RHEUMATOLOGY

INFLAMMATORY
RHEUMATIOD ARTHRITIS
- Chronic, systemic and inflammatory
- F>M: 25 – 50 y/o (SMALL joints affected); F=M: >60 y/o (LARGE joints affected)

POLYARTHRITIS OLIGOARTHRITIS
- Autoimmune disease → PANNUS FORMATION (proliferation of cells)→EROSION
- Inflammatory: SYNOVIUM affected – DIARTHRODIAL
- EPIDEMIOLOGY: MC in Caucasian; LC in African American
- ETIOLOGY: (Theories)
o INFECTION – Epstein Barr Virus; Staphylococcus Infection
o GENETICS – HLADR4
o ABERRANT FUNCTIONING of the T-CELLS
o (+) RHEUMATOID FACTOR
 (+) Rheumatoid nodules
CRITERIA TO DIAGNOSE RA:
1987 2010
Morning stiffness > 30 mins. or @ least 1 hr SCORING OF SEGMENTS SCORE
Arthritis of 3 or more joints
Arthritis of the HAND joints Joint Involvement
- MCP, WRIST PIP 1 Large joint 0
- SPARED DIP 2 – 10 Large joints 1
Symmetric Arthritis 1 – 3 Small joints 2
(+) RA Nodules 4 – 10 Small joints 3
- FA extensors >10 joints 5
- Olecranon process
- Achilles Serology
Erosion in X-ray (-) RF or ACPA (anti-citrulinated protein antibody) 0
- Abnormal alignment Low (-) RF or ACPA 1
- Bone involvements (INTRARTICULAR High (-) RF or ACPA 3
OSTEOPOROSIS)
- Cartilage involvement Duration
- Deformities <6 weeks 0
- Erosion >6 weeks 1
- Soft tissue swelling
(+) RH factor Acute Phase Reactions
Normal (M: 15; F: 25 mm/hr) 0
↑ ESR/CRP 1
st
RULE: 4 out of 7 (1 4) to consider RA in 6 TOTAL: 10
consecutive weeks NORMAL: >6 – 10
JOINTS AFFECTED: (most affected to least)
MCP Shoulder
Wrist Ankle
PIP Cervical Spine
Knee Hip
MTP Elbow
TMJ

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Cebu Doctors’ University
Batch 2015 Page 1
COMMON DEFORMITIES:
1. SWAN NECK DEFORMITY
- DIP FLEXION, PIP EXTENSION
- CAUSES:
o Reflex MUSCLE SPASM of the intrinsic muscles 2◦ inflammation
o Swelling of the VOLAR CAPSULE of the PIP muscles
o Rupture of EDC @ DIP joint
- SPLINT:
o Finger Ring Orthosis (BUNNEL RING)
o NO gripping objects using the fingers in RA; use PALM

2. BOUTONNAIRE DEFORMITY
- DIP EXTENSION, PIP FLEXION
- Seen in RA (irreversible) and SLE (reversible)

3. VAUGN JACKSON DEFORMITY

th th
- Rupture of the 4 and 5 extensor tendon
- When the patient undergoes surgery (NOT EVIDENT WHEN POSITIONED)

4. MANNER FELT DEFORMITY

- Rupture FPL

NALEBUFF DEFORMITY
1 THUMB Buotonnaire WITHOUT Adduction
2 THUMB Buotonnaire WITH Adduction
3 THUMB Swan Neck WITH Adduction
4 GAMEKEEPER’S THUMB
5 ONLY Swan Neck Deformity
6 BONES LOSS/ARTHRITIS MUTILANS

5. OPERAGLASS HAND
- Arthritis Mutilans
- Seen also in Psoriasis as Telescoping sign
- (+) folds of the skin @ the side

6. ULNAR DRIFT
- UD of the MCP
- RD of the wirst
- “Z-deformity” or “Zigzag deformity”

7. INTRINSIC PLUS DEFORMITY with WRIST FLEXION CONTRACTURE

- Losing the tenodesis effect
- (-) grip d/t weakness
- SPLINT:
o Resting Hand Splint @ night
o Functional Hand Splint @ day (NO COVER @ PALMAR AREA)

