Approach To A Patient With Polyarthritis

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Information about Approach To A Patient With Polyarthritis

Published on February 27, 2009

Author: prammy4u

Source: slideshare.net

Approach to a patient with Polyarthritis Dr. K. K. Pruthi Prof & Head S. N. Medical College, Agra

‘ Patterned’ approach Grouping a constellation of symptoms, signs and investigations to arrive at a diagnosis.

POLYARTHRITIS 4 or more joint involvement PAUCI / OLIGOARTHRITIS 2 or 3 joint involvement MONOARTHRITIS 1 joint involvement Definition

Site (distribution) Type of pain Associated features Duration and onset Risk factors Physical signs Differential diagnosis Investigation Assessment of joint pain

Site (distribution)

Type of pain

Associated features

Duration and onset

Risk factors

Physical signs

Differential diagnosis

Investigation

Site and distribution of pain Is it joint, peri-articular or muscle pain? Which joints are involved? Is it symmetrical or asymmetrical? Where did it start? Is the arthritis migratory, additive, episodic? Site & Distribution

Is it joint, peri-articular or muscle pain?

Which joints are involved?

Is it symmetrical or asymmetrical?

Where did it start?

Is the arthritis migratory, additive, episodic?

Site &

Distribution

Site and distribution of pain Site & Distribution RA PIP, MCP, wrists, elbows, shoulders, neck, knee, ankle, MTP DIP not involved symmetrical Sero-ve DIP, dactylitis, enthesitis, spinal PIP not involved asymmetrical OA Weight bearing joints DIP, PIP, CMC, ACJ MP not involved

Site &

Distribution

RA

PIP, MCP, wrists, elbows, shoulders, neck,

knee, ankle, MTP

DIP not involved

symmetrical

Sero-ve

DIP, dactylitis, enthesitis, spinal

PIP not involved

asymmetrical

OA

Weight bearing joints

DIP, PIP, CMC, ACJ

MP not involved

Site & Distribution Type Type of pain Is it inflammatory? Is it mechanical / degenerative? What makes the pain worse/better?

Site &

Distribution

Type

Is it inflammatory?

Is it mechanical / degenerative?

What makes the pain worse/better?

Site & Distribution Type Type of pain Inflammatory Mechanical Immobility stiffness Latter day EMS>30-60 mins EMS<30-60 mins Better with activity Worse with activity Joint swelling, erythema, heat Instability Systemic symptoms Locking Multi-organ involvement Trauma, strain, over usage

Site &

Distribution

Type

Inflammatory Mechanical

Immobility stiffness Latter day

EMS>30-60 mins EMS<30-60 mins

Better with activity Worse with activity

Joint swelling, erythema, heat Instability

Systemic symptoms Locking

Multi-organ involvement Trauma, strain, over usage

Site & Distribution Type Associated features Associated features Is there morning stiffness? Have there been any symptoms of infection? Have there been any rashes ? Any urinary, genital or gut problems?

Site &

Distribution

Type

Associated

features

Is there morning stiffness?

Have there been any symptoms of infection?

Have there been any rashes ?

Any urinary, genital or gut problems?

Site & Distribution Type Associated features Duration & onset Duration & onset When did the joint pains begin? Are the symptoms getting better or worse?

Site &

Distribution

Type

Associated

features

Duration &

onset

When did the joint pains begin?

Are the symptoms getting better or worse?

