ENTEROPATHIC ARTHRITIS
Both peripheral and axial arthritis may be associated with the inflammatory bowel diseases (IBD) of ulcerative colitis or Crohn’s disease. The arthritis can occur after or before the onset of intestinal symptoms. Peripheral arthritis is episodic and asymmetric; it most frequently affects knee and ankle. Attacks usually subside within several weeks and characteristically resolve completely without residual joint damage. Enthesitis (inflammation at insertion of tendons and ligaments into bone) can occur with manifestations of “sausage digit,” Achilles tendinitis, plantar fasciitis. Axial involvement can manifest as spondylitis and/or sacroiliitis (often symmetric). Laboratory findings are nonspecific; rheumatoid factor (RF) absent; only 30–70% HLA-B27 positive; radiographs of peripheral joints usually normal; axial involvement is often indistinguishable from ankylosing spondylitis.
TREATMENT Enteropathic Arthritis
Directed at underlying IBD; NSAIDs may alleviate joint symptoms but can precipitate flares of IBD; sulfasalazine may benefit peripheral arthritis; treatment of Crohn’s disease with infliximab or adalimumab has improved arthritis.
WHIPPLE’S DISEASE
Characterized by arthritis in up to 75% of pts that usually precedes appearance of other symptoms. Usually oligo- or polyarticular, symmetric, transient but may become chronic. Joint manifestations respond to antibiotic therapy.
NEUROPATHIC JOINT DISEASE
Also known as Charcot’s joint, this is a severe destructive arthropathy that occurs in joints deprived of pain and position sense; may occur in diabetic neuropathy, tabes dorsalis, syringomyelia, amyloidosis, spinal cord or peripheral nerve injury. Distribution depends on the underlying joint disease. Joint effusions are usually noninflammatory but can be hemorrhagic. Radiographs can reveal either bone resorption or new bone formation with bone dislocation and fragmentation.
TREATMENT Neuropathic Joint Disease
Stabilization of joint; surgical fusion may improve function.
RELAPSING POLYCHONDRITIS
An idiopathic disorder characterized by recurrent inflammation of cartilaginous structures. Cardinal manifestations include ear and nose involvement with floppy ear and saddlenose deformities, inflammation and collapse of tracheal and bronchial cartilaginous rings, asymmetric episodic nonde-forming polyarthritis. Other features can include scleritis, conjunctivitis, iritis, keratitis, aortic regurgitation, glomerulonephritis, and other features of systemic vasculitis. Onset is frequently abrupt, with the appearance of 1–2 sites of cartilaginous inflammation. Diagnosis is made clinically and may be confirmed by biopsy of affected cartilage.
TREATMENT Relapsing Polychondritis
Glucocorticoids (prednisone 40–60 mg/d with subsequent taper) may suppress acute features and reduce the severity/frequency of recurrences. Cytotoxic agents should be reserved for unresponsive disease or for pts who require high glucocorticoid doses. When airway obstruction is severe, tracheostomy is required.
HYPERTROPHIC OSTEOARTHROPATHY
Syndrome consisting of periosteal new bone formation, digital clubbing, and arthritis. Most commonly seen in association with lung carcinoma but, also occurs with chronic lung or liver disease; congenital heart, lung, or liver disease in children; and idiopathic and familial forms. Symptoms include burning and aching pain most pronounced in distal extremities. Radiographs show periosteal thickening with new bone formation of distal ends of long bones.
TREATMENT Hypertrophic Osteoarthropathy
Identify and treat associated disorder; aspirin, NSAIDs, other analgesics, vagotomy, or percutaneous nerve block may help to relieve symptoms.
FIBROMYALGIA
A common disorder characterized by chronic widespread musculo-skeletal pain, aching, stiffness, paresthesia, disturbed sleep, and easy fatigability along with multiple tender points. More common in women than in men. Diagnosis is made clinically; evaluation reveals soft tissue tender points but no objective joint abnormalities by exam, laboratory, or radiograph.
TREATMENT Fibromyalgia
Pregabalin, duloxetine, and milnacipran have shown benefit for fibromyalgia. Benzodiazepines or tricyclics for sleep disorder, local measures (heat, massage, injection of tender points), NSAIDs.
POLYMYALGIA RHEUMATICA (PMR)
Clinical syndrome characterized by aching and morning stiffness in the shoulder girdle, hip girdle, or neck for >1 month, elevated ESR, and rapid response to low-dose prednisone (15 mg qd). Rarely occurs before age 50; more common in women. PMR can occur in association with giant cell (temporal) arteritis, which requires treatment with higher doses of prednisone. Evaluation should include a careful history to elicit Sx suggestive of giant cell arteritis (Chap. 170); ESR; labs to rule out other processes usually include RF, ANA, CBC, CPK, serum protein electrophoresis; and renal, hepatic, and thyroid function tests.
TREATMENT PMR
Pts rapidly improve on prednisone, 10–20 mg qd, but may require treatment over months to years.
OSTEONECROSIS (AVASCULAR NECROSIS)
Caused by death of cellular elements of bone, believed to be due to impairment in blood supply. Frequent associations include glucocorticoid treatment, connective tissue disease, trauma, sickle cell disease, embolization, alcohol use, and HIV disease. Commonly involved sites include femoral and humeral heads, femoral condyles, proximal tibia. Hip disease is bilateral in >50% of cases. Clinical presentation is usually the abrupt onset of articular pain. Early changes are not visible on plain radiograph and are best seen by MRI; later stages demonstrate bone collapse (“crescent sign”), flattening of articular surface with joint space loss.
TREATMENT Osteonecrosis
Limited weight-bearing of unclear benefit; NSAIDs for Sx. Surgical procedures to enhance blood flow may be considered in early-stage disease but are of controversial efficacy; joint replacement may be necessary in late-stage disease for pain unresponsive to other measures.
PERIARTICULAR DISORDERS
BURSITIS
Inflammation of the thin-walled bursal sac surrounding tendons and muscles over bony prominences. The subacromial and greater trochanteric bursae are most commonly involved.
TREATMENT Bursitis
Prevention of aggravating conditions, rest, NSAIDs, and local glucocorticoid injections.
TENDINITIS
May involve virtually any tendon but frequently affects tendons of the rotator cuff around shoulder, especially the supraspinatus. Pain is dull and aching but becomes acute and sharp when tendon is squeezed below acromion.
TREATMENT Tendinitis
NSAIDs, glucocorticoid injection, and physical therapy may be beneficial. The rotator cuff tendons or biceps tendon may rupture acutely, frequently requiring surgical repair.
CALCIFIC TENDINITIS
Results from deposition of calcium salts in tendon, usually supraspinatus. The resulting pain may be sudden and severe.
ADHESIVE CAPSULITIS (“FROZEN SHOULDER”)
Results from conditions that enforce prolonged immobility of shoulder joint. Shoulder is painful and tender to palpation, and both active and passive range of motion is restricted.
TREATMENT Adhesive Capsulitis
Spontaneous improvement may occur; NSAIDs, local injections of glucocorticoids, and physical therapy may be helpful.
For a more detailed discussion, see Taurog JD: The Spondyloarthritides, Chap. 325, p. 2774; Crofford LJ: Fibromyalgia, Chap. 335, p. 2849; Langford CA, Mandell BF: Arthritis Associated With Systemic Disease, and Other Arthritides, Chap. 336, p. 2852; Langford CA, Gilliland BC: Periarticular Disorders of the Extremities, Chap. 337, p. 2860; and Langford CA: Relapsing Polychondritis, Chap. 328, p. 2802, in HPIM-18.