8. PIANO KEY SIGN

- Up and down movement of the DISTAL ULNA
- d/t sever inflammation 2◦ TEAR of the DISTAL RADIOULNAR LIGAMENT

Jandie Sagayno
Cebu Doctors’ University
Batch 2015 Page 2
 9. KNEE JOINT
- Slight FLEXION
- FELXION contracture
- (+) subluxation
- BED REST: (↓ in the muscle bulk)
o ↓ 30%/week (ms strength)
o ↓ 5%/day
- Formation of BAKER CYSTS
o MEDS: glucosteroids
- TARSAL TUNNEL SYNDROME
o Impingement of the tibial nerve
10. MTP
- Metatarsalgia
- HAMMER TOES
o MTP EXTENSION
o PIP FLEXION
o “APROPULSIVE GAIT” – Absence of push off
 SHOE MODIFICATION:
 High toe bix
 Wider ball of the foot
 Rocker bottom
- Hallux Valgus
o (+) BUNION
- Claw toes
o MTP EXTENSION
o PIP AND DIP FLEXION
11. SHOULDER
- Most limited: IR
12. ANKLE
- Collapse of MLA and TLA
13. CERVICAL SPINE
- C1 and C2
14. HIP
- (+) Protrusio Acetabuli
- (+) Trendelenburg gait
- EARLY LOM on IR
15. ELBOW
- Flexion contracture
- Loss of SUPINATION AND PRONATION
16. TMJ
- Limitation of MOUTH OPENING – 2’’

EXTRAARTICULAR MANIFESTATION
1. HEART
o Pericarditis
o Most serious: MYOCARDIAL INFRACTION
2. LUNGS
o CAPLAN’S SYNDROME: (+) Rheumatoid Nodules in the LUNGS
3. SKIN
o (+) Rheumatoid Nodules
4. BLOOD
o Anemia (Normocytic and normochromic)

Jandie Sagayno
Cebu Doctors’ University
Batch 2015 Page 3
 FELTY’S SYNDROME
Splenomegaly
Leukopenia
Lymphadenopathy
Arthritis
Anemia
Neutropenia
Thrombocytopenia

5. EYES
o SJOGREN’S DISEASE
 “SICCA SYNDROME/GOUGEROT’S/AUTOIMMUNE EXOCRINOPATHY”
 Dryness of EYES (xeropthalmia)
Dryness of MOUTH (xerotostomia)
Arthritis
 SPECIAL TEST:
o ROSE BENGAL SIGN: ointment is applied in the sclera to determine the
dry area → DISCOLORATION
o SCHIRMER’S TEST: filter paper → hooked in the eyelid for 5 mins to
measure the amount of wetness
 (+) may indicate SJOGREN or RA
 (+) DYSPAREUNIA
o Dryness of the female genitalia
o Painful sex
 ASSOCIATION OF SJOGREN:
o RA
o SLE
o Scleroderma
o Mixed CT Disease
 2◦ SJOGREN:
o Associated with LYMPHOMA (cancer)
 Parotid enlargement
 (+) Leukopenia
 (+) Vasculitis: with purpura (purple)

STAGES OF DISEASE FUNCTIONAL CLASSIFICATION

PROGRESSION IN RA IN RA
I MILD SELF CARE (+)
(+) juxaarticular osteoporosis VOCATIONAL (+)
AVOCATIONAL (+)
II MODERATE SELF CARE (+)
(+) osteoporosis with/without slight bone VOCATIONAL (+)
production AVOCATIONAL (-)
(+) rheumatoid nodules
(+) adjacent muscle atrophy
III SEVERE SELF CARE (+)
(+) LOM, deformities VOCATIONAL (-)
(+) extensive muscle atrophy AVOCATIONAL (-)
IV TERMINAL DEPENDENT; UNABLE TO PERFORM ALL
All manifestation in the STAGE III with
BONY ANKYLOSIS