Site & Distribution Type Associated features Duration & onset Duration & onset Acute Viral parvo/rubella Bacterial strep Rheumatoid Reactive GU/gastro Erythema nodosum Vasculitis Chronic Rheumatoid Seronegative psoriatic/AS/IBD Connective tissue disease SLE/SjS/DM Polyarticular OA

Site &

Distribution

Type

Associated

features

Duration &

onset

Acute

Viral

parvo/rubella

Bacterial

strep

Rheumatoid

Reactive

GU/gastro

Erythema nodosum

Vasculitis

Chronic

Rheumatoid

Seronegative

psoriatic/AS/IBD

Connective tissue disease

SLE/SjS/DM

Polyarticular OA

Site & Distribution Type Associated features Duration & onset Risk factors Other risk factors Age Sex Racial/ethnic background Family history Treatment history Social history

Site &

Distribution

Type

Associated

features

Duration &

onset

Risk

factors

Age

Sex

Racial/ethnic background

Family history

Treatment history

Social history

Site & Distribution Type Associated features Duration & onset Risk factors Other risk factors AGE FEMALE MALE Young adults RA Reactive arthritis SLE (Sero-ve) Psoriatic arthritis (Sero-ve) Middle age RA RA OA Gout Old age OA PMR Crystal arthritis

Site &

Distribution

Type

Associated

features

Duration &

onset

Risk

factors

Site & Distribution Type Associated features Duration & onset Risk factors Physical signs Physical signs Joint distribution +/- spine Skin and appendages Rash, nodules, eyes, mouth ulcers, hair Temp, LNs, CVS, RS, Abdomen, Neurological

Site &

Distribution

Type

Associated

features

Duration &

onset

Risk

factors

Physical

signs

Joint distribution +/- spine

Skin and appendages

Rash, nodules, eyes, mouth ulcers, hair

Temp, LNs, CVS, RS, Abdomen, Neurological

Site & Distribution Type Associated features Duration & onset Risk factors Physical signs Differential diagnosis Differential diagnosis Osteoarthritis Rheumatoid arthritis Chronic (trophaceous) gout Systemic lupus erythematous Reiter’s disease Ankylosing spondylitis Psoriatic arthritis

Site &

Distribution

Type

Associated

features

Duration &

onset

Risk

factors

Physical

signs

Differential

diagnosis

Osteoarthritis

Rheumatoid arthritis

Chronic (trophaceous) gout

Systemic lupus erythematous

Reiter’s disease

Ankylosing spondylitis

Psoriatic arthritis

Site & Distribution Type Associated features Duration & onset Risk factors Physical signs Differential diagnosis Investigati- ons Investigations Radiographs of corresponding joints Hemogram, ESR RA factor, CRP S.Uric Acid - Notoriously unreliable !! Urine, stool Synovial fluid Cultures CT/MRI Arthroscopy/Biopsy( to be considered in chronic, >6 weeks, non traumatic arthritis in which diagnosis is not established ) Bone scan Serologic tests like ANA, RF, ANCA - rarely if ever indicated

Site &

Distribution

Type

Associated

features

Duration &

onset

Risk

factors

Physical

signs

Differential

diagnosis

Investigati-

ons

Radiographs of corresponding joints

Hemogram, ESR

RA factor, CRP

S.Uric Acid - Notoriously unreliable !!

Urine, stool

Synovial fluid

Cultures

CT/MRI

Arthroscopy/Biopsy( to be considered in chronic, >6 weeks,

non traumatic arthritis in which diagnosis is not established )

Bone scan

Serologic tests like ANA, RF, ANCA - rarely if ever indicated

Site & Distribution Type Associated features Duration & onset Risk factors Physical signs Differential diagnosis Investigati- ons Investigations Synovial fluid examination most important !! Protein TLC, DLC, cells Gram stain C/S Atypical organisms Crystals with polarising microscopy Sugar Other tests

Site &

Distribution

Type

Associated

features

Duration &

onset

Risk

factors

Physical

signs

Differential

diagnosis

Investigati-

ons

Protein

TLC, DLC, cells

Gram stain

C/S

Atypical organisms

Crystals with polarising microscopy

Sugar

Other tests

Site & Distribution Type Associated features Duration & onset Risk factors Physical signs Differential diagnosis Investigati- ons Synovial fluid analysis Apperance Viscosity Cells/mm 3 %PMN Normal Transparent High < 180 < 10% OA Transparent High 200-2000 < 10% RA Translucent Low 2000- Variable 50,000 Psoriatic Translucent Low 2000- Variable Arthritis 50,000 Reactive Translucent Low 2000- Variable Arthritis 50,000 Spondlyo Translucent Low 2000- Variable -arthro. 50,000 Gout Translucent Low 200- > 90% to cloudy 50,000 Pseudo Translucent Low 200- > 90% gout to cloudy 50,000 Bacterial Cloudy Variable > 50,000 > 90% Arthritis

