Test your diagnostic knowledge: What is your top differential diagnosis for each of these patients?
Clinical Scenario #1- A 40 year old, healthy male presents with abrupt onset, non-traumatic excruciating pain and swelling affecting his right great toe.
Clinical Scenario #2- A 31 year old female presents with pain in her right hand/ wrist and left knee and a curious butterfly rash on her face. Incidentally, she also has a low-grade fever from “the flu”.
Most of us could hit the first easy lob out of the park with “Gout”. Many of us could at least get on base with the slightly trickier second pitch of “Lupus”. But how many of us could hit a big league curveball called “Polymyositis”? Chiropractors are exceptional at identifying biomechanical problems, but, we have less experience with rheumatologic disorders and can sometimes overlook these less common diagnoses. When a patient is not responding to manual therapy we should consider rheumatologic diagnoses. Check out the following infographic that summarizes the most common inflammatory arthropathies that will present to your office.
Laminate and store this chart in your treatment room for quick reference next time a patient presents with atypical, diffuse joint or muscle pain. Remember that many of these conditions have similar presentations including, “flu-like” symptoms, fever, malaise, myalgias, joint pain and swelling with morning/ inactivity stiffness.
Hopefully this is information will help you maintain clinical vigilance for these sometimes overlooked presentations. And for a more detailed refresher, you can check out the following synopses of the most common rheumatologic diseases:
Rheumatoid Arthritis (RA)
Rheumatoid arthritis is a chronic synovial inflammatory disorder that typically affects small joints in the hands and feet. Rheumatoid arthritis is an autoimmune disorder which attacks the synovium causing painful swelling and eventually bony erosion and joint deformity. The cause of RA is unknown. RA can affect anyone, but is more common in middle-aged females. RA typically affects joints bilaterally and symmetrically. The disease often begins slowly with minor joint pain. Morning stiffness with warm, swollen, tender joints is common. The symptoms seem to be aggravated by inactivity. RA is often associated with Sjogern’s syndrome (dry mucus membranes). RA specific lab work may include RA factor and anti-CCP antibody test.
Ankylosing Spondylitis (AS)
Ankylosing spondylitis, affecting 1 in 2000 persons, is a chronic inflammatory disorder of the spine and pelvis, particularly the sacroiliac joints. The specific cause of AS is unknown, but a genetic factor seems to be present. The disease starts with intermittent lower back pain and stiffness following inactivity especially in the morning. Nighttime pain, which may wake the patient from sleep is common. The pain typically improves with light activity. Bony fusion usually begins in the sacroiliac joints but over time may involve part or all of the spine as well as the rib cage. Sacroiliac fusion will result in a “waddling” gait. Typical age of onset is 20-40 years, but it may begin before age 10. The male to female ratio is 3:1. It affects males more commonly and more severely than females. AS specific lab work includes HLA-B27, which is positive in 90% of AS patients.
Psoriatic arthritis is an inflammatory arthropathy that affects approximately one in 20 psoriasis suffers. In most cases, psoriasis precedes the arthritis, but psoriatic arthritis may affect people who do not suffer with psoriasis. The cause of psoriatic arthritis is unknown, but a genetic component is suspected. Psoriatic arthritis has a variable presentation sometimes mildly affecting only the fingers and toes and other times, more severely affecting spinal joints, particularly the lumbar, sacroiliac and cervical regions. X-rays commonly show marginal erosions similar to those of rheumatoid arthritis. The disease is generally less symmetrical than rheumatoid arthritis. Typical age of onset is 35-45 years and has an equal male to female distribution. HLA-B27 is positive in 40% of psoriatic arthritis patients.
Reactive Arthritis/Reiter’s Syndrome
Reactive arthritis, formerly known as Reiter’s syndrome, is an acute non-purulent arthritis secondary to enteric or urogenital infections. Reactive arthritis and ankylosing spondylitis may appear nearly identical clinically. Reactive arthritis commonly affects the sacroiliac joints, lumbar spine and lower extremities, asymmetrically.
Three characteristic features of reactive arthritis are inflammation of the; joints, urinary tract and eyes. A fourth more recently recognized feature includes ulcerations of the skin and mouth. The disease often produces “flu like” symptoms include low-grade fever, malaise, myalgias and lower back pain. Symptoms increase with rest or inactivity. Most patients have severe symptoms lasting weeks to months. Approximately 15-50% have recurrent bouts, and chronic arthritis occurs in 15-30% of cases. Reactive arthritis primarily affects men between the ages of 20 and 40. It has a 5:1 male to female distribution. It rarely affects African Americans. HLA-B27 is positive in 80% of reactive arthritis patients.
