Inflammatory arthritis and Autoimmunity

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Inflammatory Arthritis and
Autoimmunity
Sunil Abraham, MD
Ellis Rheumatology Associates
 No disclosures
Classification
Septic
Infectious
Osteomyelitis
Monosodium urate
Crystalline
Calcium pyrophosphate
Arthritis
Rheumatoid
Inflammatory
Autoimmune
Seronegative (HLA-B27)
ANA related
Polymyalgia rheumatica
Vasculitis, Sarcoid, Misc
Non-Inflammatory
Osteoarthrosis
Case presentations
Case #1
 46 year old white female with 4 month history of
progressive fatigue associated with worsening
joint pains
 In the morning her knees are very stiff (1 hour)
and her first few steps out of bed are very painful
 She has noticed MCP swelling and that her rings
are getting tighter
 There is numbness and tingling in her fingertips
 ROS negative
Case #2
 28 year old male presents with a 5 year history of
recurring bilateral ankle pain and swelling. It is
associated with extreme morning stiffness. He
denies any back pain. He has nail pitting
 His brother recently developed a rash on his
elbows
 MRI of the of right ankle showed significant
tendon swelling and subcortical erosions
Case # 3
 82 year white female with history of diabetes,
hypertension and coronary disease presents with
2 month history of progressive fatigue, malaise
and stiffness in her hips and shoulders
 She has never taken an hmg coa reductase
inhibitor
 Review of systems is negative
 Sedimentation rate is normal
Case # 4
 An 87 year old white female presents to your
office with acute right dorsal wrist swelling,
redness, warmth and pain that has been present
for 3 weeks
 No constitutional symptoms are present
 Two courses of antibiotics provide no relief
 Xray of her wrist shows chondrocalcinosis of the
TFCC; ESR is 90
Inflammatory Arthritis
• Infiltration of synovial
capsule and surrounding joint
capsule with lymphocytes,
neutrophils, and macrophages
• Cardinal signs of
inflammation:
– Rubor, Calor, Tumor,
Dolor
• Potential for joint disruption
and destruction
Acute Inflammatory arthritis
 Abrupt onset (hours to days)
 Hot, red, swollen, exquisitely tender joint
 Constitutional symptoms (fevers, chills, sweats)
 Mono-, oligo-, poly- articular
Acute Inflammatory arthritis
 Differential
 Infectious
 Bacterial, mycobacterial, fungal
 Opportunistic
 Lyme (3rd stage)
 Crystalline
 Monosodium urate- ‘Gout’
 Calcium pyrophosphate- ‘Pseudogout‘
Acute Inflammatory arthritis
 Rule out mechanical/traumatic injury
 Olecranon bursitis, rotator cuff/ achilles
tendonitis
 Fracture
Chronic inflammatory arthritis
 Progressive, insidious (>6 weeks)
 Morning stiffness > 1 hour
 Additional signs of inflammation
 Fatigue, malaise, anhedonia
 Weight loss, anorexia
 ‘Flu like’
Chronic inflammatory arthritis
 Extra-articular manifestations
 Rash (psoriatic, erythema nodosum)
 Urethritis or sexually transmitted disease
 History of bowel infection (salmonella, shigella)
 Inflammatory bowel disease (colitis)
 Uveitis
 Sicca
Connective tissue disease
 Disorder with collagen and elastin
 Supporting structures
 Non-heritable (genetics/environmental)
 Rheumatoid arthritis
 Systemic lupus erythematosus
 Sjogrens Syndrome
 Polymyositis, Scleroderma
 Heritable
 Osteogenesis imperfecta, Marfans, Ehlers-Danlos
Connective tissue disease
 Review of systems
 Signs of inflammation
 Arthritis
 Patchy alopecia
 Oral/nasal ulcerations
 Raynauds
 Xerophthalmia/ Xerostomia
 Rash (distribution, photosensitive)
 Proximal muscle weakness
Connective tissue diseases
 Rheumatoid Arthritis
 Systemic Lupus Erythematosus
 Sjogrens Syndrome
 Systemic Scleroderma
 Polymyositis/ Dermatomyositis