Site &

Distribution

Type

Associated

features

Duration &

onset

Risk

factors

Physical

signs

Differential

diagnosis

Investigati-

ons

Osteoarthritis (OA) Most common joint disorder Affects 190 million worldwide Nearly 70% of people over 65 years Aging population over 65 years 1997~ 400 million ( 70 million plus in India ) 2025~ 800 million ( 150 million plus in India ) In India has overtaken diabetes, and now ranks 1 st in chronic debilitating disease.

Most common joint disorder

Affects 190 million worldwide

Nearly 70% of people over 65 years

Aging population over 65 years

1997~ 400 million ( 70 million plus in India )

2025~ 800 million ( 150 million plus in India )

In India has overtaken diabetes, and now ranks

1 st in chronic debilitating disease.

Predisposing factors Incongruity Trauma Diabetes Obesity Age Systemic diseases - RA Osteoarthritis

Predisposing factors

Incongruity

Trauma

Diabetes

Obesity

Age

Systemic diseases - RA

Primary Secondary SCFE CDH Infections Traumatic Dislocation Perthes Pagets Fracture Acetabulum Hemophilia Osteoarthritis Types PRIMARY OA SECONDARY OA

Primary

Secondary

SCFE

CDH

Infections

Traumatic Dislocation

Perthes

Pagets

Fracture Acetabulum

Hemophilia

Risk Factors for OA OA Increased age Genetic disposition Gender & hormonal factors Obesity Mechanical factors Systemic factors (Hypertension, raised serum cholesterol, raised uric acid levels) Prior inflammatory disease Osteoarthritis Degenerative disorder Weight bearing joints usually involved

Pathology Synovitis Cartilage fibrillation Cartilage flaking & delamination Exposure of subchondral bone Microfractures & osteophytes Fibrosis-ankylosis Osteoarthritis

Synovitis

Cartilage fibrillation

Cartilage flaking & delamination

Exposure of subchondral bone

Microfractures & osteophytes

Fibrosis-ankylosis

Clinical Features Old patient Females > males Lower limb joints~ knees, hips, 1 st CM jt Rest pain Pain during movement Crepitus Characteristic deformities Osteoarthritis Bouchard nodes Heberden nodes

Old patient

Females > males

Lower limb joints~ knees, hips, 1 st CM jt

Rest pain

Pain during movement

Crepitus

Characteristic deformities

Bouchard nodes

Heberden nodes

Radiology Sharpening of edges Subchondral sclerosis (eburnation) Decreased joint space Osteophytes Subchondral cysts Deformities Radioisotope scan-increased uptake Osteoarthritis

Sharpening of edges

Subchondral sclerosis (eburnation)

Decreased joint space

Osteophytes

Subchondral cysts

Deformities

Radioisotope scan-increased uptake

Joint space narrowing Subchondral bone sclerosis and cysts Marginal osteophyte formation

 

Kellegren & Lawrence Scale for Osteoarthritis 0 – No features of osteoarthritis 1 – Doubtful, unimute osteophylic of doubtful significance 2 – Minimal, definite osteophyte but joint space unimpaired 3 – Moderate, moderate diminution of joint space 4 – Severe, Joint space severely impaired with scelerosis of subchondral bone Osteoarthritis

