• LecturehallRheumatology Review for Podiatric Practice
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Speaker: Hello everyone and thank you for joining me. I am Richmond Robinson and today I'm going to be discussing a rheumatology review for podiatric practice. So today's learning objectives are going to be to define several common arthritis which are encountered in podiatric practice, to illustrate the epidemiology, clinical manifestation and laboratory findings of arthritic diseases, to explain the medical management of select rheumatologic diseases. So for disclosures, I have no related financial interest or anything else to disclose. Alright. Today's talk is going to consist of several different arthritis. There is non-inflammatory arthritis or osteoarthritis. There is inflammatory arthritis. We will discuss seronegative, seropositive, infectious and then endocrine based diseases. For the seronegative arthritis, we will discuss ankylosing spondylitis, reactive arthritis, psoriatic arthritis. And then for seropositive, we are going to discuss rheumatoid arthritis. So I will start with infectious or septic arthritis. When you talk about all the arthritis, it's very important that we tease out all of them and we are going to really discuss the different ways that we can diagnose and then some of the treatment options. Septic arthritis is important to include here because it should be one of the differential for most of these diseases. So septic arthritis is an acute joint infection which is typically caused by bacteria, fungi or mycobacteria. Most common bacteria which will cause septic arthritis are staph aureus and streptococcus. The incident of septic arthritis is about 8% to 27%. There is different ways of developing septic arthritis and one of them would be hematogenous spread. There is inoculation which would be actually implantation of one of these organisms to that site. So you can get this through any type of surgical procedure or by wounds and even trauma. The last of the three would be the spread from the continuous cortex or skin infection and so this will be something like patient has an ulceration which becomes infected that leads to osteomyelitis and then from cortex, it spreads into the joint.


    So the clinical presentation for a septic arthritis is typically going to be the red, hot, swollen joint. Common places for this would be in the knee, the ankle, the wrist and then the hip. In the podiatric practice, we see a lot of these in the first metatarsal phalangeal joint as well. So patient is going to come in. They are going to be complaining of pain and restriction of motion with their joint that is quite painful. So other physical exam findings that the patient might present with would be systemic illness with fever, chills. There may be other local infections that are present. Skin will be warm, swollen. Patient also might have UTI or respiratory tract infection that has led to the condition. And then infected endocarditis is also commonly seen. The diagnosis of septic arthritis is typically through a synovial fluid analysis. Ideally, you want to performed this before the initiation of the antibiotics so you can get the best or the most accurate bacteria. Along with the synovial fluid analysis, you want to get gram stain and culture. Within your synovial fluid analysis, you are going to want to look at the clarity of the fluid. In septic arthritis, it is certainly going to be opaque. The color will be yellow. There could be a variable amount of viscosity. The white blood cell count may be greater than 20,000 and culture of the synovial fluid will often be positive. It's important to also look in the synovial fluid analysis for crystal evaluation to rule out things like CPPD or gout. The treatment of septic arthritis is going to consist of intravenous antibiotics. Patient may also need a joint aspiration or some type of drainage procedure and you can do these drainage procedures through the use of needle. Some patients will have this done arthroscopically and then an arthrotomy can also be considered, especially in patients that have prosthetic joint, that needs to be opened up, irrigated and in some cases, antibiotic beads may be placed or spacer and then come back and replace the prosthetic joint.


    The next type of arthritis that we are going to look at is endocrine and this is going to be subdivided into gout and pseudogout with calcium pyrophosphate deposition disease. So let's first talk about gout. Gout is a condition where hyperuricemia leads to uric crystal deposition on the soft tissue and joint structures causing pain. It's more common in men than women. It can affect over 3% of American adults according to some studies. So gout is associated with hyperuricemia and hyperuricemia can be affected by over-production or under-excretion. The over-producers are going to be the ones that have the dietary condition that maybe leads to gout. For the under-excretors, they may have chronic renal disease or it could be medication related such as patients who is on thiazide diuretic. There are several different predisposing factors to an acute gout attack. Those factors will include trauma, surgery, starvation, fatty food, dietary overindulgence, dehydration, medication, so those will be the loop or thiazide diuretics and then alcohol consumption. When evaluating these patients, it's important to take a look at their diet. You want to ask about what the patient is eating and what may have predisposed them to a gout attack. Bad foods are things that are considered purine rich food, red meat, seafood and poultry, any type of process foods or alcohol and a high fat or sodium diet. These are all things that may predispose that patient to the acute gout attack. Patient will often come in complaining of pain, swelling, redness and difficulty using the affected part. These attacks typically have sudden a onset and are likely to occur overnight or in the morning. 80% of the cases will involve one joint and it typically involves the distal or the more peripheral joint such as the first metatarsal phalangeal joint.


