SLE

Gout
Middle age men (HTN, obese) Hyperuricemia * Renal Excretion (#1) * Production *Diet high in PURINES Meat, Seafood, Anchovies, Sardines, Sweetbread, Liver *ETOH *Surgery *Trauma *Dehydration

CPPD
*Female > 65 * Idiopathic (#1) *2arys in cartilage matrix Chondrocalcinosis, Hemachromatosis, *ATP Breakdown CPPD Crystal Deposition in Fibrocartilaginous Stuctures Inflammation & Bone/Joint Destruction

Osteoarthritis
*(#1) Musculoskeletal Disorder *Female >45yrs *Obesity (Meniscal / Ligament) *Genetics *Muscle Atrophy * Metabolic Disorders, Gout *Repetative Trauma Chondrocytes release Proteolytic Enzymes Biochemical Breakdown of Articular(Hyaline) Cartilage in Synovial Joints/ Subchondral Bone/Synovium Narrowing of Joint Space, Expose Unprotected Subchondral Bone Thickened/Dense (Sclerosis) or Cystic s Osteophyte Formation

Rheumatoid Arthritis
*Female (30-50) *Smoking *Family Hx *Improves w/Pregnancy *Genetic/Environmental HLA-DR1/DR4 *External trigger Autoimmune Rxn (Tcells) of Synovium Bcells make RF antibodies/Cytokines, TNF-alpha IL 1&6 Hyperplastic Synovial Tissue Invasive Pannus Tissue Invades/Destroys Bone & Cartilage via Osteoclasts

Pathophysiology/ Risk

*MOST pts Dont develop Gout* Hyperuricemia IgG/Temp Crystal deposit in joint/tissue Neutrophils phagocytize releasing inflammatory mediators Inflammation Acute Monoarthropathy * PAIN, Red, Swollen, Stiff *Peaks 12-24hrs *Resolves days-wks (untreated) *Desquamation of overlying Skin* Podagra Big Toe, Knees, Ankle Confused w/ Cellulitis Chronic Tophi Soft tissue crystals surrounded by Granulomatous Inflammation *NOT Painful/Tender Helix of Ear (#1) **Asymptomatic (#1)** Acute Pseudo Gout (MALE) *Self-limiting *Monoarthropathy (25%) *Pain, Red, Swelling, Stiff *Knee>Wrist>Hip>Shoulder >Ankle>Elbow Chronic Pseudo RA (FEMALE) *Progressive, Symmetrical *Polyarthritis *Morning Stiffness *Knee>Wrist>2/3 MCP>PIP> Hip>Shoulder>Spine

*Chronic Articular Cartilage Damage & Degeneration *Slow Progressive PAIN

*Chronic Inflammatory Persistent Symmetric Polyarthritis (Synovitis) w/ Bone Erosion, Cartilage Destruction, Loss of Joint Structure *Prodrome Fatigue, wt, weakness

* Weight Bearing Joints *Morning Stiffness >35min *Knee, Hip, Feet, C & L Spine *Evening Stiffness (p Effort) *Weather s *Hot, Swollen, Tender,BoggyJoints *ROM & Crepitus *Atrophied Muscles * Inflammation *ADLs Difficult *DIP (Herberden Nodes) Female HANDS *Thumb **Non-Reducible** *Swan Neck PIP ext, DIP flex Volar Subluxation Ulnar Deviation (MCP) *Boutonniere PIP flex, PIP ext *SQ Rheumatoid Nodules Elbow/Knuckles *Small joints (hands/feet) Symmetrical MCP>Wrist>PIP>Knee>MTP> Shoulder>Ankle

Clinical

Chondrocalcinosis Uric Acid StonesSrCr, Uric Acid *Cartilage Calcification Uric Secretion, Urine Volume, *Xray Punctate, Linear, Urine pH Radiodensities in Fibrocartilage BP, DM, Obese, Atherosclerosis Pseudo OA *Acute CHANGES in levels* Pyrophosphate Arthropathy NOT Levels *Progressive Joint Degenerate *Multiple (Non-typical) MCP

SLE

Gout

CPPD

Osteoarthritis
*Clinical & Radiologic Evidence*

Rheumatoid Arthritis
***Early Dx Critical*** ** Definitive Dx** *>3 Joints *Morning Stiffness *>6wks Duration *ESR, *CRP MONITOR Progression *(+)RF (IgM Ab against Fc IgG) Specific/ Measure of Progress *(+) anti-CCP Ab (more specific) Correlate Dz Progress *Anemia & Thrombocytosis *ANA 1/3 pts (Exclude SLE) *Osteopenia/Erosions Early Stage *Narrowing, Subluxation, Deformity, Periarticular SwellAdvanced Stage

ArthrocentesisSynovial Fluid (#1) ArthrocentesisSynovial Fluid (#1) Negatively Birefringent Needle Positively Birefringent Rhomboid *X-ray* Shaped Urate Crystals Shaped CPPD Crystals Narrow Joint Space Polarizing Microscopy Polarizing Microscopy Subchondral Bone Cyst WBC (15-30) Sclerosis *Clinical Criteria ( Arthrocentesis) Monoarthropathy (24hrs), Tophi, X-ray *Clinical* Podagra, Subcortical Bone Cyst, *Chondrocalcinosis Hard, Bony Joints (DIP) Hyperuricemia Narrowing/Density Joint Space Inflammatory Signs Evening Stiffness p Effort *CBC, X-ray, Gram Stain* Limited Morning Stiffness

Diagnosis

*ACUTE* ***Asymptomatic Tx #1) NSAIDs ( Aspirin) Indomethacin/Naproxen #2) Colchicine (Colsalide/Colcrys) Inflammation/Neutrophils MUST start <24hrs of onset S/E N/V/D *Pseudo OA Tylenol *Supportive* #1) NSAIDs *wt, Exercise, Warm Compress, Pain Control Physical Therapy Affect Dz #2) Steroids Low Dose Oral / Intraarticular Bridge Therapy

*Pseudo RALow Steroid (5mg) #1) Tylenol

*Acute CPPD* #2) NSAIDs #1) Steroids (Intraarticular/IV/PO)*Knee Topical/Capsaicin Cream Safer in Elderly #3) DMARDs #3) Steroids #2) NSAIDs #3) Steroids Prevent Inflammation/Preserve NSAID / Colchicine Intraarticular 3x/yr Fxn #3) High Dose Colchicine *CHRONIC* Steroids / NSAIDs #4) Sodium Hyaluronate (Hyalgan) Nonbiologic (p Acute Resolved) Mtn Synovial Fluid Viscosity *Methotrexate, Leflunomide (Severe) *Chronic CPPD* Intraarticular Qwk x 3-5 *Hydroxychloroquine, Sulfasalazine, #1) Allopurinol (Zyloprim) *NSAIDs Colchicine Uncertain Dx, *Renal Toxic* Febuxostat (Uloric)*(Renal) #5) Prosthetic Replacement *Minocycline Inhibits Xanthine Oxidase Biologic S/E Maculopapular Rash #6) Glucosamine / Chondroitin *Recombinant DNA *Target Cytokines #2) Probenecid (Benemid/Probalan) *Infliximab, Etanercept, Renal Excretion (Uricosuric) Dalimumab, Anakinra, C/I Renal Azithroprine, Gold D-pcn #3) Colchicine (Colsalide/Colcrys) *ONLY* Acute & Chronic #4) Vit C / Losartan Uricosuric **Cyclophosphamide, Chlorambucil, Cyclosporine REFRACTORY RA

Treatment