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Rheumatoid arthritis. Rheumatoid arthritis affects the small joints, symmetrical, synovitis with systemic complications. You shouldn’t have any problem with that. The key thing about rheumatoid I want you to remember is rheumatoid factor is not a good diagnostic test. I see way too many patients come into my office who have aches and pains with a positive rheumatoid factor and somebody has diagnosed them as rheumatoid arthritis.
Degenerative Joint Disease. The keys. DIP involvement, Heberden’s nodes. Always look for the first carpometacarpal joint. See if they have involvement. That’s only DJD if you can eliminate trauma.
The comparison. The central versus the distal. The degenerative symptoms worse in the night. The inflammatory symptoms worse in the morning. Nobody has much difficulty with those things and Jim has just talked about the treatment for the inflammatory component. So let’s go into the connective tissues diseases and briefly talk about some of the salient features here. I put this as a male because we always think of females with lupus, because most of them are, but males can get lupus. There are some caveats about lupus that I want you to remember. In the back of your handout are the criteria or someplace listed in there. You need to have four out of the eleven criteria. One of the criteria is photosensitivity.
Raynaud’s syndrome. Remember what Raynaud’s phenomenon is. It is vasospasm. The patient should tell you the following: "When I go out and get cold" or particularly the classic is, "If I pull things out of the freezer"… a true Raynaud’s patient will tell you what about getting things out of the freezer? They don’t. Or they put on gloves to get things out of the freezer. That’s true Raynaud’s.
Systemic Lupus Erythematosus. If you get an ANA, the problem is it’s still vague. You still don’t know. So in that case where you really don’t know for sure, I’d probably say maybe a referral would be appropriate or at least perhaps more diagnostic studies like DNA antibodies, SM, etc. So the anemia, leukopenia, arthritis.
The other one that’s relatively specific is RNP and the reason it’s specific is because that’s how a disease was defined is that mixed connective tissue disease is defined as having a positive RNP. Nothing else can have it. Well, nothing’s absolute but anyway, that’s close enough and that’s just an overlap. That’s just sort of our way of saying we don’t know how to sort it out any better and it’s a whole bunch of different diseases.
A few words about drug induced lupus. Think about it this way. Two drugs are hydralazine and procainamide that are the two classic drugs. Well, those aren’t used very much anymore but I did see a patient on procainamide just a couple of weeks ago who had drug induced lupus.
The thing to remember about drug induced lupus are probably these two things, at least in my mind: (1) It may be that somebody has subclinical lupus that gets placed on one of these drugs like penicillin or INH or birth control pulls who then gets pushed over the clinical exposure level and they start having the symptoms. You stop the drug and it goes back subclinical and their symptoms go away. So that’s one group. (2) Then the other group is maybe you give them a little bit of Dilantin or something like that and they just get stimulated to produce antibodies and the body keeps going and keeps producing antibodies and they maintain their drug induced lupus state even though the drug is withdrawn. Both things occur and there’s no way that I know that you can predict.
Drug induced antibodies. Characteristically, the anti-histone antibody is what you would see. So you can order that specifically if you want to know but it’s not universally present.
Antiphospholipid antibody syndrome. Another key problem. Who do you worry about? Well, you worry about the following: Anybody with unexplained thrombosis clot, arterial or venous, with the exclusion of a woman who has had one spontaneous miscarriage.
Dermatomyositis. He has the heliotropic rash here. You would say, it’s just a sick gentleman and it would be difficult to tell but there is really a darkish blue discoloration around this gentleman’s eyelids. They may also have what’s called Gottron’s sign or Gottron’s papules which is a rash over the knuckles.
Most patients with this entity do not have skin rash. Most of them just have muscle weakness. Historical clues to this diagnosis is to ask them what happens when they try to get off a stool or out of a chair. How do they do that? If they have to push themselves off then that is proximal muscle.
Polymyositis is weakness not pain. People get this confused a lot. Polymyalgia rheumatica is pain without weakness. They may have secondary weakness but it’s primarily pain. So PMR is pain, polymyositis is proximal weakness. This gentleman was so weak that he had no respiratory control.
Scleroderma. You can see this gentleman has had some problems with sores here because of Raynaud’s. Thick skin. Here he is. He’s also in the intensive care unit which tells you a lot about how I take care of patients, doesn’t it? This gentleman is how old? 33? He’s 68-years-old and the reason he doesn’t look 68, one of the reasons besides all the edema here, is that they get very tight shiny skin. So that’s very characteristic.
One of the things I would hope you learn from scleroderma is what I call the pinch sign and that is that if you take your hand and try to pinch the skin.