    It also has predilection for areas of repetitive microtrauma, areas that have prior degenerative disease, so an osteoarthritic condition and then a decreased temperature is likely to predispose the patient to acute gout attack [indecipherable] [00:06:19] some of the peripheral joints are more susceptible to these attacks. It's important to draw labs on these patients. Under CBC, you might see leukocytosis. The serum uric acid level should also be drawn. It's important to note that during an acute flare, they may not have an elevation of the serum uric acid level as those crystals are being precipitated out. Typically, what you are going to want to see is something that's above 6.8 mg/dL to be consistent with gout. It's possible that you might be able to see this better at baseline about two weeks post flare. The true diagnosis of gout will be done through a synovial fluid analysis. In that synovial fluid analysis, what you will see are needle shaped negatively birefringent crystals that are evident upon compensated polarized microscopy. There is a good picture on the right hand corner of the screen. Calcium pyrophosphate deposition disease would be similar except for those crystals are going to be rhomboid shaped as opposed to the needle shape crystal seen in gout. The radiographic features of gout mainly be seen after several flares. It's typically not going to be seen after an acute flare early in the process. What we would see in chronic gout would be periarticular erosions and so that would be the Martel's sign or rat bite lesions. You might also see subcortical cyst and other osseous erosions. In chronic longstanding gout, you might even also see tophi that's present. The treatment of acute gout typically revolves around nonsteroidal anti-inflammatory medications such as naproxen and indomethacin. For patients that have chronic kidney disease, cardiovascular disease or gastroesophageal reflux disease, it may be better idea to consider colchicine or the oral glucocorticoids.


    For colchicine, the dosing would be 1.2 mg p.o. once then 0.6 mg p.o. one hour later followed by 0.6 mg b.i.d. after day one. The oral glucocorticoid options are the Medrol Dosepak and use of prednisone. Finally, patients can get an intra-articular injection of glucocorticoid. For patients with chronic gout, we need to consider if they are over-producers or under-excretors. One of the things that's very important would be evaluating their lifestyle and making changes whether it's dietary or to their medications. Medications should be evaluated and consider potassium sparing diuretic. Many of the patients for their chronic condition will be placed on xanthine oxidase inhibitor or uricosuric. So like I said before, it's very important to sit down and actually counsel your patient on the dietary choices that they are making and here we just listed a few of the different foods that can be used that can help to decrease risk of gout attacks. Patient should also maintain a healthy hydration status to help prevent gout from forming. The next disease we are going to talk about is calcium pyrophosphate crystal deposition or CPPD disease. CPPD is also known as pseudogout because it gives a similar clinical appearance as gout. It is a crystal based deposition disease process which affects the joint and soft tissues around the joint structures. It's very common in older adults and affects both men and women. Many patients with CPPD disease are asymptomatic. Patient is going to present very similarly to acute gout attack with erythematous, edematous, painful and warm joints. It usually affects one joint but it can be multiple. The majority of the cases for CPPD will affect the knee as opposed to first metatarsal phalangeal joint as we see in gout.


    Radiographic findings for CPPD will consist of chondrocalcinosis. If you look at the bottom right hand picture, you can see that the new joint cartilage has started to become calcified. Other areas that could become calcified will be the joint capsule, synovial tissues, bursa, ligaments and tendinous attachments. Upon arthrocentesis of the involved joint, patient will have positive birefringent crystals by compensated polarized light microscopy. These are going to be rhomboid shaped crystals as opposed to the needle shaped sodium uric crystals seen in gout. Treatment will again be very similar for the acute gout attack using an arthrocentesis and glucocorticoid injection for the affected joint, nonsteroidal anti-inflammatory medications, colchicine or even glucocorticoid and again that's going to be prednisone or Medrol Dosepak. For chronic CPPD, patient can be put on colchicine 0.6 mg b.i.d. Next, we are going to talk about seropositive arthritis. In this case, it's going to be rheumatoid arthritis. Rheumatoid arthritis has been considered an autoimmune disorder but its true etiology remains unknown. It's a systemic and inflammatory disorder primarily affecting synovial joints and connective tissues. This disease process will progress from more peripheral joints to the joints of proximal. It affects about 1% of the population with annual incidents of 40 per 100,000. Women are more likely to be affected than men. In rheumatoid arthritis, you have inflammation of the synovium, which causes damage to the joint and the joint capsule. You will also see erosion of the cartilage and bone. Patients with rheumatoid arthritis are typically going to present with erythema, pain and swelling of the involved joint. Typically, the disease is symmetrical and will affect the hand, wrist and the forefoot. Patients are going to be complaining of tenderness upon palpation and joint range of motion.