0 – No features of osteoarthritis

1 – Doubtful, unimute osteophylic of doubtful significance

2 – Minimal, definite osteophyte but joint space unimpaired

3 – Moderate, moderate diminution of joint space

4 – Severe, Joint space severely impaired with scelerosis of

subchondral bone

Role of inflammation in OA OA is not characterized by a significant systemic inflammatory process Inflammation, where present, is usually mild Osteoarthritis

OA is not characterized by a

significant systemic inflammatory process

Inflammation, where present,

is usually mild

A common chronic inflammatory joint condition ‘ Rheumatoid’ first used in 1859 by Garrod Little evidence for RA prior to 16th Century Possibly earlier in New World Rheumatoid Arthritis

A common chronic inflammatory joint condition

‘ Rheumatoid’ first used in 1859 by Garrod

Little evidence for RA prior to 16th Century

Possibly earlier in New World

Epidemiology Incidence 1.4/10000 male, 3.6/10000 females Prevalence 0.5-2 % male:female 1:3 Worldwide distribution higher in native Americans absent in some parts of Africa Onset any age but maximum 40 - 70 years in women 60 - 70 years in men Rheumatoid Arthritis

Incidence

1.4/10000 male, 3.6/10000 females

Prevalence 0.5-2 %

male:female 1:3

Worldwide distribution

higher in native Americans

absent in some parts of Africa

Onset any age but maximum

40 - 70 years in women

60 - 70 years in men

Etiology Rheumatoid Arthritis Post viral immunomodulation RA HLA DR4 Genetic disposition monozygotic twins – 15% dizygotic twins – 4% Gender & hormonal factors Prior inflammatory disease Multifactorial etiology

Excised synovial membrane shows many villous folds with compact nodular clusters of lymphocytes and plasma cells. Pathology Rheumatoid Arthritis

Onset Typical Insidious onset polyarthritis Affecting small joints of hand & feet Atypical Polymyalgic Palindromic Systemic Persistent monoarthritis Rheumatoid Arthritis

Typical

Insidious onset polyarthritis

Affecting small joints of hand & feet

Atypical

Polymyalgic

Palindromic

Systemic

Persistent monoarthritis

One can confidently make a diagnosis of RA on clinical grounds even if RF is absent. Clinical features RA is entirely a clinical diagnosis . only 80-85% of the individuals are seropositive. 15-20% are seronegative. A negative RF may be repeated 4-6 monthly for the first 2 years of disease, since some patients with RA may take 18-24 months to become seropositive. Rheumatoid Arthritis

RA is entirely a clinical diagnosis .

only 80-85% of the individuals are seropositive.

15-20% are seronegative.

Clinical features Symmetrical deforming polyarthritis Affects synovial lining of joints, bursae and tendons More then just joint disease Rheumatoid Arthritis Progression of joint involvement Spread occurs within months to years to other joints Almost any joint may be involved Spontaneous remission can occur Poor prognosis – RA factor exists Symptoms Of inflammation Stiffness, pain, swelling, warmth, redness

Symmetrical deforming polyarthritis

Affects synovial lining of joints, bursae and tendons

More then just joint disease

Progression of joint involvement

Spread occurs within months to years to other joints

Almost any joint may be involved

Spontaneous remission can occur

Poor prognosis – RA factor exists

Symptoms

Of inflammation

Stiffness, pain, swelling, warmth, redness

Pattern of joint involvement symmetrical small joints of hands - DIP spared characteristic features Boutonniere Swan neck Z thumb Volar subluxation Ulnar deviation Rheumatoid Arthritis Clinical features Swan neck deformity Boutonniere deformity Ulnar deviation & nodule Hammer toe deformity Hallux valgus

Pattern of joint involvement

symmetrical

small joints of hands - DIP spared

characteristic features

Boutonniere

Swan neck

Z thumb

Volar subluxation

Ulnar deviation

Radiology Soft tissue swelling Juxta-articular osteoporosis Juxta-articular and subchondral erosions Joint space narrowing & subluxation Secondary OA & bony ankylosis