Here’s the Raynaud’s that I was talking about earlier. You shouldn’t have any question about this, if they describe something like this. The textbooks say red, white and blue color – worthless. As far as I can tell, I’ve never seen that help me because I can’t remember what order it’s supposed to go in. That was my first problem. And then I kept worrying about was it blue first and then white and then red or was it white, red.
CREST syndrome. A relatively benign form. One of the ladies I saw last week had telangiectasis and sclerodactyly on her hands. She did not have calcinosis. She had Raynaud’s as well so she had three out of the five. No good treatment unfortunately.
There are ARA criteria for the diagnosis. Proximal scleroderma meaning thickness proximal to the wrist or off the face. So if you just have face and hands that could be the CREST syndrome – the relatively benign form. Then sclerodactyly, pitting scars or bibasilar pulmonary fibrosis.
Seronegative spondyloarthropathies. The key here is that most of these people don’t complain of back pain. Why not? It’s so slow, it’s so indolent. In fact, I always tell the story of the man who was referred to me by a cardiologist.
Well, think about the different diseases – the pure disease ankylosing spondylitis, sacroiliitis, fusion of the spine and those that are associated with Reiter’s syndrome, psoriatic arthritis and inflammatory bowel disease. The key symptom, if they have a symptom, is back stiffness. Here’s the characteristic finding. The spondylitis, squaring of the vertebral bodies, sort of the bamboo spine, Reiter’s, acute arthritis, conjunctivitis, urethritis. If you want to remember something, a lot of connective tissue diseases, rheumatic diseases have eye problems. The only one that has conjunctivitis and not iritis is Reiter’s syndrome. All the rest are iritis or some type of uveitis.
Crystal induced diseases. Not too much here. This is the typical picture of a patient with gout. The real clue to gout, of course, is the pain. The pain is 10 on a 10 point scale and the pain is so severe that the weight of the sheet is too much. It’s one of those textbook descriptions.
Gout. (1) Make the diagnosis. Tap the joint, find the crystals. (2) Treat them with allopurinol for the first three to six months. Why allopurinol? It’s easy. I don’t have anything against probenecid but we generally just use the allopurinol even though most patients have problems with uric acid
Chondrocalcinosis. I just saw a lady with renal failure on two separate occasions due to nonsteroidals who came in with acute knee pain. She had the renal failure before I had ever seen her. I want to make sure you got that straight. I did not give her the nonsteroidals. Anyway, she had acute knee pain for a month. I tapped it, found chondrocalcinosis on the x-ray and she also had the calcium pyrophosphate crystals. Weekly negative birefringence.
Calcium Pyrophosphate deposition disease. Typical patient is an older female with knee pain. Diagnosis by joint. Aspiration. Usually treat them with nonsteroidals. The key here is early treatment. Again, colchicine may well work.
Once again we’re back in the Intensive Care Unit with another one of my patients. This is a lady who came in… several patients in the last year have come in with vague complaints but one thing they had in common was transient visual loss. In fact I saw a lady this spring who came in who had three
Polymyalgia rheumatica is appropriate clinical setting, proximal aches and pains associated with a sed rate more than 50 and an age over 50. I would add a fourth thing. Rapid response to treatment. What does that mean? That means that if you give them low dose steroids or nonsteroidals, they will
Septic bursitis is similar to septic arthritis. There’s no way to know. Stick a needle in there if you have a question about it. Look for organisms and treat them appropriately. The key here is aspiration daily. Get rid of the organisms. Look for either gonorrhea or Staph aureus.
Lyme disease, however, is different. I want to just make a few comments. First of all, Lyme disease only occurs in endemic areas. The endemic areas are, as you should know, the northeastern United States, north central United States and with the ticks in California, there’s a few cases but mostly in the northeastern United States. The diagnosis should be made first of all in the spring and summer. I have seen people refer me patients who said, "I got bitten by a tick in December.
Fibromyalgia. The number one diagnosis in rheumatologists clinic and may well be in your office as well. Let me tell you a few things about it. Is it a true disease? Of course it is. I describe this to patients as an exaggerated normal response to stress and strain. That’s sort of my way of thinking about this. The trigger points are at the point of insertion of muscles and tendons into the bone. It’s a round joint so it doesn’t cause arthritis.
Osteoporosis. A very serious problem. Underdiagnosed. Undertreated. There’s no question about what this diagnosis is. We’ve all seen these women in our office. You know the risk factors. I don’t have that in the handout, by the way. All the risk factors are listed here. The key thing here is just recognition of the risk and treating people. I have a lot of problem remembering this. I try to. I just constantly forget but I keep working on it.