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Classification &

Differential Diagnosis
of
Rheumatic Diseases
by
Dr. Ibtessam Abd El Hamid
Professor of Internal Medicine
Rheumatology unit
Faculty of Medicine
Alexandria University
Classification of rheumatic diseases
1-Diffuse
1-Diffuse connective
connective tissue
tissue diseases:
diseases:

a)
a) Rheumatoid
Rheumatoid arthritis
arthritis
b)
b) Systemic
Systemic lupus
lupus erythematosus
erythematosus
c)
c) Progressive
Progressive systemic
systemic sclerosis
sclerosis
d)
d) Polymyositis/
Polymyositis/ Dermatomyositis
Dermatomyositis
e)
e) Vasculitis
Vasculitis
2-Sero-negative
2-Sero-negative spondyloarthropathies:
spondyloarthropathies:
a)
a) Ankylosing
Ankylosing spondylitis
spondylitis
b)
b) Reiter's
Reiter's syndrome
syndrome (Reactive
(Reactive arthritis)
arthritis)
c)
c) Psoriatic
Psoriatic arthritis
arthritis
d)
d) Enteropathic
Enteropathic arthritis
arthritis
 3-Degenerative joint disease (osteoarthritis)
4- Infective arthritis :

e.g.

Septic arthritis
T.B.
Rheumatic fever
Hepatitis B & C
AIDS
5-Metabolic
5-Metabolic and
and endocrine
endocrine diseases:
diseases: (associated
(associated
with
with rheumatic
rheumatic disease)
disease)
a)
a) Crystal-induced
Crystal-induced arthropathy
arthropathy (gout
(gout and
and
pseudogout)
pseudogout)
b)
b) Endocrine
Endocrine diseases
diseases (diabetes
(diabetes mellitus,
mellitus,
acromegaly,
acromegaly, hyperparathyroidism,
hyperparathyroidism, thyroid
thyroid
diseases)
diseases)
6-
6- Hematological
Hematological disorders:
disorders: Haemoglobinopathies,
Haemoglobinopathies,
leukaemia,
leukaemia, lymphoma,
lymphoma, haemophilia
haemophilia
7-Neoplasms
7-Neoplasms
8-Neuropathic
8-Neuropathic disorders:
disorders: charcot
charcot joint,
joint, carpal
carpal tunnel
tunnel
syndrome
syndrome
9-Bone
9-Bone and
and cartilage
cartilage disorders:
disorders: Osteoporosis,
Osteoporosis, osteomalacia
osteomalacia
10-Non
10-Non articular
articular rheumatism:
rheumatism: Fibromyalgia
Fibromyalgia ,, tendinitis
tendinitis ,,
plantar
plantar fasciitis
fasciitis
11-Trauma
11-Trauma
12-
12- Miscellaneous
Miscellaneous disorders:
disorders: Familial
Familial Mediterranean
Mediterranean
fever,
fever, Sarcoidosis,
Sarcoidosis, Behçet
Behçet disease
disease
Diagnosis
Diagnosis of
of rheumatic
rheumatic diseases:
diseases:

A)
A) Medical
Medical history
history

B)
B) Physical
Physical examination
examination

C)
C) Investigations
Investigations
A)
A) Medical
Medical history
history

** Demographic
Demographic considerations:
considerations:
 Sex:
Sex:
RA
RA -- SLE
SLE >> in
in females.
females.
AS
AS -- Gout
Gout >> in
in males
males
 Age
Age at
at onset
onset of
of symptoms
symptoms
 Ethnic
Ethnic background:
background: Familial
Familial
Mediterranean
Mediterranean fever,
fever, Behçet.
Behçet.

** History
History of
of trauma,
trauma, infection,
infection, drugs,
drugs,
menstruation,
menstruation, fertility
fertility and
and pregnancies
pregnancies

