumatology Clinic Chief Associate Clinical Professor University of California, San Francisco Objectives Clinical Case #1 • Recognize the key features of polymyalgia • A 66 year old man comes to see you complaining of shoulder pain. The pain rheumatica came on suddenly about 3 weeks ago, • Recognize inflammatory back pain initially affecting his right shoulder and • Know the differential diagnosis of subacute then the left. The pain radiates down into the upper arms and somewhat monoarticular arthritis across his upper back and is • Know the hallmarks of fibromyalgia. exacerbated by shoulder abduction. • Distinguish rheumatoid arthritis from • He also complains of new onset lower osteoarthritis by hand joint involvement back and hip discomfort. 1
All of the following symptoms tipped you off Clinical Case #1 - Question to the diagnosis of PMR EXCEPT: You diagnose him with Polymyalgia Rheumatica (PMR). All of the following symptoms tipped you off to the 67% diagnosis of PMR EXCEPT: a. AM stiffness >45 min a. Morning stiffness lasting >45 minutes b. Hand numbness b. Hand numbness c. Pain & stiffness affects the lower back and pelvic c. lower back stiffness girdle 19% d. Better w/ activity d. Pain & stiffness improves with activity 9% e. ESR >40 mm/hr 3% 2% e. ESR >40 mm/hr n s s y r h i s s t m e e i / v n n m 5 b i f t m 4 m f c i a > t u s 0 / s n k w 4 s e c > d a n r R n b e f S f a t i H r t E t e e s w B M o l A Dasgupta B, et al, Ann Rheum Dis 2012, EULAR/ACR Classification Criteria Some Tips about PMR Clinical Case #1 - Question You diagnose him with Polymyalgia Rheumatica (PMR). • Typical distribution of All of the following symptoms tipped you off to the PMR symptoms… diagnosis of PMR EXCEPT: • Subdeltoid bursitis & a. Morning stiffness lasting >45 minutes biceps tenosynovitis are b. Hand numbness common in one or both c. Pain & stiffness affects the lower back and pelvic shoulders girdle • Patients may develop d. Pain & stiffness improves with activity adhesive capsulitis e. ESR >40 mm/hr Dasgupta B, et al, Ann Rheum Dis 2012, EULAR/ACR Classification Criteria Salvarani, C, et al, Nat Rev Rheumatol, 2012, PMID 22825731 2
Some more Tips about PMR Some more Tips about PMR • PMR is uncommon in patients < 60 years old • PMR is uncommon in patients < 60 years old 97 cases of PMR identified during a 10 year study from • ESR is helpful - but it is <40 mm/hr in 10-20% of patients Olmstead County, Minnesota – CRP can be helpful when ESR is <40 0-49 years 1 in a million • 15% will have Giant Cell Arteritis (new onset head pain) 50-59 years 1 in 5,000 – New onset head pain 60-69 years 1 in 2,000 – Scalp tenderness 70-79 years 1 in 900 – Jaw claudication when chewing – Sudden vision loss or diplopia Chuang TY , et al, Ann Intern Med 1983, PMID 6982645 Dasgupta B, et al, Ann Rheum Dis 2012, EULAR/ACR Classification Criteria Things patients with PMR often tell me When To Refer PMR to a rheumatologist • “I feel like I am 100 years old!” • Rheumatologists are generally pleased to see cases of PMR • “I need to crawl out of bed in the morning” • Partial response to treatment with prednisone – should have fully response to 15-20 mg/d. • “I feel okay as long as I keep moving, but I stiffen up as • Difficulty tapering prednisone soon as I sit down – like the • Symptoms of Giant Cell Arteritis tin man” • “That prednisone is a miracle” 3
Clinical Case #2 Clinical Case #2 • A 26 year old man comes to see you • The shoulder exam is notable for complaining of shoulder pain. The pain limitation in shoulder ROM (abduction, came on about 3 weeks ago, initially internal & external rotation) without affecting his right shoulder and then weakness in the rotator cuff muscles. the left. The pain does not radiate. There is some tenderness over the Range of motion of motion of both glenohumeral joint. No effusion. shoulders is limited. • Cervical spine flexion & rotation as • He also notices pain and stiffness in well as lumbar spine flexion are his neck and lower back. This is somewhat limited. Straight leg raise is worse recently, but has been present unremarkable. on an off for the past couple of years. • Hip rotation is also somewhat limited. • He complains of a hour of morning • The remainder of the joint exam is stiffness in his shoulders and low unremarkable. back. Which of the following conditions is the most likely Clinical Case #2 cause of this man’s shoulder, neck and lower back pain: Which of the following conditions is the most likely cause of this man’s shoulder, neck and 82% a. AS lower back pain: b. PMR a. Ankylosing Spondylitis c. RA b. Polymyalgia Rheumatica d. SLE c. Rheumatoid Arthritis e. CPPD d. Systemic Lupus Erythematosus e. Calcium Pyrophosphate Dihydrate Disease 10% (CPPD) 4% 1% 1% S R A E D A M R L P S P P C 4
