I have arthritis that affects many of my joints … He could be rheumatoid arthritis and the doctor should know?
There are over 100 different types of arthritis. Most of them involve inflammation. When a patient goes to a rheumatologist for diagnosis, there is a process of elimination to reach an accurate diagnosis. This removal process is called “differential diagnosis”.
Diagnosis of the difference can be a difficult task because so many forms of arthritis, particularly inflammatory forms of arthritis are similar. The following is a list of the types of inflammatory arthritis that can be seen and should be considered when evaluating patients with symptoms of inflammatory arthritis.
Rheumatoid arthritis (RA)
Rheumatoid arthritis is a chronic autoimmune inflammatory disease that can affect any joint in the body, but preferably attacks the peripheral joints (fingers, wrists, elbows, shoulders, hips, knees, ankles and feet. It can also affect non-common organ systems such as the lungs, eyes, skin and cardiovascular system. RA onset can be insidious, slow-non-specific symptoms, including fatigue, malaise, loss of appetite, low-grade fever, weight loss, and vague aches and pains, or may have a sudden onset with inflammation involving multiple joints. Common symptoms usually occur bilaterally symmetrical, and the damage. for joints called “erosion”, can be seen with magnetic resonance imaging at the beginning or the X-ray later in the course of the disease. Approximately 80% of RA patients have high levels of rheumatoid factor (RF) or anti-CCP.
Juvenile rheumatoid arthritis (JRA)
JRA describes a group of arthritic conditions that occur in children younger than 16 years. There are three forms of JRA, including oligoarticular (1-4 joints), polyarticular (> 4 joints) and systemic disease occurrence or still. The latter is associated with significant internal organ involvement and May also have fever and a rash, other than joint disease. Juvenile idiopathic arthritis is considered a type that is most similar to adult RA, is responsible for about 30% of cases of juvenile rheumatoid arthritis. Most children with juvenile idiopathic arthritis were negative for RF and their prognosis is generally good. About 20% of patients with polyarticular JRA have elevated RF and these patients appear at greater risk for chronic, progressive joint destruction and damage. Uveitis, an inflammatory eye disease is a common finding in oligoarticular JRA, especially in patients who have antinuclear antibodies (ANA) were positive. Hazardous characteristics of uveitis that may cause symptoms of a relatively careful selection is recommended to prevent blindness.
Lupus erythematosus (SLE)
SLE is a chronic, inflammatory autoimmune disorder that can involve the skin, joints, kidneys, brain and blood vessel walls. At least four of the following symptoms that are of the American College of Rheumatology are usually present diagnosis
? Red, butterfly-shaped rash on the face, affecting the person;
? Rash typical of other parts of the body
? Sensitivity to sunlight;
? Mouth sores;
? Inflammation of the joints (arthritis),
? Fluid around the lungs, heart and other organs,
? Renal dysfunction,
? Low white blood cell count, low red blood cells due to hemolytic anemia or low platelet count,
? Nervous system or brain dysfunction,
? The positive results of blood test for ANA, and
? Positive results in blood for anti-dsDNA antibodies or other anti-Smith, including antibodies and antiphospholipid antibodies.
Patients with lupus can have a significant inflammatory arthritis. Thus, lupus can be difficult to distinguish from RA, especially if other signs and symptoms of lupus are minimal.
inflammatory muscle disease
Polymyositis (PM) and dermatomyositis (DM) are types of inflammatory muscle disease. These conditions generally have a weakness of bilateral (both sides) large. In the case of DM, the rash can be a sign of surrender. Diagnosis is made up of four main characteristics, including elevated creatine kinase (CK), the signs and symptoms such as muscle weakness, elevated muscle enzyme (creatine kinase, aldolase), electromyogram (EMG) abnormalities, and muscle biopsy is positive. Often, abnormal laboratory test can be seen, including the presence of autoantibodies such as antinuclear antibodies (ANA) and myositis associated with antibodies.
In both PM and DM, inflammatory arthritis May be present and may resemble RA – including the participation of the lungs. In RA, however, except to say -.- overlap syndrome, patients with both RA and muscle disease) is present, muscle function must be normal. Also, in PM and DM, erosive joint disease is unlikely. RF and anti-CCP antibodies are typically high in RA, but not PM or DM.