*
*** Chief
Chief complaints:
complaints:
•• Articular
Articular -- Periarticular
Periarticular -- Extraarticular
Extraarticular
 Articular
Articular complaints:
complaints:
 Onset.
Onset.
•• Abrupt
Abrupt onset:
onset: symptoms
symptoms develop
develop over
over minutes
minutes to
to hours.
hours. e.g.
e.g.
trauma-infection-gout/pseudogout
trauma-infection-gout/pseudogout
•• Insidious
Insidious onset:
onset: symptoms
symptoms develop
develop over
over weeks
weeks to
to months.
months. e.g.
e.g.
RA-OA
RA-OA
 Duration
Duration
•• Acute
Acute << 66 weeks
weeks
•• Chronic
Chronic >> 66 weeks
weeks
 Temporal
Temporal patterns
patterns of
of joint
joint involvement:
involvement:
•• Migratory:
Migratory: (inflammation
(inflammation persists
persists for
for only
only aa few
few days
days in
in each
each
joint)
joint) Acute
Acute rheumatic
rheumatic fever
fever -- gonococcal
gonococcal infection
infection
•• Additive
Additive or
or simultaneous:
simultaneous: Symptoms
Symptoms begin
begin in
in certain
certain joints
joints and
and
persist
persist with
with subsequent
subsequent involvement
involvement ofof other
other joints.
joints.
•• Intermittent
Intermittent (episodic):
(episodic): intervening
intervening periods
periods free
free of
of joint
joint
symptoms
symptoms e.g.
e.g. gout,
gout, pseudogout
pseudogout
 n
n of
of involved
involved joints
joints
•• Monoarthritis:
Monoarthritis: involvement
involvement of
of one
one joint.
joint.
•• Oligo-or
Oligo-or pauciarthritis:
pauciarthritis: involvement
involvement of of 2-4
2-4 joints.
joints.
•• Polyarthritis:
Polyarthritis: involvement
involvement of
of 55 or
or more
more joints.
joints.

Symmetry
Symmetry of of joint
joint involvement
involvement
•• Symmetric
Symmetric arthritis:
arthritis: involvement
involvement ofof same
same joints
joints on
on each
each
side
side of
of the
the body
body (RA,
(RA, SLE
SLE && other
other CT
CT diseases)
diseases)
•• Asymmetric
Asymmetric arthritis
arthritis psoriatic
psoriatic arthritis,
arthritis, reactive
reactive arthritis
arthritis
(Reiter's
(Reiter's syndrome)
syndrome)

Distribution
Distribution of
of affected
affected joints:
joints:
•• DIP
DIP joints
joints of
of fingers
fingers usually
usually spared
spared inin RA
RA and
and usually
usually
involved
involved in
in psoriatic
psoriatic arthritis,
arthritis, gout
gout or
or OA
OA
•• Lumbar
Lumbar spine:
spine: typically
typically involved
involved in
in AS
AS && spared
spared in
in RA
RA
 Distinctive
Distinctive types
types of
of musculoskeletal
musculoskeletal involvement:
involvement:

RA 
•• RA  synovitis
synovitis
•• Spondyloathropathy
Spondyloathropathy involves
involves joints
joints && entheses
entheses (heel
(heel pain)
pain)
dactylitis
dactylitis (sausage
(sausage digits),
digits), tendinitis
tendinitis &
& back
back pain.
pain.
•• Gout
Gout &
& infection
infection may
may involve
involve joints,
joints, tendon,
tendon, sheaths
sheaths &
& bursae.
bursae.

 Peri-articular
Peri-articular involvement:
involvement:

Tendinitis
Tendinitis –– Bursitis
Bursitis –– Fasciitis
Fasciitis

 Extra-articular
Extra-articular manifestations:
manifestations:

*Constitutional
*Constitutional symptoms
symptoms (fatigue-malaise-wt
(fatigue-malaise-wt loss)
loss) suggest
suggest
an
an underlying
underlying systemic
systemic disorder
disorder SLE,
SLE, RA
RA but
but not
not OA.
OA.

*Systemic
*Systemic involvement:
involvement:
pleurisy
pleurisy & & pericarditis
pericarditis (SLE,
(SLE, RA)
RA)
oral
oral or
or genital
genital ulcers
ulcers (Behçet,
(Behçet, Reiter,
Reiter, SLE)
SLE)
urethral
urethral oror vaginal
vaginal discharge
discharge (reactive)
(reactive)
photosensitivity,
photosensitivity, hair
hair loss
loss (SLE)
(SLE)
diarrhea
diarrhea (reactive
(reactive arthritis)
arthritis)
dysphagia
dysphagia & & Raynaud's
Raynaud's (Systemic
(Systemic sclerosis)
sclerosis)
conjunctivitis
conjunctivitis (Reiter)
(Reiter)
scleritis
scleritis && episcleritis
episcleritis && Sjogren
Sjogren (RA)
(RA) -- uveitis
uveitis (AS)
(AS)
skin
skin lesions
lesions (SLE,
(SLE, Dermatomyosits,
Dermatomyosits, psoriasis,
psoriasis, Henoch-
Henoch-
Schonlein
Schonlein Purpura
Purpura ….)
….)
 B) Physical examination

