Diagnosis and differential diagnosis of rheumatoid arthritis. Literature review current through. May 2. 01. 7. It typically leads to deformity through the stretching of tendons and ligaments and destruction of joints through the erosion of cartilage and bone. If it is untreated or unresponsive to therapy, inflammation and joint destruction lead to loss of physical function, inability to carry out daily tasks of living, and difficulties in maintaining employment. What are the symptoms of reactive arthritis? The most common symptoms of reactive arthritis are arthritis, conjunctivitis, and urethritis. Circinate balanitis:A form of skin inflammation around the penis in males with Reiter's syndrome. The skin around the shaft and tip (glans) penis can become inflamed. Early recognition and treatment with disease- modifying antirheumatic drugs (DMARDs) is important in achieving control of disease and prevention of joint injury and disability. However, in patients with early disease, the joint manifestations are often difficult to distinguish from other forms of inflammatory polyarthritis. The more distinctive signs of RA, such as joint erosions, rheumatoid nodules, and other extraarticular manifestations, are seen primarily in patients with longstanding, poorly controlled disease but are frequently absent on initial presentation. This topic will review the approach to the diagnosis and differential diagnosis of RA. The clinical features of this disorder, its extraarticular manifestations, and laboratory markers that are clinically useful in the diagnosis of RA are discussed in detail separately. The initial evaluation of such patients requires a careful history and physical examination, along with selected laboratory testing to identify features that are characteristic of RA or that suggest an alternative diagnosis. The absence of other conditions or symptoms suggesting an alternative diagnosis, such as psoriasis, inflammatory bowel disease (IBD), or a systemic rheumatic disease such as systemic lupus erythematosus (SLE), helps to exclude other disorders. Symptoms of arthritis that have been present for a short time (for example, less than six weeks) may well be due to an acute viral polyarthritis rather than to RA. The longer symptoms persist, the more likely the diagnosis of RA becomes. Thus, in patients presenting very early, close observation with frequent follow- up appointments is required, with repeated serologic analysis for anti- cyclic citrullinated peptide (CCP) antibodies, rheumatoid factor (RF), and acute phase reactants. In a minority of patients, several such visits are required before the differential diagnosis between RA and viral arthritis becomes established. The results of both tests are informative, since a positive result for either test increases overall diagnostic sensitivity, while the specificity is increased when both tests are positive. Despite this, both tests are negative on presentation in up to 5. RA. In patients with a positive ANA, anti- double stranded DNA and anti- Smith antibody testing should also be performed; these antibodies have high specificity for SLE. Liver and kidney testing abnormalities indicate a disorder other than RA; if caused by comorbid conditions, they may affect therapeutic choices or drug dosing. Conditions by signs and symptoms (A-D) Conditions by signs and symptoms (E-I) Conditions by signs and symptoms (J-O) Conditions by signs and symptoms (P-R). Rheumatoid arthritis (RA) is a symmetric, inflammatory, peripheral polyarthritis of unknown etiology. It typically leads to deformity through the stretching of. Dermatologic Signs of Systemic Disease Online Medical Reference - from diagnosis through treatment options. Co-authored by Lisa M. Grandinetti and Kenneth J. Balanitis is a medical condition in which the head of the penis becomes inflamed, red, swells, and has a rash, irritation, or pain. Balanitis symptoms may include an. T his is an arthritis characterised by an arthritis of the sacroiliac joints and the spinal ligaments, leading to progressive, ascending spinal stiffening and spinal. Hyperuricemia may prompt additional efforts, including arthrocentesis and crystal search, to exclude gout; polyarticular gout can infrequently be mistaken for RA. However, characteristic joint erosions may be observed in patients presenting with symptoms for the first time and, hence, aid in diagnosis. Additionally, in patients with other disorders, such as psoriatic arthritis, spondyloarthropathy, gout, or chondrocalcinosis, radiographic changes more characteristic of these conditions may point to an alternative diagnosis. In areas endemic for Lyme disease, we perform serologic studies for Borrelia as well. Synovial fluid testing should include a cell count and differential, crystal search, and Gram stain and culture. Synovial fluid analysis should also be obtained to exclude infection or crystalline arthropathy in patients who undergo glucocorticoid injections for symptomatic relief. However, MRI and ultrasound are more sensitive than radiography at detecting changes resulting from synovitis and may be helpful in establishing the presence of synovitis in patients with normal radiographs and uncertainty regarding either the diagnosis or the presence of inflammatory changes, such as patients with obesity or subtle findings on examination. The wrists are also commonly involved, as are the metatarsophalangeal (MTP) joints in the feet, but any upper or lower extremity joint may be affected. Symmetric