Jandie Sagayno
Cebu Doctors’ University
Batch 2015 Page 4
 JUVENILE RHEUMATOID/IDIOPATHIC ARTHRITIS

PAUCIARTICULAR POLYARTICULAR SYSTEMIC/STILL’S

1 – 4 joints: KAWT Resembles the elastic RS but RAREST
(+) ANA – (+) Iridocyclitis onset MC: Knee
G>B; 1 – 4 y/o or 5 y/o YOUNG LC: cervical spine
>4 y/o (+) high grade fever
(+) RF – poor prognosis (+) EVANESCENT RASH
(disappearing rash)
POLYMYALGIA RHEUMATICA
ST
- 1 complain: MUSCLE STIFFNESS AND PAIN
- PROXIMAL:
Stiffness
o Neck Elderly
o Shoulder Caucasian
o Pelvic Girdle
- SYSTEMIC: Rheumatism
o Low grade fever Elevation of ESR
o Fatigue
Temporal Arteritis (GIANT
CELL ARTERITIS)

SYSTEMIC LUPUS ERYTHEMATOSUS

- Chronic multisystem disease COMMON CAUSE OF DEATH:

- CLASSIC autoimmune disease
- F > M; African American 1. Lupus nephritis
- Child bearing age 2. CNS lupus
- CRITERIA: @4/more over 11 to confirm 3. ↓ immune system
DOPAMIN RASH 4. Cardiovascular disease

D DISCOID RASH @ Scalp, Face and Jaw

may lead to ALOPECIA

O ORAL ULCERATION – (+) infection

OSTEONECROSIS: (+) crescent sign (single joint pain)

P PHOTOSENSITIVITY

A JACCOUD’S ARTHRITIS
Non erosive but deforming deformities → REVERSIBLE

M MALAR/BUTTERFLY RASH
when expose to sunlight → cheeks

I IMMUNOLOGIC RESPONSE
↑ risk of infection

N NEUROLOGIC INVOLVEMENT
Cognitive Dysfunction
Psychosis

Jandie Sagayno
Cebu Doctors’ University
Batch 2015 Page 5
 R RENAL DISEASE
(+) lupus nephritis

A ANA (+)
Antinuclear Antibody – HALLMARK OF SLE

S SEROSITIS
HEART: pericarditis
LUNGS: pleuritis

H HEMATOLOGIC DISEASE: FELTY’S SYNDROME

SCLERODERMA

- “PROGRESSIVE SYSTEMIC SLEROSIS”

- ↑ collagen production
- F>M
- SYMMETRIC – arthritis/arthalgia
- Synovitis with edema (RA → NO EDEMA)
TYPES: Calcinosis
1. DIFFUSE Raynaud’s Phenomenon
 SKIN – distal and proximal
 MAJOR ORGANS: Kidneys
Esopahgeal Dysmotility
2. LIMITED Sclerodactyly
 SKIN – distal only Telangiectasis
 (+) CREST SYNDROME

LOCALIZED SCLERODERMA – only SKIN is involved

1. MORPHEA
 plaque formation/thickening of the skin and TRUNK
2. LINEA
 Seen in the extremities
o ENCOUP DE SABRE – a wound inflicted by a sword in the FACE
o ENCOUP DE BAND – related in the extremities (UE) but only the skin; LE
relatively spared
STAGES:
EDEMATOUS SCLEROTIC/INDURATIVE ATROPHIC
(
Pitting or non-ptting edema Fingers may have FLEXION +) atrophy of the skin/thinning
CONTRACTURE
st
1 : DISTAL extremities esp. (+) Sclerodactyly When you ask the patient to
the HANDS (-) Skin folds perform a grip, the skin on the
(+) thickening of trunk and neck dorsal side will tear.
Few weeks/month (+) pinched nose
(+) tobacco pouch lips
(+) HYPER/HYPOpigmentation
(+) skiny skin