Enteropathic arthritis is a chronic inflammatory arthropathy associated with inflammatory bowel disease (IBD), the two most common of which are Ulcerative colitis and Crohn’s disease. Approximately 20% of IBD sufferers will be affected with enteropathic arthritis. Although the exact mechanism is unknown, the disease is though to be triggered from abnormal bowel permeability allowing microorganisms to enter the blood stream, triggering an autoimmune arthropathy. This hypothesis is not confirmed. Symmetric involvement of the lower extremity is a common presentation. The severity of the disease often correlates with the course of the IBD. The disease is often self limiting, but recurrences are common. It does not seem to have a predilection for any specific age or gender. HLA-B27 is positive in 30% of enteropathic arthritis patients.
Systemic Lupus Erythematosus (SLE)
SLE is a chronic autoimmune disorder affecting the skin joints and organs. The underlying cause of the disease is not fully understood. Symptoms vary from patient to patient and are often relapsing and remitting. Nearly all patients present with joint pain and swelling- typically involving the fingers, hands, wrists and knees. In contrast to rheumatoid arthritis, SLE may be asymmetrical with pain that is disproportionate to swelling. “Flu-like” symptoms often accompany new or recurrent SLE exacerbations. Three characteristic symptoms of SLE include; butterfly/ malar rash over the cheeks and nasal bridge (50% of cases), photosensitivity of the skin, discoid lesions– usually on sun-exposed areas. Including these common presenting symptoms, there are 11 recognized diagnostic criteria of SLE. The presence of 4 of the following 11 criteria yield a sensitivity of 85% and a specificity of 95% for SLE:
- Serositis (pleurisy or pericarditis)
- Oral ulcers
- Nonerosive arthritis affecting two or more peripheral joints
- Blood disorder (abnormal CBC)
- Abnormal urinalysis (proteinuria or cellular casts)
- Positive ANA
- Immunologic phenomena
- Neurologic disorders (seizures or psychosis),
- Malar rash
- Discoid rash (erythematous raised-rimmed lesions with scarring) Patients who have only skin symptoms are diagnosed with “Discoid lupus”
Scleroderma or “systemic sclerosis” results from an overproduction and accumulation of collagen in body tissues. The disease may be “Localized”-affecting only the skin, or “Systemic”- affecting organs and vessels as well. The exact cause of scleroderma is unknown but an autoimmune mechanism is present. Scleroderma symptoms vary depending on which organ systems are affected, and diagnosis can be difficult because some of the early symptoms are non-specific to scleroderma. The most prevalent signs and symptoms of scleroderma include Raynaud’s phenomenon, GERD and thickened, tight or shiny skin on the hands, face or mouth. Age of onset is typically between 30 and 50. The disease is four times more common in women than men and is more common in African Americans and Native Americans.
One subtype of “Systemic” scleroderma is “CREST syndrome”, also called “Limited scleroderma”. Symptoms of this less aggressive variant include: Calcium deposition in connective tissue, Raynaud’s phenomenon, Esophageal dysmotility/ GERD, Sclerodactyly-tight, thickened or shiny skin commonly affecting the fingers or toes, and Telangiectasis-red vascular lines on hands and face.
Lyme disease is caused by bites from tiny black-legged ticks infected with a bacteria called Borrelia burgdorferi. Lyme disease was first reported in the United States in the town of Old Lyme, Connecticut in 1975. Lyme disease infections have been reported in all 50 states but 95% of cases originate in 12 states: the Northeastern states from Virginia to Maine, the North central states, mostly Wisconsin and Minnesota and Northern California. In certain areas of New York where Lyme disease is common, over half of the ticks are infected. In most cases, a tick must be attached to your body for 24-36 hours to spread to the bacteria to your blood. Symptoms of early localized Lyme disease begin days or weeks after infection. Initial symptoms are similar to the flu, and 75% of the time will include a “bulls eye” rash with a flat or slightly raised red spot at the site of tick bite and a clear area in the center of the rash. The rash is often expansile and resolves without treatment in about a month. Early symptoms are relapsing and remitting but if left untreated, 60% of patients will eventually develop pain and swelling of the large joints. Lyme disease typically affects one or two joints at a time with the knee involved most commonly. Painful episodes are separated by periods of complete remission. Chronic Lyme disease may result in paresthesias, weakness, paralysis of facial muscles and difficulty speaking. The most commonly used Lyme-specific lab test is the ELISA for Lyme disease. A Western blot test is done to confirm ELISA results.