Typical distribution Clinical Case #2 of involved joints in rheumatoid arthritis Which of the following conditions are a likely (and lupus) cause of this 26 y.o. man’s shoulder, neck and lower back pain: a. Ankylosing Spondylitis b. Polymyalgia Rheumatica (age >50) c. Rheumatoid Arthritis d. Systemic Lupus Erythematosus e. Calcium Pyrophosphate Dihydrate Disease (CPPD) (usually older people, typically spares lumbar spine) www.studyblue.com Ankylosing Spondylitis Rheumatoid Psoriatic Ankylosing Osteoarthritis Arthritis Arthritis Spondylitis https://dundeemedstudentnotes.wordpress.com/2014/06/16/polyarthritis/ 5
AS – “bamboo spine” Ankylosing Spondylitis - sacroiliitis Ankylosing Spondylitis Clinical Case #2 All of the following symptoms are associated with DIAGNOSIS inflammation of the spine (spondylitis) EXCEPT: a. Pain & stiffness improve with exercise. Non-radiographic stage Radiographic stage b. Onset of back pain was insidious Back pain Back pain Back pain c. Back pain & stiffness gets worse at night Sacroiliitis on Radiographic Syndesmophytes d. Burning pain in the thighs with standing MRI sacroiliitis e. Symptoms began before age 40 Time (years) Rudwaliet M, et al. Arthritis Rheum . 2005;52(4):1000-1008. 6
All of the following symptoms are associated with inflammation of the spine (spondylitis) EXCEPT: Clinical Case #2 All of the following symptoms are associated with inflammation of the spine (spondylitis) EXCEPT: 62% a. Pain & stiffness improve with exercise. a. Improves w/ exercise b. Onset of back pain was insidious b. Insidious onset c. Back pain & stiffness gets worse at night c. Pain worse at night d. Burning pain in the thighs with standing d. Burning pain in thighs e. Symptoms began before age 40 e. Symptoms <40 y.o. 14% 14% 7% 4% e t t . e s o s h h i s . c n g g y r i o n i 0 e h x 4 s t t e u a < n / o i s e w i s n m d r i s i o a o s t e n w p p v I g o n m n r i y p a i n S m P r u I B Inflammatory Back Pain: NHANES 2009-2010 Hallmark Features Feature Odds Ratios • 19.2% of US Adults age 20-69 years old reported Insidious onset 12.7 chronic axial pain Pain at night (with improvement upon getting up) 20.4 • In patients with chronic axial pain, 28% to 35.5% Age at onset <40 years 9.9 had Inflammatory Back Pain Improvement with exercise 23.1 • US prevalence of IBP: 5% to 6% No improvement with rest 7.7 Sensitivity 79.6% & Specificity 72.4% Positive LR = 79.6/(100-72.4) = 2.9 ~ Probability = 14% • Self-reported prevalence of ankylosing spondylitis = 0.55 LR=likelihood ratio Reveille JD, et al. Arthritis Care & Res . 2012;64(6):905-910.Weisman MH, et al . Ann Rheum Dis. Sieper J, et al, Ann Rheum Dis 2009, PMID 19147614 Rudwaleit M, et al. Ann Rheum Dis . 2009; 68(6):777-83. Ozgocmen S, et al. J Rheumatol . 2010;37(9):1978. 2013;72(3):369-373. 7
When to refer a patient with back pain AS: Treatment to a rheumatologist • Inflammatory Back Pain • HLA-B27+ (present in 85-95% of patients with AS) Axial disease only • Elevated CRP • Sacroiliitis on imaging (x-rays or MR) • Family history of Ankylosing Spondylitis TNF NSAID NSAIDs sulfasalazine inhibitors Physical Therapy Poddubnyy D, van Tubergen A, Landewé R, et al. Ann Rheum Dis 2015;74:1483–1487 Braun J, et al.,, Ann Rheum Dis 2011; 70: 896-904; van der Heijde D, et al, Ann Rheum Dis 2011; 70:905-08 Clinical Case #3 Clinical Case #3 • 45 year old man comes to see you with left knee To identify the cause of the knee swelling, what is the swelling for the past 7 days. He has no other best next test to obtain: complaints. A. Aspirate Knee Fluid for cell count and crystal search • ROS is unremarkable. No fevers or rashes B. MRI of knee • Physical Exam: unremarkable except for swelling C. X-ray of knee and warmth of the left knee with limited ROM. D. CBC with Differential E. Rheumatoid factor & CCP antibody 8
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