Transcript Achy shoulders and a very high CRP
Achy shoulders and a very high CRP
Sarah Tansley Rheumatology, Clinical Fellow
Case discussion
A case of polymyalgic onset rheumatoid arthritis was discussed – details removed for confidentiality purposes.
PMR diagnosis
Core Inclusion criteria
Age > 50 Bilateral shoulder or pelvic girdle aching or both Morning stiffness >45 minutes Evidence of acute phase response No active cancer, active infection or active GCA
No urgency to start steroids
first – can investigate
Factors which Increase the likelihood of a non-PMR diagnosis Age <60 years Chronic Onset Lack of shoulder involvement Lack of inflammatory stiffness Normal or very high CRP Peripheral arthritis Systemic symptoms, weight loss, neurological signs Incomplete or non-response to steroids
15mg Prednisolone should result in >70% improvement within 1 week and normalisation of inflammatory markers within 4 weeks
Who to refer
BSR guidelines recommend specialist referral when Age <60 Chronic onset >2 months Lack of shoulder involvement Lack of inflammatory stiffness Prominent systemic features; weight loss, night pain, neurological signs Features of other rheumatic disease Normal or extremely high acute phase response Treatment dilemmas (inadequate response to steroids, inability to reduce steroids, contraindication to steroids etc)
RA diagnosis
Aim for early diagnosis and treatment but lack of features of established disease can cause difficulty Considerable variability in presenting symptoms and lab results History Polyarticular involvement –may be small number of joints initially Morning stiffness (>30 minutes) suggests inflammatory joint pain Chronicity Examination Joint tenderness MCP, MTP, wrists RA nodules, not usually seen until later Upper and lower extremity involvement
Synovitis
Rheumatoid Arthritis Investigations
No single diagnostic test Serology RF • • • • Positive in 70-80% of patients with RA May be negative, especially early Also seen in other conditions eg Sjogrens Syndrome Positive in 5-10% of healthy individuals Anti- CCP Abs • • As sensitive Much more specific
Rheumatoid Arthritis Investigations
Inflammatory markers Non-specific Useful for distinguishing inflammatory conditions from non-inflammatory Full blood count Anaemia of chronic disease, leucocytosis, thrombocytosis Radiology Erosions of cartilage and bone Presence more useful diagnostically with increasing duration of disease
Radiology
ACR/EULAR classification criteria
Score Designed to classify patients as RA earlier for purpose of clinical trials – not diagnostic criteria Still useful, several differences from 1987 criteria which aimed to classify people with established disease Target population At least 1 joint with definite synovitis/swelling Synovitis not better explained by another disease Score >6 classified as RA
Joint Involvement
1 large 2-10 large 1-3 small 4-10 small >10 joints
Serology
Negative RF
&
anti-CCP Ab Low positive RF
or
anti-CCP Ab High positive RF
or
anti-CCP Ab
Acute Phase Reactants
Normal CRP
&
ESR Abnormal CRP
or
ESR
Duration of Symptoms
< 6 weeks >6 weeks 0 2 3 0 1 2 3 4 0 1 0 1
Polymyalgic onset RA
Bajocchi et al 2000
LO-RA vs YO-RA • Polymyalgic symptoms more common in LO RA • Higher frequency of shoulder involvement in LO RA
Lopez-Hoyos et al 2004
Anti-CCP Abs in differential diagnosis of RA vs PMR • 65% LO RA anti-CCP Ab +ve • • No PMR patients anti-CCP Ab +ve Polymyalgic onset RA 2/10 anti-CCP +ve
Polymyalgic onset RA
Gran, Mykebust 1999 Incidence and Characteristics of peripheral arthritis in PMR & TA • • 231 patients prospectively studied 1987-1993 All ?PMR/TA in Norwegian county referred to rheumatology before treatment • Followed throughout the disease course 187 ‘pure’ PMR 38.5% developed peripheral arthritis 11 developed RA (4.8% 6 female and 5 male)
Polymyalgic RA
Mean duration of PMR at RA diagnosis was 63.2 months 5/8 patients had erosive x-ray changes 6/11 patients had positive RF (all negative initially) Mean CRP higher at diagnosis among those who developed arthritis (88.6 vs 59.7)
Polymyalgic onset RA
Pease et al 2009 Prospective study of 147 patients presenting with PMR & 142 patients with LO-RA Reviewed accuracy of initial diagnosis • • 23% PMR patients had peripheral synovitis In contrast to seronegative LO-RA, PMR patients younger, myalgia more frequent, PIP/MCP/wrist arthritis less frequent • Combination of wrist + MCP and/or PIP highly suggestive of RA
Polymyalgic onset RA
Pease et al 2005 349 patients with new onset LO-RA, PMR or TA >60 yrs • • 9/171 initially diagnosed PMR changed to LO-RA All 9 dependant on higher steroid dose than typically expected for their stage of disease • Initially synovitis suppressed by steroids but returned when dose lowered • Initial plasma viscosity higher in this group (mean of 2.0 vs 1.86) • Difficulty to distinguish may lead to delay in correct diagnosis (average 13 months)
Summary
Several challenges in diagnosing RA, particularly early in the disease course Variety of possible presentations Polymyalgic symptoms are common in elderly onset RA May lead to diagnostic delay No single diagnostic test; clinical history and examination important