CRITERIA FOR DIAGNOSIS:

MAJOR MINOR
Scleroderma proximal to MCP, MTP, TRUNK, Digital pitting scars 2◦ ulcerations
NECK or FACE Sclerodactyly
Bibasilar pulmonary fibrosis

Jandie Sagayno
Cebu Doctors’ University
Batch 2015 Page 6
RULE: 1 Major or @ least 2 Minor
OTHER ORGANS AFFECTED:
1. HEART
o Arrhythmias – problem with the conduction of impulse
2. LUNGS
o Pulmonary fibrosis – “HONEYCOUMB’S LUNGS”
o Pulmonary hypertension
3. GIT
MOST SERIOUS COMPLICATIONS: Lung Disease

POLYMYOSITIS/DERMATOSITIS

- Symmetrical affectation
- Under the inflammatory Muscle Disease

A. POLYMYOSITIS
- PROXIMAL muscle weakness
- MC in adult MALES
B. DERMATOMYOSITIS
- PROXIMAL muscle weakness with Characteristic rash
- MC in GIRLS and ADULT FEMALES

CHARACTERISTIC RASH:

HELIOTROPHIC RASH Eyelids/around the eyes

COLOR: purple or violet
V-SIGN RASH Anterior cervical spine/anterior neck
SHAWL RASH SHOULDER and UPPER arm
MECHANIC’S HAND FINGERTIPS HAVE CRACKS
CRACKING and FISSURING of the skin in the finger
Dark/dirty
GOTTRON’S DISEASE Seen in BILAT. hands
Over the KNUCKLES – indicates possibility of CANCER
(if between joints: PHOTOSENSITIVITY RASH)

TYPES:
I PM (idiopathic)
II DM (idiopathic)
III PM + DM with MALIGNANCY (DM>PM)
IV PM + DM with VASCULITIS
V PM + DM with COLLAGEN VASCULAR DISEASE (Felty’s syndrome)
VI PM + DM with INCLUSION BODY MYOSITIS

PM/DM IBM
MC in FEMALES MC in MALES
PROXIMAL weakness DISTAL muscles
(-) facial weakness (+) facial muscles weakness
(-) falling (+) falling
(+) dysphagia

Jandie Sagayno
Cebu Doctors’ University
Batch 2015 Page 7
 SPONDYLOARTHROPATHIES

- (+) HLA B27 – enthesitis

o Enthesis – insertion of a tendon to a bone
- Asymmetric affectation

PSORIASIS ANKYLOSING REITER’S INFLAMMATORY

SPONDYLITIS DISEASE BOWEL DISEASE
M=F; MC in UE Has highest association with M>F if STD 9:1 CROHN’S DISEASE
HLA B27 Chlamydia
Psoriatic Arthritis M>F (3:1); 20 – 40 y/o Salmonella Involves the WHOLE GIT
Yersinia (+) ulcerations
ASYMMETRIC AKA Marie-strumpell/Von Shigella Stomach pain
OLIGOARTICULAR: Bechterev Campylobacter Vomiting
Diarrhea
DIP Earliest symptom: MORNING M=F if food borne (+) asymmetric arthritis
Elbow BACK PAIN MC KNEE JOINT
MANIFESTATIONS:
Knee (+) SACROILITIS: inflammation
Hip of the SI joint Conjunctivitis
Special test: ULVERATIVE
(+) Patrick’s/FABER/Figure of 4 Urethritis COLITIS
Auspitz sign: bleeding Test
after Keratoderma
Involves the COLON
scraping/scratching Gaenslen’s test: similar to Blenorrhagicum: lupus like
Thomas test; knee to chest but lesions @ palms and soles
Koebner’s Same manifestation with
the untested side dangled
Phenomenon: Crohn’s Disease
outside the table Arthritis
formation of new MC HIP AND ANKLE
lesions in areas Pelvic Rock test: sidelying;
exposed to trauma
JOINT
compress the pelvis
Carcinate Balanitis:
Pencil in a cup (+) ascending involvement of
painless ulceration in the
deformity the soine
glans penis
Telescoping sign: (+) formation of cqlcification on
unilateral Arthritis the annulus fibrosis
Mutilans (syndesmophyte formation)
↓
Onycholysis: (+) bamboo spine
degenerative nail ↓
changes secondary to (+) SCHOBER’S TEST
mutilation of distal
phalanx EXTRAARTICULAR
MANIFESTATIONS:
Eyes: Anterior Uveitis
Heart: Aortitis
Lungs: limited chest expansion
secondary to Kyphosis (RLD)