Spondyloarthropathies (SA)
A group of arthritic conditions called the spondyloarthropathies, including psoriatic arthritis, reactive arthritis, ankylosing spondylitis, arthritis and enteropathica are a class of diseases that cause inflammation in the body, especially in parts of the spine and joints where tendons attach to other bones. They can also cause pain and stiffness in the neck, upper and lower back, tendonitis, bursitis, heel pain and fatigue. Often referred to as seronegative arthritis. “Seronegative” term means that the testing laboratory markers such as rheumatoid factor were negative. Symptoms in adults with include:
? Return and / or joint pain;
? Morning stiffness;
? Tenderness near the bone
? Sores on the skin />
? Inflammation of the joints on both sides of the body
? Skin ulcers or mouth;
? A rash on the soles of the feet, and
? Inflammation of the eye.
In some cases of AS, peripheral arthritis resembling rheumatoid arthritis may be present. History and physical examination can usually differentiate between these syndromes, especially if the disease is obvious that this is aggravating the inflammation (psoriasis, inflammatory bowel disease). Additionally, since RA rarely affects the joints of the fingers (DIP joints), if these compounds are involved in inflammatory arthritis, a diagnosis of SA is promoted. Typically, RF and anti-CCP antibodies were negative in South Africa, although in some cases, psoriatic arthritis can be an elevation of RF and anti-CCP.
Crystal Arthritis Associated
Disease monosodium urate (gout)
Gout is caused by deposits of monosodium urate crystals in joints. Gouty arthritis is usually sudden onset, very painful, with signs of significant inflammation of the exam (red, hot, swollen joints). Gout can affect almost any joint in the body but most commonly affects more “cool” regions, including the toes, feet, ankles, knees and hands. Diagnosis is made by removing fluid from the joint and examining the fluid under a polarizing microscope. Patients can also have high levels of uric acid in serum.
In most cases, gout is an acute disease that affects the joint, and is easily distinguished from RA. However, in rare cases, chronic inflammation may develop erosive and affect more joints. And where tophi (deposits of uric acid under the skin) are present, it can be difficult to distinguish from erosive RA. However, analysis of crystal joints or tophi and blood should be useful in distinguishing the fall of RA.
Deposits of calcium pyrophosphate disease (CPPD, pseudogout)
CPPD disease is caused by deposits of crystals of calcium pyrophosphate dehydrated in the joint. Body’s reaction to these crystals leads to significant inflammation. Diagnosis includes:
? A detailed medical history and physical examination;
? The withdrawal of fluid from the joint with a needle />
? Joint x-rays to show the crystals deposited in cartilage (chondrocalcinosis) />
? Blood tests to rule out other diseases (eg RA or osteoarthritis).
In most cases, CPPD arthritis presents with acute arthritis affecting one or more joints. However, in some cases, the disease can present with chronic arthritis, CPPD symmetrically similar to the more common erosive RA. PR and CPPD disease can usually be distinguished by examining the joint fluid showing crystals of calcium pyrophosphate, and blood, including anti-CCP antibodies and RF, which should be negative for rheumatoid CCPD.
Sarcoid arthritis
Sarcoidosis is an inflammatory type of arthritis. Most patients with this disease have pulmonary disease, eye and skin diseases as the next most common sign of illness. In most cases, the diagnosis of sarcoidosis may be the clinical presentation and X-rays alone. Patients with acute arthritis, painful nodes under the skin on the shins (erythema nodosum), and chest X-ray shows an increase of lymph NIOD. In some cases, demonstration of a specific type of changes in inflammation, called noncaseating granulomas on tissue biopsy, is needed for definitive diagnosis.