In clinical rounds
DD- acute and chronic mono and
polyarthritis


Acute
Acute monoarthritis
monoarthritis
Inflammatory
Inflammatory
 Septic
Septic arthritis.
arthritis.
 Gout
Gout and
and Pseudogout
Pseudogout
 Reiter
Reiter
 Atypical
Atypical presentation
presentation of
of RA
RA ,, SLE
SLE ,, AS,
AS, RF
RF

Non
Non inflammatory
inflammatory
 Trauma
Trauma and
and internal
internal derangement
derangement
 Hemarthrosis
Hemarthrosis (( trauma
trauma –– hemophilia-
hemophilia-
anticoagulants)
anticoagulants)
Investigations
Investigations for
for acute
acute monoarthritis
monoarthritis

 Synovial
Synovial fluid
fluid analysis:
analysis: The
The single
single most
most useful
useful test
test
CBC 
 CBC leucocytosis 
 leucocytosis  infection
infection
 ESR
ESR and
and CRP
CRP non specific 
non specific  may
may suggest
suggest inflammatory
inflammatory process
process
 Serum
Serum uric
uric acid:
acid: unreliable-
unreliable- maymay be
be elevated
elevated in in acute
acute inflammatory
inflammatory
conditions
conditions not
not related
related to
to gout-
gout- may
may bebe acutely
acutely diminished
diminished in in true
true gout
gout
attack-aspirin
attack-aspirin taken
taken as analgesics 
as analgesics  may
may lower
lower serum
serum uric
uric acid
acid
 Radiograph
Radiograph of of joint
joint && contra
contra lateral
lateral joint
joint (for
(for comparison)
comparison)
frequently
frequently normal,
normal, maymay diagnose
diagnose fracture
fracture or or pseudogout
pseudogout
 ANA
ANA and and RF
RF
 Cultures
Cultures of
of blood,
blood, urine
urine or
or other
other possible
possible sites
sites of
of infection
infection important
important
in
in septic
septic arthritis
arthritis
 Serum
Serum prothrombin
prothrombin & & partial
partial thromboplastin
thromboplastin time time  coagulation
coagulation
disorders
disorders and
and patients
patients on on anticoagulants
anticoagulants

Chronic
Chronic monoarthritis
monoarthritis

 Inflammatory
Inflammatory
 Chronic
Chronic infectious
infectious arthritis
arthritis (mycobacterial
(mycobacterial TB
TB
fungal)
fungal)
 Gout
Gout and
and pseudogout
pseudogout
 Atypical
Atypical presentation
presentation of
of RA
RA & & sero
sero -- ve
ve
spondyloarthropathy
spondyloarthropathy


 Noninflammatory
Noninflammatory
 Osteoarthritis
Osteoarthritis
 Hemarthrosis
Hemarthrosis
 Charcot
Charcot joint
joint
Investigations
Investigations for
for chronic
chronic mono
mono arthritis
arthritis ::

1.
1. X-ray
X-ray of
of affected
affected joint
joint && contralateral
contralateral joint
joint mycobacterial.
mycobacterial. & &
fungal
fungal infection-characteristic
infection-characteristic features
features of
of osteoarthritis
osteoarthritis
2.
2. Synovial
Synovial fluid
fluid ifif possible
possible (inflammatory
(inflammatory ## noninflammatory)
noninflammatory)
cultures
cultures (mycobacterial
(mycobacterial or or fungal
fungal infection)
infection)
3.
3. ESR
ESR & & CRP
CRP non specific 
non specific  inflammatory
inflammatory process
process
4.
4. X-ray
X-ray ofof SI joints 
SI joints  spondylo
spondylo arthritis
arthritis
5.
5. RF
RF & & ANA
ANA
6.
6. X-ray chest -- Tuberculin
X-ray chest test ::
Tuberculin test  TB
TB
7.
7. MRI:
MRI: earlyearly inflammatory
inflammatory changes,
changes, destruction
destruction of of
periarticular
periarticular bone
bone
8. Arthroscopy 
8. Arthroscopy  visualization
visualization ofof structure
structure ,, internal
internal
derangement,
derangement, synovial
synovial biopsy
biopsy
9.
9. Synovial
Synovial biopsy,
biopsy, microscopic
microscopic evaluation
evaluation & & culture
culture synovial
synovial tisse
tisse
diagnosis
diagnosis of of tumors,
tumors, fungal
fungal && mycobacterial
mycobacterial affection
affection