SHOULDER JT – most
commonly affected

DDX: Diffuse Idiopathic

Skeletal Hyoerstosis/
Forestier’s Disease
(non inflammatory and non-
systemic; >40 y/o

Jandie Sagayno
Cebu Doctors’ University
Batch 2015 Page 8
 CRYSTAL-INDUCED ARTHRITIS

GOUTY ARTHRITIS PSEUDOGOUT

M>F, 30 – 50 y/o MC in elderly; >5o y/o
M=F, >60 y/o Secondary to DIET and exposure to TRAUMA

(+) hyperuricemia “CHONDROCALCINOSIS”

- ↑ uric acid in the blood (+) CALCIUM PYROPHOSPHATE DIHYDRATE
- ↑ purine diet (not all will be
dissolved; converted to URIC MC KNEE
ACID)
URICASE Drug: Cholchicine
- Dissolves purine
- N↓
- If ↑ = (+) MONOSODIUM URATE
CRYSTALS
st
PODAGRA: 1 MTP
GONAGRA: Knee
CHIERGRA: Wrist

In cartilage, (+) TOPHI FORMATION

- Nose
- Achilles
- Ear
DRUG: Cholchicine (monosodium urate crystals
will not deposit to the joints and capsule)

NON-INFLAMMATORY ARTHRITIC DISEASE

OSTEOARTHRITIS

- DDD, DJD or KELLGREN’S DISEASE

- Degeneration of IVD or joints
- SPINE: C5C6; lumbar spine
- Affects the weight bearing joints
- F>M; F=M >70 t/o
- HALLMARK: JOINT SPACE NARROWING
- (+) bony spurs – osteophytes → LOM and bony block
HANDS:
 DIP: Herberden’s Node
 PIP: Bouchard’s Node
 1 CMC: most disabling complication
st

SHOULDER
 AC joint: Primary OA
 GH joint: Secondary OA
HIP
 Malum Coxae Senilis – most disabling complication in HIP; >70 y/o
KNEE
 MC involved
 (+) genu varum

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Cebu Doctors’ University
Batch 2015 Page 9
 st
1 MTP
 (+) Hallux Valgus
o If bony block, hallux valgus rigidus is formed
o (+) bunion formation
FACET JOINT
 Primary: C5C6

SUBTYPE OF OA

CRAIN’S DISEASE
- (+) inflammation and erosion
- MC in F 50 – 55 y/o
- Small joints of the hand (BOTH DIP AND PIP)
- (+) X-ray
o (+) GULL WING SIGN
o (+) INVERTED T-SIGN
- Medication: Glucosamine Sulfate

FIBROMYALGIA SYNDROME

- Rheumatic disorder; non-inflammatory

- F>M; as early as 10 y/o = menarche
MANIFESTATION
 Widespread of pain (TENDER POINTS)
 (+) fatigue
 Disturbance of sleep
 Anxiety
 Irritability
 Depression
 Raynaud’s Phenomenon
18 TENDER POINTS

OCCIPUT
TRAPEZIUS
SUPRASPINATUS
GLUTEALS
2nd RIB
LOWER CERVICAL
LATERAL EPICONDYLE
GREATER TROCHANTER
MEDIAL FAT PAD OF THE KNEE
NO STEROIDS ALLOWED

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Cebu Doctors’ University
Batch 2015 Page 10