Septic arthritis is a joint infection secondary to an infection elsewhere in the body, most commonly, an upper respiratory tract or urinary tract infection. Less commonly, a puncture wound, drug injection or surgical puncture near a joint may precipitate the infection. Pathogens may be viral but are much more commonly bacterial. Bacterial septic arthritis is commonly classified as either gonococcal or non-gonococcal. Non-gonococcal arthritis is mostly commonly caused by staph or strep bacteria. Patients with an infected joint typically present with a triad of; low-grade fever (40-60%), pain (75%), and impaired range of motion. Symptoms may develop over a period of days to weeks. Young children and elderly are most likely to develop septic arthritis. 45% of septic arthritis patients are older than 65 years old. In adults, the knee is the most common site of infection, and in children, the hip joint is most likely to be affected.
The following conditions are known risk factors for developing septic arthritis: arthroplasty, diabetes, rheumatoid arthritis, IV drug use, immunosuppressive therapy, recent joint injury or surgical procedure. Lab evaluation includes joint aspiration and culture as well as blood culture.
Gout is a complex form of arthritis characterized by sudden, severe attacks of pain and swelling in joints-most commonly the great toe. Gout occurs when excess uric acid accumulates in the body. This may occur because of increased uric acid production or the inability for the kidneys to clear uric acid from the blood stream. Over time, increased uric acid levels in the blood lead to deposits of monosodium urate crystals in and around the joints. These crystals can provoke severe painful gout attacks. Certain foods, that are rich in purines such as anchovies, sardines, shellfish, red meat, organ meat, and alcohol may increase uric acid levels and precipitate gout attacks. Symptoms are generally monoarticular and most commonly involve the great toe and less commonly the knee or ankle joints. The pain of gout often starts suddenly and is described as crushing or excruciating. Joint palpation will reveal exquisite tenderness, warmth and swelling. Initial attacks may last for days. Half of first-time gout patients will suffer a subsequent attack, and additional attacks often last longer. Gout is more common in men than women. Co-morbidities, including hypertension, diabetes, renal insufficiency, elevated triglycerides or cholesterol, diabetes, obesity, and early menopause, are associated with a higher incidence of gout. Lab tests to determine the presence of gout include synovial fluid analysis demonstrating the presence of uric acid crystals and high uric acid levels in the blood, although not everyone with high uric acid levels in the blood will suffer from gout.
Pseudogout or Calcium Pyrophosphate Dihydrate (CPPD) crystal deposition disease is characterized by sudden painful swelling in one or more joints. Pseudogout is aptly named because of its similarity to gout. Gout is caused by uric acid crystals. Pseudogout is caused by calcium pyrophosphate crystals accumulating in joints. While gout has a tendency to affect the great toe, pseudogout typically affects the knees but may also develop in ankles, wrists and elbows. Symptoms include severe pain, warmth and swelling of a joint. Pseudogout typically occurs in older adults and affects men and women equally.
Polymyalgia Rheumatica (PMR)
Polymyalgia rheumatica is an inflammatory disorder that causes muscle pain and stiffness, primarily involving the proximal limb regions. Its cause is unknown, but the disease often co-exists with Giant-cell arteritis. Polymyalgia rheumatica and Giant-cell arteritis may in fact be variations of the same disease since there is significant overlap and concurrence.
Symptoms of polymyalgia rheumatica include “flu-like” aches and pains involving the shoulders, neck, trunk, back and hips. Fever, weakness, myalgia, inactivity stiffness and limited range of motion are common. PMR occurs in older adults and very rarely in people younger than age 50. The average age of onset of symptoms is 70, and women are affected twice as often as men. The disease often develops very quickly. Lab work should search for the presence of inflammation, including elevated ESR and CRP levels.
Polymyositis is a chronic inflammatory myopathy causing weakness of skeletal muscles. It is hypothesized to be an unidentified autoimmune disorder. Polymyositis signs and symptoms usually develop gradually over weeks or months and include progressive symmetrical muscular weakness, difficulty swallowing, difficulty speaking, mild joint and muscle tenderness, fatigue and shortness of breath. Polymyositis typically affects the muscles closest to the trunk, particularly those in the hips, thighs, shoulders, upper arms and neck. Polymyositis may occur at any age but most often affects middle-aged adults. It is more common in the African American population, and women are affected twice as often as men. Remission of symptoms is rare, and tests to assist with the diagnosis include CPK, urine myoglobin, serum aldolase, EMG/NCV and muscle biopsy. A similar condition called Dermatomyositis causes a reddish-purple rash on the face or trunk.
About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.
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