 Mixed Connective Tissue Disease
Labs for Autoimmunity
ACR Position Statement
 Immunofluorescence testing is the gold standard
for ANA testing
 HEp-2 cells have multiple autoantigens (>100)
 Need to have results reported with titer and
pattern
 Current technology employs ELISA and
multiplex technologies
 Allows processing of large volumes
 Limits diagnostic accuracy
 8-10 autoantigens
Conditions with positive ANA
 Essential for diagnosis
 SLE
 Systemic sclerosis
 Mixed connective tissue disease
 Somewhat useful
 Poly-, Dermatomyositis
 Sjogrens
 Other conditions with +ANA
 Autoimmune hepatitis/thyroid disease
 Multiple sclerosis
 Malignancy
 Age
 Infection
ANA pearls
 Not a screening test
 Is there a high pre-test likelihood:
 SLE
 Scleroderma
 Sjogrens
 Autoimmune myopathy
 Obtain results in titer and pattern
 Consider other causes for positivity
Related Autoantibodies
RA
MCTD
SLE
Sjogrens
RNP
SSA/B
dsDNA
PM/DM
Scl
Jo-1
Smith
Scl-70
RF CCP
“ANAnegative”
Centromere
Seronegative Arthritis
 Associated conditions:
 Psoriatic arthritis
 Ankylosing spondylitis
 Reactive arthritis
 Enteropathic related
 Undifferentiated spondyloarthropathy
 HLA-B27
 Not useful as a diagnostic test
 Presence in 6% of normal population
Polymyalgia Rheumatica
 ?Autoimmune inflammatory condition
 Periarthritis
 Subdeltoid bursitis, glenohumeral synovitis, biceps
tenosynovitis
 Consider diagnosis is those >50 years old, especially >70
 ~15% association with Giant Cell Arteritis
 Check ESR, CRP, SPEP
 Exquisitely responsive to glucocorticoids
 1-2 years with slow taper
Crystalline Arthritis
 Monosodium urate deposition (Gout)
 Affects 1st MTP, knees, wrist
 Destructive
 Consider in post menopausal women
 Gold standard diagnosis is by joint fluid analysis
 Goal uric acid <6
 Calcium pyrophosphate deposition (Pseudogout)
 Disruption of cartilage calcification
 Senior population
Cases Revisited
Case #1
 46 year old white female with 4 month history of
progressive fatigue associated with worsening
joint pains
 In the morning her knees are very stiff (1 hour)
and her first few steps out of bed are very painful
 She has noticed MCP swelling and that her rings
are getting tighter
 There is numbness and tingling in her fingertips
Case #2
 28 year old male presents with a 5 year history of
recurring bilateral ankle pain and swelling. It is
associated with extreme morning stiffness. He
denies any back pain. He has nail pitting
 His brother recently developed a rash on his
elbows
 MRI of the of right ankle showed significant
tendon swelling and subcortical erosions
Case # 3
 82 year white female with history of diabetes,
hypertension and coronary disease presents with
2 month history of progressive fatigue, malaise
and stiffness in her hips and shoulders
 She has never taken an hmg coa reductase
inhibitor
 Review of systems is negative.
 Sedimentation rate is normal
Case # 4
 An 87 year old white female presents to your
office with subacute right dorsal wrist swelling,
redness, warmth and pain that has been present
for 3 weeks
 No constitutional symptoms are present
 Two courses of antibiotics provide no relief
 Xray of her wrist shows chondrocalcinosis of the
TFCC; ESR is 90; Uric acid 5.4
Conclusions
 Appreciate the spectrum of inflammatory arthritis and its




relation to connective tissue diseases
Understand the importance of patient demographics in
narrowing your differential
Before ordering an ANA, consider whether the patient truly
has a connective tissue disease
Always make sure ANA’s are ordered by IFA with titer and
pattern
Don’t forget about psoriatic arthritis and pseudogout!
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