    On palpation, the patient's joint may actually feel boggy, spongy or rubbery when you are trying to palpate around that swollen joint. This is going to be due to the synovial thickening and inflammation around the joint capsule itself. Patients are also going to be complaining of reduced grip and strength and they may have inability to hyperextend their toes. As the disease progresses, they are going to become chronica and is going to affect both the upper and lower extremity. In the upper extremity, you should look for what are called rheumatoid nodules which are commonly found around the elbow. Patients may also have ulnar drift, swan neck boutonniere deformities of their fingers. In the lower extremity, we are typically going to see a lateral drift to the toes and hallus valgus type deformity. You may also see a plantar subluxation of the metatarsal heads as the patient losses those collateral ligament and develop hammertoe deformities. This reverse buckling type of effect is going to lead to increase in plantar calluses and pain along the metatarsal phalangeal joint level. Patients can also develop heel pain related to bursitis and nerve entrapment. Pain also may be present upon eversion and inversion of the foot. So next, we are going to talk about laboratory findings for rheumatoid arthritis. For many patients that present with erythematous, edematous and painful joints, they are going to get a very similar laboratory workup. It's important for patients that have what looks to be septic joint that they have a synovial fluid analysis performed. It's also maybe more important for patients that have gout or pseudogout to have the synovial fluid analysis done. For patients with rheumatoid arthritis, it would be typical to see the CBC, ESR and CRP, rheumatoid factor, anti-CCP antibody test, ANA test, all performed to help rule in and rule out other arthritic disease.


    For patients with rheumatoid arthritis, white blood cell count may be elevated, especially during the inflammatory period. The hemoglobin and hematocrit may be decreased as this will be a form of anemia of chronic disease. ESR and CRP may be elevated but they probably won't be elevated to the point of 60 or 70 that we would expect in the case of osteomyelitis. Rheumatoid factors typically might be positive in cases up to 75% to 85%. We are also going to look for anti-CCP antibodies. If we do an ANA test, this test is typically going to be negative and this is a good test to help differentiate lupus from rheumatoid arthritis. Let's take a look at some of the radiographic findings for rheumatoid arthritis. As the disease progresses, you are going to see joint space narrowing most likely at the metatarsal phalangeal joint level. You may also start to see osseous erosions and if the osseous erosions are taking place in the medial side of that joint, the capsular ligaments may loosen and that's what going to result in the lateral drift of the toes and hammertoe deformities. You also, on the longstanding cases, may start to see joint subluxation as that disease process worsens. It's also likely that you are going to see periarticular osteopenia. The diagnosis of rheumatoid arthritis can be made when all the following are present. It will involve greater than three joints, a positive rheumatoid factor or anti-CCP, elevation of ESR or CRP, once the other diseases have been ruled out and if the duration of the symptoms is greater than six weeks. There is a classification criteria which was created in 2010 by the ACR and EULAR and I put a link to that website on the bottom of the page. With the management of the rheumatoid arthritis, early diagnosis initiation of therapy is very key. It's especially important for rheumatoid arthritis patients because the damage that's done to their joints is irreversible.


    You can see radiographic damages within the first two years with joint space narrowing and joint erosions on the plain film radiograph. It's also important to get the patient into the hands of an appropriate provider such as rheumatologist. Rheumatologist is going to be someone who is going to specialize in the management with different medication and kind of quarterbacking a team to make sure that the patient receives the optimal treatment. Nonsteroidal anti-inflammatory medication and corticosteroids can be used as needed for adjunctive treatment. Then physical and occupational therapy should be involved as well since most of these patients are going to have difficulty with joint range of motion or pain with some of their activities of daily living. It's also going to be important to manage any other medical comorbidities and to keep in mind that the patient needs to maintain a healthy diet, exercise, be compliant with their medications and then be compliant with followup appointment and any type of bracing or physical therapy needs. So next, we are going to take a look on some of the medications that might be used for management of rheumatoid arthritis. I think it's important to point out that these medications are probably going to be prescribed by their primary care physician or the rheumatologist. So we are going to look at some of the DMART or disease modified anti-rheumatic drugs. There are two different types of DMARTs and those are going to be the nonbiologics and then the biologic forms. The nonbiologics consist of methotrexate, hydroxychloroquine and sulfasalazine. The biologics, there is TNF alpha inhibitors, IL-1 antagonist and then some others that don't necessarily fit in to those first two groups. I think it's important to realize that when the patients are on some of these medications, they are going to have a difficulty fighting off these viral infections like hepatitis B, C or latent tuberculosis. So it's important that they get screening for these prior to initiation of this type of therapy.


