Pattern Recognition in

Arthritis

Dr. Reena Sharma

Consultant Rheumatologist
CIMS Hospital, Ahmedabad
Definitions

 Polyarthritis – Arthritis involving 5 or

more joints

 Oligoarthritis or Pauciarthritis – Arthritis

involving 2-4 joints

 Monoarthritis – Arthritis of a single joint

 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 HISTORY

Onset of symptoms

 Abrupt  Insidious
 Infectious arthritis  Rheumatoid arthritis
 Crystal induced  Seronegative
spondyloarthropathy
 Traumatic
 Osteoarthritis
 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Duration of symptoms

 Acute : less than 6-8 weeks

 Chronic : more than 6-8 weeks

 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Pattern of joint involvement
 Additive pattern
 Rheumatoid
arthritis

 Migratory pattern
 Acute rheumatic
fever
 Acute post
gonococcal arthritis
 Pattern of joint involvement contd…

 Monoarticular
 Osteoarthritis

 Septic arthritis
 Crystal arthropathy

 Palindromic Rheumatism
 Pattern of joint involvement contd…

 Symmetric small joints

 Rheumatoid Arthritis

 Asymmetric large joints

 Seronegative
spondyloarthropathy
Pattern of joint involvement contd…

 Axial joint
involvement
 Ankylosing Spondylitis
 Reiter’s Syndrome
 Enteropathic Arthritis
 Psoriatic Arthritis
 Cervical Spine in RA
 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Specific joint symptoms

 Locking

 Giving way without warning

 Palpable or audible crepitus

 Warmth and swelling

 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Morning stiffness

 Marker of inflammatory activity

 Present or not

 Duration
 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Systemic symptoms
 Fever

 Night sweats
 Weight loss

 History of disease flares

 Remissions / Relapses
 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Associated conditions
 H/o recent Viral Infections
 Sexual exposures
 Dysentery
 Rash
 Alopecia
 Raynaud’s phenomenon
 Uveitis /Scleritis
 Oral / Genital ulceration
 Symptoms of Inflammatory Bowel Disease
 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Past History
 Psoriasis
 IBD
 Diabetes
 Hemochromatosis
 Endocrinopathies
 Rheumatic fever / Tuberculosis
 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Treatment history

 Drug Induced Lupus

 Raynaud’s Phenomenon – Beta Blockers

 Myositis

 Antituberculous drugs
 HISTORY
 Onset of symptoms  History of disease flares
 Duration of symptoms  Associated conditions
 Pattern of joint
 Past History
involvement
 Treatment history
 Specific joint symptoms
 Family History
 Morning stiffness
 Systemic symptoms
 Family History

 Gout

 Rheumatoid Arthritis

 Ankylosing Spondylitis

 Osteoarthritis

 Psoriasis / Uveitis / Inflammatory Bowel Disease

Approach to a polyarthritis patient

Step I:

Eliminate other causes of

joint pain
Step II

Inflammatory or
Non-Inflammatory?
 Inflammatory or Non-Inflammatory

Inflammatory Non-inflammatory

Prolonged morning
Yes No
stiffness >1 hr
Spontaneous flares Yes No
Improvement of joint
Yes No
symptoms on joint usage
Night worse than days Yes No
Constitutional symptoms Yes No
Elevated ESR, CRP Yes No
Step III

Symmetrical
or
Asymmetrical?
Step IV

Watch out for Extraarticular features

Extraarticular Features contd…

 Fever
 Clubbing
 Hair loss
 Nodules
 Skin changes
 Nail changes
 Mucous membrane changes
 Eye changes
Step V
Lab Investigations

 Thoughtful and judicious plan is needed.

 To under investigate is bad, to over investigate is

worse.
 Lab investigations
 Complete blood counts
 ESR
 CRP
 Peripheral smear
 Urine microscopy
 Blood sugar
 Rheumatoid factor
 Uric acid
 VDRL
 X-rays
To summarize
 Classification of Arthritis

Acute <6 weeks

Chronic >6 weeks

Adult >16 years

Juvenile <16 years
 Classification of Polyarthritis

Based on

 Presence or absence of inflammation

 Number and pattern of joint involvement

 Inflammatory
 Peripheral polyarticular
 Rheumatoid arthritis
 SLE
 Viral arthritis

 Peripheral pauciarticular
 Psoriatic arthritis
 Adult rheumatic fever
 Reiter’s syndrome
 Polyarticular gout
Inflammatory contd…

 Peripheral with axial joint involvement

 Ankylosing spondylitis
 Reiter’s syndrome
 Enteropathic arthritis
 Psoriatic arthritis
 Non inflammatory
 Hereditary
 Osteoarthritis of the hands
 Primary generalized OA
 Traumatic OA
 Metabolic diseases
 Haemochromatosis
 Ochronosis
 Acromegaly
 Idiopathic
Take Home Message

By careful history taking and physical

examination along with appropriate lab
investigations, the clinician can almost
always establish the correct diagnosis and
institute appropriate therapy.