Acute
Acute polyarthritis
polyarthritis


 Rheumatic
Rheumatic fever
fever

 Gonococcal
Gonococcal arthritis
arthritis –meningococcal
–meningococcal

 Viral
Viral arthritis
arthritis (eg.,
(eg., hepatitis
hepatitis B&C
B&C infection,
infection, rubella,
rubella, HIV)
HIV)

 Bacterial
Bacterial endocarditis
endocarditis (infective
(infective endocarditis)
endocarditis)

 Polyarticular
Polyarticular gout
gout & & pseudogout
pseudogout

 Rheumatoid
Rheumatoid arthritis
arthritis

 Systemic
Systemic lupus
lupus erythematosus
erythematosus (other
(other diffuse
diffuse CT-diseases)
CT-diseases)

 Sero
Sero -ve
-ve spondylo
spondylo arthritis
arthritis

 Familial
Familial Mediterranean
Mediterranean Fever
Fever
Investigations
Investigations for
for acute
acute polyarthritis
polyarthritis

 CBC
CBC
 ESR,C-reactive
ESR,C-reactive protein-ASO
protein-ASO titer
titer
 RF,
RF, anti-CCP
anti-CCP
 ANA,
ANA, other
other auto
auto antibodies
antibodies
 HBsAg-HCV
HBsAg-HCV antibodies
antibodies
 HLA-B27,
HLA-B27, ifif compatible
compatible with
with spondyloarthritis
spondyloarthritis
 Synovial
Synovial fluid
fluid analysis
analysis to
to rule
rule out
out crystalline
crystalline arthropathy
arthropathy
 X-rays
X-rays of
of involved
involved and
and contra-lateral
contra-lateral joints-ultrasound-CT
joints-ultrasound-CT
scan-MRI
scan-MRI
 Culture
Culture of
of cervix,
cervix, rectum,
rectum, throat,
throat, and
and skin
skin lesions
lesions when
when indicated.
indicated.
 ECG
ECG –– Echocardiography
Echocardiography (( Rheumatic
Rheumatic Fever
Fever ))

Chronic
Chronic polyarthritis
polyarthritis

 Inflammatory
Inflammatory ::
 Rheumatoid
Rheumatoid arthritis
arthritis
 Systemic
Systemic lupus
lupus erythematosus
erythematosus &
& other
other diffuse
diffuse
CT
CT diseases
diseases
 Sero
Sero -ve
-ve spondyloarthropathies
spondyloarthropathies
 gout
gout

 Non
Non –– inflammatory
inflammatory
Osteoarthritis
Osteoarthritis
Investigations for chronic polyarthritis
CBC
CBC
ESR
ESR ,, C-reactive
C-reactive protein
protein
Test
Test for
for RF,
RF, anti-CCP
anti-CCP
ANA,
ANA, other
other autoantibodies
autoantibodies
Creatinine
Creatinine kinase
kinase ,, aldolase,
aldolase, EMG
EMG (myositis)
(myositis)
HLA-B27,
HLA-B27, ifif compatible
compatible with with spondyloarthritis
spondyloarthritis
HCV
HCV AbAb -- HIV
HIV AbAb assay
assay
Thyroid
Thyroid function
function tests,
tests, ifif appropriate
appropriate
X-rays
X-rays of
of involved
involved and
and contralateral
contralateral joints-ultrasound-CT
joints-ultrasound-CT scan-
scan-
MRI-Bone
MRI-Bone scanscan
Chest
Chest X-ray
X-ray
Synovial
Synovial fluid
fluid analysis
analysis
Investigations
Investigations (contd.)
(contd.)

 Special
Special procedures,
procedures, when
when appropriate:
appropriate:
•• Serum
Serum complement
complement
•• Creatinine
Creatinine clearance
clearance
•• Coagulation
Coagulation screening
screening
•• Esophageal
Esophageal motility
motility studies
studies
•• Contrast
Contrast studies
studies of
of the
the gastrointestinal
gastrointestinal tract
tract
•• Biopsy
Biopsy of
of subcutaneous
subcutaneous nodules,
nodules, tophi,
tophi, or
or synovium
synovium
Examination of joint fluid
Measure Normal Group I Group II Group III

Noninflammatory Inflammatory Septic

Volume (ml)(knee) <3.5 Often <3.5 Often > 3.5 Often > 3.5

Clarity Transparent Transparent Translucent-opaque Opaque

Color Yellow Yellow Yellow or white Yellow to green

Viscosity High High low Variable

WBC/l <200 200 to 2000 2000 to 100,000 >100,000

Polymorphonuclear <25% < 25% 50% or more 75% or more

leukocytes(%)

Culture Negative Negative Negative Often positive


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