polyarthritis, particularly of the MCP, MTP, and/or PIP joints, strongly suggests RA. Although distal interphalangeal (DIP) joint disease can occur in patients with RA, DIP involvement strongly suggests a diagnosis of osteoarthritis or psoriatic arthritis. Their diagnostic utility is limited by their relatively poor specificity, since they are found in 5 to 1. SLE, virtually all patients with mixed cryoglobulinemia (usually caused by hepatitis C virus . Higher titers of RF (at least three times the upper limit of normal) have somewhat greater specificity for RA. The prevalence of RF positivity in healthy individuals rises with age. Anti- CCP antibodies have a similar sensitivity to RF for RA but have a much higher specificity (9. The specificity is greater in patients with higher titers of anti- CCP antibodies (at least three times the upper limit of normal). Another test, anti- mutated citrullinated vimentin, gives similar results to anti- CCP and is used as an alternative in some laboratories . Normal acute phase reactants may occur in untreated patients with RA, but such findings are very infrequent. The degree of elevation of these acute phase reactants varies with the severity of inflammation. As an example, an ESR of 5. RA. By comparison, an ESR of 2. Although increased levels of acute phase reactants are not specific for RA, they are often useful for distinguishing inflammatory conditions from noninflammatory disorders that present with musculoskeletal symptoms (eg, osteoarthritis or fibromyalgia). Examples include the following. Such patients with seronegative RA differ from anti- CCP- positive patients genetically and in their environmental risks, disease severity, and clinical responsiveness to some medications . Additional research is needed to better characterize this population. These criteria were developed for the classification of patients with RA for the purpose of epidemiologic studies and clinical trials, not primarily for clinical diagnosis. Nevertheless, the same features that are of value in classification tend to be useful for the purpose of diagnosis in clinical practice. Further study is required to establish their utility as diagnostic criteria in general practice. The 1. 98. 7 ACR criteria were formulated to distinguish patients with established rheumatoid arthritis (RA) from patients with other defined rheumatic diseases; the 2. ACR/EULAR criteria for RA focused on identifying the factors, among patients newly presenting with undifferentiated inflammatory synovitis, which could allow for the identification of patients for whom the risk of symptom persistence or structural damage is sufficient to be considered for intervention with disease- modifying antirheumatic drugs (DMARDs) . The highest score achieved in a given domain is used for this calculation. These domains and their values are. A patient was classified as having RA if at least four of these seven criteria were satisfied; four of the criteria must have been present for at least six weeks: morning stiffness, arthritis of three or more joint areas, arthritis of the hands, and symmetric arthritis. Rheumatoid factor (RF) was included as a criterion, but anti- cyclic citrullinated peptide (CCP) antibody testing was not available at that time. The other two criteria were rheumatoid nodules and radiographic erosive changes typical of RA, but these are generally not present in the early stages of disease. Thus, while these criteria were very good at separating inflammatory from noninflammatory arthritis, the major drawback of the 1. RA . On the other hand, the criteria did not require any exclusions, and patients could initially fulfill the diagnostic criteria but occasionally evolve into other diagnoses, particularly systemic lupus erythematosus (SLE), Sj. Features of some disorders that are included in the differential diagnosis of RA are shown in the table (table 2). However, the syndrome is usually short- lived, lasting only from a few days to several weeks, and rarely beyond six weeks. Hepatitis C virus (HCV) can cause a polyarthritis or oligoarthritis in a minority of patients, but is more commonly associated with arthralgias. Serologic testing can help identify patients with HBV, HCV, or human parvovirus B1. Among all of the viruses that can cause arthritis, the alphaviruses are unusual because nearly all symptomatic infections in adults result in joint symptoms. The incubation period lasts from several days to three weeks; infection is typically associated with triad of fever, arthritis, and rash . However, all aspects of the triad may not be present, thereby making the diagnosis difficult. One such alphavirus, Chikungunya, has become a global disease with increasing world travel and has caused large outbreaks in Italy, India, Indian Ocean islands, and in the Caribbean region and surrounding countries . Patients with more persistent disease can mimic seronegative RA clinically to a sufficient degree to satisfy the 2. RA if the initial symptoms of fever and rash and history of travel to an endemic region are not appreciated . Serologic studies can help to document exposure to the Chikungunya virus. The diagnosis of alphavirus infection can be made by appropriate serologic testing in travelers from endemic areas with persistent arthritic symptoms. These infections are sometimes associated with the presence of RFs (usually in low titer), antinuclear antibodies (ANA), and elevated acute phase reactants.
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