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RH6 Rheumatology
Seropositive Rheumatic Disease
Toronto Notes 2019
Differential Diagnosis of Elevated ESR
• Systemic inflammatory diseases • Localized inflammatory diseases • Malignancy
• Trauma
• Infection
• Tissue injury/ischemia
The Radiographic Hallmarks of OA
• Joint space narrowing • Subchondral sclerosis • Subchondral cysts
• Osteophytes
Joint Involvement
• generalizedosteoarthritis:3+jointgroups
• asymmetric(kneesusuallyaffectedbilaterally) • hand
■ DIP (Heberden’s nodes = osteophytes → enlargement of joints) ■ PIP (Bouchard’s nodes)
■ CMC(usuallythumbsquaring)
■ 1st MCP (other MCPs are usually spared)
• hip
■ usually presents as groin pain ± dull or sharp pain in the trochanteric area, internal rotation and
abduction are lost first
■ pain can radiate to the anterior thigh, but generally does not go below the knee
• knee
■ initial narrowing of one compartment, medial > lateral; seen on standing x-rays, often patellar-
femoral joint involved • foot
■ common in first MTP and midfoot • lumbarspine
■ very common, especially L4-L5, L5-S1
■ degeneration of intervertebral discs and facet joints
■ reactive bone growth can contribute to neurological impingement (e.g. sciatica, neurogenic
claudication) or spondylolisthesis (forward or backward movement of one vertebra over another) • cervicalspine
■ commonly presents with neck pain that radiates to scapula, especially in mid-lower cervical area (C5 and C6)
Investigations
• bloodwork
■ normal CBC and ESR, CRP ■ negative RF and ANA
• radiology:4hallmarkfindings,seesidebar
• synovialfluid:non-inflammatory(seeTable8)
Treatment
• presentlynotreatmentaltersthenaturalhistoryofOA
• prevention: prevent injury (sports, work-related), healthy weight management, maintenance of good
muscle strength
• non-pharmacologicaltherapy
■ weight loss (minimum 5-10 lb loss) if overweight
■ physiotherapy: heat/cold, low impact exercise programs ■ occupational therapy: aids, splints, cane, walker, bracing
• pharmacologicaltherapy(seeTable33)
■ 1st line – oral: acetaminophen/NSAIDs
■ treat neuropathic pain if present (anti-depressants, anti-epileptics, etc.)
■ joint injections: corticosteroid (effective for short-term treatment), hyaluronic acid (evidence of
long-term benefits)
■ topical: capsaicin, NSAIDs
■ glucosamine ± chondroitin (efficacy not well supported)
• surgicaltreatment
■ totaland/orpartialjointreplacement,jointdebridement,osteotomy,fusion
Seropositive Rheumatic Disease
• diagnosisvs.classificationinrheumatology
■ diagnostic criteria are often dependent on disease progression and evolution over time, as early
objective measures are often unavailable
■ classification criteria are derived from studying patients with long-term diseases and clear diagnoses
in order to determine which criteria have good specificity in the early prediction of certain
diagnoses
• seropositivearthropathiesarecharacterizedbythepresenceofaserologicmarkersuchaspositiveRFor
ANA
• asmallsubsetofthevasculitides,thesmallvesselANCA-associatedvasculitides,haveameasurable
serological component, but they are often considered a separate entity from seropositive disease by experts