Soft tissue swelling

Juxta-articular osteoporosis

Juxta-articular and subchondral erosions

Joint space narrowing & subluxation

Secondary OA & bony ankylosis

Extra articular findings Nodules Eye Lung Cardiac Vasculitis Nerves Felty’s (Neutropenia + RA) Rheumatoid Arthritis Rheumatoid nodule Episcleritis Digital infarcts

Nodules

Eye

Lung

Cardiac

Vasculitis

Nerves

Felty’s

(Neutropenia + RA)

Be Cautious to diagnose RA if : Monoarticular Hands not involved Asymmetrical or unilateral involvement Only DIP are involved Lumbar spine involved Mere presence of rheumatoid factor in blood is not enough to make a diagnosis of RA. Rheumatoid Arthritis

Monoarticular

Hands not involved

Asymmetrical or unilateral involvement

Only DIP are involved

Lumbar spine involved

Diseases associated with a positive RF Condition Prevalence (%) RA 80-85 Elderly people 5 Other chronic inflammatory rheumatic diseases – Primary Sjogren’s syndrome 75-90 – Mixed cryoglobulinaemia 90-100 – SLE 20-30 – Systemic sclerosis 20-30 – Mixed connective tissue disease 50-60 Chronic bacterial infections – Subacute bacterial endocarditis 25-50 Miscellaneous conditions – Sarcoidosis 5-33 – Interstitial pulmonary fibrosis 10-50 – Chronic active hepatitis 25-40 Not all seropositive arthritides are RA Rheumatoid Arthritis

Diseases associated with a positive RF

Condition Prevalence (%)

RA 80-85

Elderly people 5

Other chronic inflammatory rheumatic diseases

– Primary Sjogren’s syndrome 75-90

– Mixed cryoglobulinaemia 90-100

– SLE 20-30

– Systemic sclerosis 20-30

– Mixed connective tissue disease 50-60

Chronic bacterial infections

– Subacute bacterial endocarditis 25-50

Miscellaneous conditions

– Sarcoidosis 5-33

– Interstitial pulmonary fibrosis 10-50

– Chronic active hepatitis 25-40

Criterion Definition 1. Morning stiffness Stiffness in joints lasting at least 1 hour 2. Arthritis in 3 or more joints Pain and swelling in at least 3 joints 3. Arthritis in hand joints Swelling in at least 1 of the following areas: wrist, MCP or PIP joint 4. Symmetric arthritis Involvement of the same joint area on both sides of the body 5. Rheumatoid nodules Subcutaneous nodules over bony prominences or extensor surfaces or around joints 6. Serum rheumatoid factor Positive rheumatoid factor 7. Radiologic changes Periarticular osteopenia or erosions in joints visible on radiographs of hands or feet Criteria 1 through 4 must be present for at least 6 weeks. Confirmation of 4 or more of these 7 criteria is considered diagnostic of rheumatoid arthritis. American Rheumatism Association,1997 revised criteria for diagnosing RA Rheumatoid Arthritis

Criterion Definition

1. Morning stiffness Stiffness in joints lasting at least 1 hour

2. Arthritis in 3 or more joints Pain and swelling in at least 3 joints

3. Arthritis in hand joints Swelling in at least 1 of the following

areas: wrist, MCP or PIP joint

4. Symmetric arthritis Involvement of the same joint area on

both sides of the body

5. Rheumatoid nodules Subcutaneous nodules over bony prominences

or extensor surfaces or around joints

6. Serum rheumatoid factor Positive rheumatoid factor

7. Radiologic changes Periarticular osteopenia or erosions in

joints visible on radiographs of hands or feet

Criteria 1 through 4 must be present for at least 6 weeks.

Confirmation of 4 or more of these 7 criteria is considered diagnostic of rheumatoid

arthritis.

Predictive factors for persistent RA Rheumatoid Arthritis Morning stiffness > 1 hours Arthritis in 3 or more joints Bilateral compression pain in MP joints IgM RA factor > 5 I.U.