    Next, we are going to talk about the seronegative arthritis. First will be psoriatic arthritis. Psoriatic arthritis is an inflammatory disease of the joints associated with the condition of psoriasis. It's the seronegative disease which affects women and men about equally. The typical age range for the patients is going to be between 30 and 50 years of age and it's going to affect one to two per 1000 of the general population. It's also going to affect about 30% of the patients that do have psoriasis. So next, we are going to talk about the objective findings for psoriatic arthritis. One of the first things to look for is whether the patient has other psoriatic lesions present. The presence of psoriatic lesions and asymmetrical joint pain should raise the suspicion for psoriatic arthritis. Next, in the integument exam, we should take a look at the nails. Often with psoriatic arthritis, we are going to see that there is nail pitting, hypertrophy and the lysis of nail plate from the nail bed. This could be very difficult to evaluate and differentiate from onychomycosis since they have the similar appearance. Patient is also going to be complaining of inflammation and tenderness of their infected joints. Typically, psoriatic arthritis is a disease of the small joint of hand and feet. So this will involve the distal IPJs of hands and feet. Patient might also be complaining of axial skeletal pain and especially sacroiliitis. Patient could also have heel pain or dactylitis which is a sausage toe appearance. Appearance of red, warm and swollen second toe which is asymmetrical should again raise the suspicion for arthritis such as psoriatic arthritis. Very important to remember that psoriatic arthritis is typically going to be an asymmetrical disease process. This is in contrast to rheumatoid arthritis where most of those symptoms are going to be found bilateral.


    Laboratory findings for rheumatoid arthritis are slightly different from those of psoriatic arthritis, but they do seem to be similar is that the patient also might have anemia in psoriatic arthritis. ESR and CRP for psoriatic arthritis will also be elevated but the rheumatoid factor will be negative. Anti-CCP antibodies typically won't be found and the ANA test should be negative. The HLA-B27 may be positive especially in those patients who have spondylitis. So let's take a look at the radiographic appearance for psoriatic arthritis. If you look at the image on the bottom right hand side of the screen, I'm going to draw your attention to the interphalangeal joint level. Let’s look especially close at bilateral hallux. At the IPJ of both hallux, you definitely see that there is erosive changes of the joint with joint space narrowing. This is going to be something that you see with psoriatic arthritis with erosive changes in the new bone formation typically the IPJ level. You are going to also see these findings present on the right second toe. It's also important to look at the metatarsal phalangeal joint level. You can see that these joints are relatively spared. This is going to be again one of the big differences between rheumatoid arthritis and psoriatic arthritis is that rheumatoid arthritis is going to involve the MTPJ where as psoriatic arthritis typically involves the interphalangeal joints. Some other more chronic findings that you might see will be the pencil in cup and telescoping appearance. Patients might also present with acroosteolysis, enthesis and various osteophytes. The diagnosis of psoriatic arthritis is going to depend upon radiographic findings, laboratory findings and then comparing all those in clinical findings help support the diagnosis. Treatment then is going to consist of referral to rheumatologist, probably the use of NSAIDs or DMARTs. It's recommended to avoid use of glucocorticoids since it does increase the risk for erythroderma or pustular psoriasis. Then to have the patient involved in physical therapy and occupational therapy.


    Next arthritides that we are going to discuss is reactive arthritis which is formerly known as Reiter's disease. So reactive arthritis is an arthritis that develops after there is infection somewhere else in the body. Some of the infectious organisms include Chlamydia, Yersinia, Salmonella, Shigella, campylobacter, E. coli, C. diff. and then Chlamydia, and pneumonia. Reactive arthritis typically affects young adults both men and women. The global incidence is 30 to 40 per 100,000 adults. Many of the cases will actually follow an outbreak of some type of enteric bacterial infection or 3% to 8% of patients with chlamydial infection may develop reactive arthritis. Patient with reactive arthritis will typically complain of a past medical history that includes things like diarrhea, urethritis or conjunctivitis. The patient's arthritic condition will usually develop about one to four weeks after the initial infection. The arthritis is typically going to be located in the lower extremity and can affect both the feet and ankles. Patient may also complain of low back pain and then tendon and ligament insertions. On physical exam, patient may also be found to have dactylitis, oral mucosal ulcers and nails that appear very similar to those in psoriatic arthritis. One of the hallmark findings that's linked to reactive arthritis is keratoderma blennorrhagica pictured in the bottom right hand corner. The patient workup for reactive arthritis should consist of several different lab components. Stool culture can be done to look for the enteric pathogen that may be causing the arthritic condition.