Arthritis can be present in about 15% of patients with sarcoidosis, and in rare cases may be the only sign of illness. In sarcoidosis acute rheumatoid joint disease is usually rapid in onset, symmetrical, including the ankle joints. Knees, wrists and small hand joints may be involved. In most cases of acute diseases, lung and skin are also present. Chronic sarcoid arthritis usually involves several joints or perhaps because it is often erosive <-! Nextpage ->. It can be difficult to distinguish from RA
Polymyalgia rheumatica (PMR) / temporal arthritis
RMP is a form of arthritis that causes inflammation of the tendons, muscles, ligaments and tissues around the joints. It is characterized by large muscles (shoulders, hips, thighs, neck) pain, pain, morning stiffness, fatigue, and in some cases, fever. This may be associated with arthritis, temporal / giant cell arthritis (TA / GCA) is a condition related to, but severe infections in which large blood vessels can lead to complications such as blindness, aneurysm and cramps in the arms or legs (limb claudication) due to inflammation and narrowing of the large blood vessels in the chest and limbs. PMR is diagnosed when the clinical picture was accompanied by elevated inflammatory markers (ESR and / or CRP). If arthritis is suspected of the time (headaches, visual disturbances, limb claudication), temporal artery biopsy may be necessary to make a diagnosis.
TA and PMR / GCA may present with symmetrical inflammatory arthritis similar to RA. These diseases can usually be distinguished by blood. In addition, headaches, visual changes of acute pain in muscles and large are rare in RA, and if present, PMR and / or TA / GCA should be considered.
Infectious arthritis
Many infections can present with arthritis is due to a spouse or direct infection due to autoimmune inflammation of the joints. In most cases, lead to acute arthritis, one joint, but in some cases, chronic arthritis affecting several joints or more May be present. Because infection can result in missed significant complications, it is crucial to have a high index of suspicion of infection in patients with either acute or chronic arthritis.
Lyme disease
Lyme disease is an infection caused by bacteria called a spirochete type. The disease is characterized by a rash, swollen joints and flu-like symptoms, caused by the bite of infected ticks. Symptoms may include:
? Skin rash, often resembling a target (target lesion) />
? Fever;
? Headache,
? Muscle pain;
? Stiff neck, and
? Swelling of the knees and other large joints.
Diagnosis of Lyme disease is usually made from the blood. If, however, is only common acute and chronic arthritis, the analysis of joint fluid or joint tissue biopsies May be required for diagnosis. Lyme arthritis can usually be distinguished from RA by clinical presentation and blood tests.
Rheumatic fever (ARF)
Rheumatic fever is an inflammatory disease that can develop after an infection with streptococcus bacteria (strep throat or scarlet fever). The disease can affect the heart, joints, skin and brain. Symptoms include:
? Fever;
? Joint pain;
? Arthritis (mostly in the knees, elbows, ankles and wrists);
? Joint swelling, redness or heat
? Abdominal pain;
?
rash
? Skin nodules
? Proper motion disorder (Sydenham’s tremors)
? Nosebleeds; />
? Heart problems, which may be asymptomatic.
The diagnosis of ARF performs clinical assessments and blood tests for antibodies against the streptococcal protein. ARF and RA May have similar clinical features, including arthritis and nodules. However, ARF can usually be distinguished from RA by clinical presentation. Rash and migratory arthritis is uncommon in RA. Using the blood is also beneficial.
Arthritis viral (hepatitis B and C, parvovirus, EBV, HIV)
Arthritis can be a symptom of many viral diseases. This is an enemy hidden viral infection. Duration is usually brief, and usually resolve without any lasting effect. Clinical features in adults:
? Common symptoms occur in up to 60%. It can be symmetrical, affecting the small joints of hands, wrists and ankles and knees. Morning stiffness is also present.
? Parvovirus B19 is a very common viral infection that resembles RA.
? The diagnosis of viral arthritis is made by serological tests. A high percentage of patients with hepatitis C, may have high titers of RF. Therefore, the RF test is not useful to distinguish between hepatitis C and RA. However, in such situations, anti-CCP test may be useful as anti-CCP is shown to be significantly higher in remote areas of hepatitis C infection.
So as you can see … “It’s not easy …” P
Nathan Wei, MD FACP Facre a rheumatologist and director of the Center for Arthritis and Osteoporosis Maryland. He is an assistant clinical professor of medicine at the University of Maryland School of Medicine. For more information:
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December 5, 2011 
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