Morning stiffness > 1 hours

Arthritis in 3 or more joints

Bilateral compression pain in MP joints

IgM RA factor > 5 I.U.

Seronegative RA Psoriatic arthropathy SLE Scleroderma Juvenile idiopathic arthritis Adult onset Still’s disease Inflammatory bowel disease Seronegative Inflammatory polyarthritides

Seronegative RA

Psoriatic arthropathy

SLE

Scleroderma

Juvenile idiopathic arthritis

Adult onset Still’s disease

Inflammatory bowel disease

Ankylosing spondylitis Reactive arthritis (including Reiter’s syndrome) Psoriatic spondyloarthropathy Inflammatory bowel disease (Enteropathic spondyloarthropathy) Juvenile spondyloarthropathy Unclassifiable or undifferentiated spondyloarthropathy Seronegative Spondyloarthropathies (SpA)

Ankylosing spondylitis

Reactive arthritis (including Reiter’s syndrome)

Psoriatic spondyloarthropathy

Inflammatory bowel disease

(Enteropathic spondyloarthropathy)

Juvenile spondyloarthropathy

Unclassifiable or undifferentiated spondyloarthropathy

Seronegative, that is, rheumatoid factor is absent Affect the axial skeleton; inflammatory low back pain is common. Cardinal feature is involvement of sacroiliac joints Peripheral joint involvement is usually asymmetrical Oligoarticular, below waist Usually associated with HLA-B27. Enthesopathy is characteristic Usual age < 40 years Male preponderance Seronegative SpA Features

Seronegative, that is, rheumatoid factor is absent

Affect the axial skeleton; inflammatory low back pain

is common.

Cardinal feature is involvement of sacroiliac joints

Peripheral joint involvement is usually asymmetrical

Oligoarticular, below waist

Usually associated with HLA-B27.

Enthesopathy is characteristic

Usual age < 40 years

Male preponderance

Ankylosing spondylitis Spondyloarthropathy Late adolescence & early adulthood Spine & large joints Leads to fibrous/bony ankylosis

Spondyloarthropathy

Late adolescence & early adulthood

Spine & large joints

Leads to fibrous/bony ankylosis

Etiology Male predisposition 7:1 Autosomal inheritance 70% penetrance 90% association with HLA B27 Rare in negroes Ankylosing spondylitis

Male predisposition 7:1

Autosomal inheritance

70% penetrance

90% association with HLA B27

Rare in negroes

Pathology Similar to RA Articular & bone destruction Fibrous & bony bridging Para- articular calcification & ossification Bamboo spine Ankylosing spondylitis

Similar to RA

Articular & bone destruction

Fibrous & bony bridging

Para- articular calcification & ossification

Bamboo spine

Clinical Features Morning pain & stiffness Sacroiliac pain Muscle spasm- flexed posture Wt loss, anaemia Decreased chest expansion Ankylosis Ankylosing spondylitis

Morning pain & stiffness

Sacroiliac pain

Muscle spasm- flexed posture

Wt loss, anaemia

Decreased chest expansion

Ankylosis

Radiology Patchy osteoporosis Fusion of SI joints Squaring of vertebral bodies Syndesmophytes – bone bridge Diminished joint space Bony ankylosis of major joints Ankylosing spondylitis

Patchy osteoporosis

Fusion of SI joints

Squaring of vertebral bodies

Syndesmophytes – bone bridge

Diminished joint space

Bony ankylosis of major joints

Crystal Arthropathies Monosodium urate crystals Gouty Arthritis Calcium Pyrophosphate crystals Chondroclacinosis Calcium hydroxyapatite crystals Calcific Periarthritis destructive arthropathy