    Urine and general swab testing can also be completed looking for Chlamydia. It has also been seen that Chlamydia can be present in the scrapings off of conjunctiva in the case of conjunctivitis. HLA-B27 can be positive and may be positive in most cases. Rheumatoid factors will be negative and ESR and CRP may be elevated as with most of these inflammatory arthritic conditions. Radiographic imaging performed on these patients and many times will be looking for a heel spur with a fluffy periosteal reaction at one of the enthesis, especially the inferior portion of the calcaneus. Diagnosis of reactive arthritis is based on the clinical presentation as well as any associated laboratory or radiographic findings. For treatment, patients will typically be started on NSAID and can also be given glucocorticoids either in injectable or in oral form. Most patients will not require disease modifying antirheumatic drug and they will improve within three to five months on their own. There is a small number of patients that will have recurrence of prolong symptoms where advanced therapy may be warranted. Other treatment that can be provided would be immobilization of the affected part, physical therapy and then treatment of underlying infection. For patients that have general urinary infection, typically treatment will be doxycycline or azithromycin. Patients with enteric infection, they will be treated with fluoroquinolones or azithromycin and then the conjunctivitis can be treated with erythromycin ophthalmic ointment. So the last arthritides that we are going to be discussing today is ankylosing spondylitis. This is a chronic inflammatory disease to the axial skeleton. Patients are typically going to be presenting to the clinic complaining of back pain and neck pain.


    It's important that we talk about ankylosing spondylitis because some of these patients will be presenting to your clinic complaining of foot and ankle pain. The prevalence of ankylosing spondylitis in North America is 31.9 per 10,000. It does happen to affect males more than females. The age of onset is going to be a younger patient typically less than 40 to 45 years old. There is an increased risk of developing ankylosing spondylitis in patients who have a family member who is also affected with the disease. So patients are typically going to be complaining of low back and neck pain. But they could also be presenting and complaining of hip and shoulder pain or buttock pain. Like I said earlier, some patients will be presenting to clinic complaining of ankle pain and this could be present in about 40% of patients that have ankylosing spondylitis. Typically, the patient is also going to say that this pain improves with physical activity. It's important to keep in mind that there is other medical comorbidities that may go along with ankylosing spondylitis including inflammatory bowel disease and psoriasis. When evaluating the patient's posture, you may notice a hunchback type of appearance with forward stooping of the thoracic and cervical spine. There can be tenderness of the axial skeleton as well as with range of motion and tenderness of palpation of hip, knees, ankles, shoulder and sternoclavicular joints. You may see limited lumbar spine motion in anterior and lateral flexion and extension. When asked to breathe deeply, you may see limited chest expansion to 1 inch or less. Aside from evaluation of axial skeleton, there may be dactylitis which is present and enthesitis including the Achilles tendon, plantar fascia, costochondral junction, manubrium of sternum and sternoclavicular joints, superior iliac crest. So laboratory findings for ankylosing spondylitis are most likely going to show a positive HLA-B27 which is going to be positive in up to 90% to 95% of cases.


    Other lab that may be drawn and evaluated would be ESR and CRP which may show elevation or rheumatoid factor which will be negative, possibly anemia and then in the case of other medical comorbidities, an IgA may also be increased. There are several different radiographic features which may be present with ankylosing spondylitis. On the right hand side of the screen, there is a typical bamboo spine appearance. You might also see narrowing and ankylosis of the sacroiliac joint. It's also common to see spurring of the inferior, superior or posterior calcaneus. The treatment for ankylosing spondylitis will consist of physical therapy and some home exercise programs. Patients may also be on nonsteroidal anti-inflammatory medications or biologic disease modifying antirheumatic drugs. The traditional disease modifying antirheumatic drugs are not as effective as biologic medications. Glucocorticoid injections can also be of use for patients that are complaining of painful enthesitis. Okay, thank you very much. That concludes our lecture today covering arthritides and review of what we might see in the podiatric practice.

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