ARTHRITIS: RHEUMATOID &

GOUT

Dr. Edward Ogwang.

Dermatologist.
 Outline.
• Rheumatologic Terminology.

• Rheumatoid Arthritis.

• Gout.
 Rheumatologic Terminology.
• Arthralgia: pain arising from joint (subjective)
• Arthritis/arthropathy: Objective signs of joint
abnormality
• Monoarthritis: arthritis of single joint
• Oligoarthritis: 2-4 joints or small group of joints
• Polyarthritis: > 4joints(or groups of joints)
• Synovitis: clinically apparent joint inflammation
(tenderness+swelling)
• Tenosynovitis: inflammation of tendon sheath
• Enthesitis: inflammation of enthesis
 Evaluating arthritis n rheumatic diz..

• Distribution
• Acute versus chronic
• Symptoms beyond arthritis e.g. other organ
involvement like skin rash
• Joint inflammation. Does patient have joint
inflammation.
 Distribution.
• Polyarticular symmetric : RA,SLE, VIRAL

• Monoarticular : OA, SEPTIC ARTHRITIS, GOUT

• Migratory: Lyme, GC, rheumatic fever

• Oligoarticular Assymetric: OA and

spondyloarthropathies
 Acute or Chronic
• Consider a patient presenting with
monoarthritis, if the symptoms have been for
months to years this is likely osteoarthritis.

• On the other hand if the monoarthritis just

occurred a couple of days ago we are likely
dealing with septic arthritis or crystal induced
arthropathy
 Evidence of systemic disease.
• SLE: Skin, lungs, kidneys, blood, CNS

• Sjogrens: sicca, parotid enlargement

• Systemic sclerosis: skin, raynaud’s

• Wegener’s: sinusitis, rhinitis, lung, kidney

• OA: Paucity of systemic symptoms.

 Evidence of inflammation.
• Erythema, warmth
• Joint stiffness> 1hour
• Elevated ESR, CRP
• Elevated white cells in the joint aspirate
• E.g.: OA versus RA
 Rheumatoid arthritis.
• Chronic systemic inflammatory multi-systemic
disease of unknown etiology.
• Main focus: synovium
• Hallmark: inflammatory synovitis in a symmetric
fashion

• Prevalence 1-2%
• Female : Male ratio 3:1
• Usual age of onset 20-40 years though
individuals of any age group may be affected
Rheumatoid arthritis.
 Clinical Presentation
• Insidious onset.
• Prodrome: malaise, weight
loss, periarticular pain and
stiffness.
• Symmetric joint
involvement with pain,
warmth, stiffness and
tenderness.
• Radial deviation of wrist
• Ulnar deviation of
metacarpophalangeal joints
• Extra articular features are
associated with severe
seropositive joint disease.
• Anaemia of chronic
disease, serositis,
subcutaneous nodules,
peripheral neuropathy,
cutaneous vasculitis, carpel
tunnel syndrome,
keratoconjunctivitis sicca
 RA
• After months to years, deformities can occur; the
most common are

– ulnar deviation of the fingers

– Radial deviation of the wrist
– swan neck deformity, which is hyperextension of the PIP
joint and permanent flexion of DIP
– boutonniere deformity, which is flexion of the PIP joint and
extension of the DIP.
Rheumatoid nodule.
 Rheumatoid arthritis..
• Felty’s syndrome: RA, splenomegaly and
neutropenia ( infections)

• Caplan’s syndrome.: coal worker’s

pneumoconiosis plus rheumatoid nodules.
 RA complication
• Atlantoaxial subluxation
• Atlas (c1) and axis (c2) are involved in 25 to 80%
• Paraplegia; quadriplegia
• Subtle symptoms: neck pain (occipital), c2
radicular pain (paraesthesias of hands and feet)
• Dx: xray of cervical spine
• Screen for c1/ c2 subluxation before intubation
or anaesthesia
Rheumatoid arthritis.
 Laboratory workup
• Rheumatoid Factor: 1/3 of African patients
seronegative.
• Anti-CCP (Anti-cyclic citrullinated peptide)
antibodies. Sensitivity 50-70%. 90% specificity
• ESR/CRP: monitor disease activity.
• CBC: anaemia
• Radiographs of hands and feet.: Characteristic juxta-
articular osteopenia and/or marginal erosions.
• Synovial fluid analysis: not necessary.
 2010 ACR/EULAR CRITERIA
• Four main domains for classification:.
 Joint Involvement (0-5)
 Serology( 0-3)
 Symptom Duration (0-1)
 Acute phase reactants (0-1)