Monosodium urate crystals

Gouty Arthritis

Calcium Pyrophosphate crystals

Chondroclacinosis

Calcium hydroxyapatite crystals

Calcific Periarthritis destructive arthropathy

Primary Gout Heritable Error of metabolism Causing overproduction or retraction of uric acid Secondary Gout Myeloproliferatic disease Chronic haemolytic slab Drug – Dicureties pyrzinemide Starvation Chronic glomerulo-nephritis and pyelonephritis Hypothyroidis Crystal Arthropathies Types & Causes

Primary Gout

Heritable Error of metabolism

Causing overproduction or retraction of uric acid

Secondary Gout

Myeloproliferatic disease

Chronic haemolytic slab

Drug – Dicureties pyrzinemide

Starvation

Chronic glomerulo-nephritis and pyelonephritis

Hypothyroidis

Gout Hyperuricaemia Monoarticular in early stage MCP joint - great toe Uric acid crystal deposition Tophus Punched out para-articular lytic lesion Tophi & synovial fluid shows presence of MSU crystals - confirmatory of diagnosis Crystal Arthropathies

Hyperuricaemia

Monoarticular in early stage

MCP joint - great toe

Uric acid crystal deposition

Tophus

Punched out

para-articular lytic lesion

Tophi & synovial fluid shows

presence of MSU crystals

- confirmatory of diagnosis

Monosodium Urate Crystal Crystal Arthropathies Positive bifringence & needle shaped

Pseudogout Crystal Arthropathies Younger age group compared to gout Larger joints involved compared to gout Knee most commonly involved Severity of clinical features less compared to gout Calcification of cartilages hallmark sign Negative bifringent and rhomboid shaped crystals

Younger age group compared to gout

Larger joints involved compared to gout

Knee most commonly involved

Severity of clinical features less compared to gout

Calcification of cartilages hallmark sign

Negative bifringent and rhomboid shaped crystals

Psoriatic Arthritis Symmetric polyarthritis Higher frequency of DIP involvement Enthesitis Dactylitis (sausage shape digits) Recognition of psoriatic plaques is important

Symmetric polyarthritis

Higher frequency of DIP involvement

Enthesitis

Dactylitis (sausage shape digits)

Recognition of psoriatic plaques is

important

Radiology Erosion Osteolysis Bone proliferation Ankylosis Psoriatic Arthritis

Erosion

Osteolysis

Bone proliferation

Ankylosis

Reiter’syndrome Triad of : May be associated with : Mucocutaneous disease (balanitis, ulcers, keratoderma ) Asymmetrical arthritis Urethritis/cervicitis or Diarrhoea Conjunctivitis

Triad of :

May be associated with :

Mucocutaneous disease

(balanitis, ulcers, keratoderma )

Systemic Lupus Erythematous Photosensitivity Malar or discoid rash Mucosal ulcers (hair loss) Raynaud’s, vasculitis Arthritis (non-erosive) Serositis: pleurisy/pericarditis Neurological: fits/psychosis Renal disease (urinalysis) Haematological: low platelets, leucopenia, haemolytic anaemia Anti-ds DNA antibodies ANA Features Photosensitivity Butterfly facial rash Discoid rashes

Photosensitivity

Malar or discoid rash

Mucosal ulcers (hair loss)

Raynaud’s, vasculitis

Arthritis (non-erosive)

Serositis: pleurisy/pericarditis

Neurological: fits/psychosis

Renal disease (urinalysis)

Haematological:

low platelets,

leucopenia,

haemolytic anaemia

Anti-ds DNA antibodies

ANA

Arthritis most common manifestation Symmetric non erosive arthritis Small joints of hand, wrist, knee most commonly involved Nodules similar to RA present Jaccoud’s arthropathy ( ulnar deviation + swan neck deformity ) Systemic features help in reaching diagnosis. Arthritis in SLE SLE

Arthritis most common manifestation

Symmetric non erosive arthritis

Small joints of hand, wrist, knee most commonly involved

Nodules similar to RA present

Jaccoud’s arthropathy

( ulnar deviation + swan neck deformity )

Systemic features help in reaching diagnosis.

THANK YOU

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