Score of >or=6 is definite RA

 JOINT INVOLVEMENT (0-5)
1 Large Joint 0

2-10 large joints 1

1-3 small joints (large joints not counted) 2

4-10 small joints (large joints not counted) 3

>10joints (atleast one small joint) 5

Joint involvement: refers to any swollen or tender joint ( excluding DIP of hands
and feet, 1st MTP, 1st CMC)
Additional evidence from MRI/US may be used for confirmation of clinical
finding.
 SEROLOGY (0-3)
Negative RF and negative ACPA 0

Low positive RF or low positive ACPA 2

High positive RF or high positive ACPA 3

Negative: < or = ULN ( For the respective

laboratory)
Low positive: > ULN but < or = 3x ULN
High positive: >3x ULN
 SYMPTOM DURATION (0-1)
<6 weeks 0

> Or = 6 weeks 1

Symptom duration: refers to the patient’s self

report on the maximum duration of signs and
symptoms of any joint that is clinically involved
at the time of assessment.
 ACUTE PHASE REACTANTS (0-1)
Normal CRP or normal ESR 0
Abnormal CRP or abnormal ESR 1

Note:
Criteria are classification NOT diagnostic criteria. In
clinical practice they may inform the Physician’s
diagnosis.
We donot have a diagnostic criteria for RA. Typically
in rheumatic diseases, criteria are labelled as
‘’classification’’ criteria. These are helpful in defining
homogeneous treatment populations for study
purposes.
 Radiographic Assessment.
• Radiographs are not required in the 2010
acr/eular classification criteria
• EXCEPTIONS:
 In the unclassified patient when longstanding
inactive disease is suspected
 And if radiographs are already available in early
arthritis patient, their information can be used
for classification purposes ( eg taken by GP
before referral)
 Treatment.
• Multidiscplinary: physician, physiotherapist,
occupational therapist and surgeons.
• Non biologic DMARDS: chloroquine, sulfasalazine,
methotrexate,leflunamide,cyclosporine,gold salts
and D-penicillamine.
• Anti-TNF biologics. Eternacept , infliximab,
adalimumab etc.
• Biologic non TNF DMARDS: Rituximab, anakinra etc.
• Other drugs: NSAIDS, corticosteroids analgesics
Questions!
 Chrystal induced arthropathies..
• Due to micro-crystal deposition
• Monosodium urate MSU – GOUT
• Calcium pyrophosphate (CPPD) –
PSEUDOGOUT
• Calcium oxalate, calcium hydroxyapatite
• Identical clinical presentations.
• Distinguished by synovial fluid analysis
 GOUT.
• Synonym: Podagra.
• Disorder with abnormal purine catabolism
leading to hyperuricemia and then possibly
deposition of urate crystals.
• 2-12% of population has elevated uric acid
levels.
• Gout occurs almost exclusively in adult men
and postmenopausal women.
 Causes of Hyperuricemia
Underexcretion of uric acid (90% of
cases)
• Familial
• Intrinsic renal disease
• Drugs e.g diuretics esp
thiazides, low dose aspirin,
pyrazinamide
• Lead poisoning
Over production of uric acid (10%)
• Inherited enzyme defects eg
Lesch-Nyan syndrome
• Increased cell turnover eg
malignancies and psoriasis
• Alcohol
• High purine diet
• Cytotoxic drugs
 Clinical features..
• Acute gout: monoarthritis or oligoarthritis most
commonly on lower limb joints and typically the
big toe (podagra). Fever and chills might
accompany acute attack.
• Chronic gout: destructive arthritis, chronic renal
disease or both
• Tophus: accumulation of uric acid crystals in the
subcutaneous tissue. Typical sites are helix of
ear, digital joints, elbows, archilles tendon
 Precipitants of gout.
• ETOH

• INFECTION eg peumonia etc

• TRAUMA .. injury

• DRUGS. Especially diuretics, aspirin! TB drugs

ethambutal and pyrazinamide
 Diagnosis
• Document Hyperuricemia.
• Demonstrate presence of urate crystals in joint
fluid under polarized light microscopy.
( needle shaped crystals negative birefringent)
• Radiographs show periarticular bony erosions
• Showing a therapeutic response to colchicine
(not required)
Gout xrays.
 Treatment
• Acute attacks: NSAIDS eg indomethacin 50mg
qid. Colchicine 1.2 mg stat. then 0.6mg bid is
an effective alternative especially in patients
with an active PUD orrenal disease

• Prophylactic therapy with allopurinol or a

uricosuric agent like probenecid is indicated in
patients with : frequent attacks >3/yr; chronic
tophaceous gout; and renal calculi