There is an old joke. It goes like this: “Neurologists diagnose the untreatable while rheumatologists treat the undiagnosable.” Nothing could be truer than when it comes to what is termed “inflammatory arthritis.”

Most rheumatologists tend to divide arthritis into two major categories: inflammatory and non-inflammatory. The latter category is also termed “degenerative” arthritis.

The major distinction is that inflammatory types of arthritis have a significant amount of inflammatory cells that attack the joints. These types of arthritis tend to cause more symptoms, particularly stiffness and pain. They also tend to be progressive. Oftentimes inflammatory types of arthritis are associated with constitutional symptoms, meaning low grade fever, weight loss, and fatigue. Inflammatory types of arthritis can also cause significant damage to internal organs. Disability and early death may be a consequence of some types of inflammatory arthritis. Examples of inflammatory arthritis are rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, gout, infectious arthritis, and ankylosing spondylitis.

Inflammatory types of arthritis can strike at any age.

Inflammatory types of arthritis have typical patterns although theoretically any joint in the body can be affected.

Inflammatory forms of arthritis may not be easy to categorize. Sometimes it will be obvious that inflammation is present and is a prominent component of the symptom complex. However, a specific diagnosis may not be apparent. Eventually most forms of inflammatory arthritis do “declare” themselves and ultimately fall into a category. But not always! This is a situation where a skilled diagnostician and clinician is worth their weight in gold!

On the other hand, non-inflammatory types of arthritis cause symptoms based on mechanical factors. Often degenerative arthritis affects weight-bearing joints such as the neck, low back, hips, and knees. It tends to occur in older people. While it may progress, it does so relatively slowly. It is rarely, if ever, associated with constitutional symptoms. In fact if constitutional symptoms are present, then either the patient has more than non-inflammatory arthritis or has another illness in addition to their arthritis. This is the type of arthritis people often associate with getting older.

Non-inflammatory types of arthritis may also be confusing some times. An example is a condition like fibromyalgia where the pain occurs pretty much all over. Symptomatic and subjective joint swelling may make the clinical diagnosis difficult.

The distinction between inflammatory and non-inflammatory arthritis is made on the basis of a careful history, physical examination, laboratory tests, and imaging procedures such as magnetic resonance imaging (MRI) and ultrasound.

Sometimes a patient can have both types of arthritis. For instance it is not uncommon for a patient with longstanding rheumatoid arthritis to also have degenerative arthritis (osteoarthritis) in a knee or hip.

Interestingly, when an arthroscope (small telescope) is used to visualize the interior of a joint, almost all types of arthritis have an inflammatory component to them. The extent and type of inflammatory change though varies from disease to disease.

The treatment for inflammatory arthritis will vary. While anti-inflammatory medicines are sometimes helpful, it may be necessary to start disease modifying drug therapy. Again the skill and experience of the arthritis specialist is paramount in determining which direction to head. Obviously, if the inflammatory arthritis becomes more well-defined, then treatment becomes easier to define as well.

The key point to remember is that if you do have arthritis, it’s important to seek the opinion of an expert arthritis specialist.



Thanks to Nathan Wei for contributing this article to our Arthritis blog:

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Arthritis is a disease that causes pain and loss of movement of the joints. Joint pain is referred to as arthralgia. Arthritis is the leading cause of disability in people over the age of 55. The causes of arthritis depend on the form of arthritis. Causes include injury (leading to osteoarthritis), abnormal metabolism (such as gout and pseudogout), inheritance, infections, and for unclear reasons (such as rheumatoid arthritis and systemic lupus erythematosus). There are many forms of arthritis .There are about 200 different kinds of arthritis. The most common type is osteoarthritis (or degenerative arthritis), where the cartilage that protects the bones gets worn away. This makes joints stiff, painful and creaky. About 5 million people in the UK have osteoarthritis. OA is a chronic degenerative arthropathy that frequently leads to chronic pain and disability. With the aging of our population, this condition is becoming increasing prevalent and its treatment increasingly financially burdensome. Using radiographic criteria, the distal and proximal interphalangeal joints of the hand have been identified as the joints most commonly affected by OA, but they are the least likely to be symptomatic. Age is the most consistently identified risk factor for OA, regardless of the joint being studied. Prevalence rates for both radiographic OA and, to a lesser extent, symptomatic OA rise steeply after age 50 in men and age 40 in women. Occupation-related repetitive injury and physical trauma contribute to the development of secondary (non-idiopathic) OA, sometimes occurring in joints that are not affected by primary (idiopathic) OA, such as the metacarpophalangeal joints, wrists and ankles.

Rheumatoid arthritis (RA) is traditionally considered a chronic, inflammatory autoimmune disorder. Rheumatoid arthritis occurs when the body’s defence mechanisms go into action when there’s no threat and start attacking the joints and sometimes other parts of the body. RA affects 2.1 million Americans, or about 1% of the adult population in the United States. This disease is 2 to 3 times more common in women than in men, and generally affects people between the ages of 20 and 50. However, young children can develop a form of RA called juvenile rheumatoid arthritis. Two of the 100 types of arthritis are rheumatoid arthritis and lupus. There are specific symptoms, distinguishing characteristics, as well as overlapping symptoms associated with rheumatoid arthritis and lupus. Rheumatoid arthritis is an additive polyarthritis, with the sequential addition of involved joints, in contrast to the migratory or evanescent arthritis of systemic lupus erythematosus or the episodic arthritis of gout. Occasionally, patients experience an explosive polyarticular onset occurring over 24 to 48 hours. Morning stiffness, persisting more than one hour but often lasting several hours, may be a feature of any inflammatory arthritis but is especially characteristic of rheumatoid arthritis. Its duration is a useful gauge of the inflammatory activity of the disease.

Psoriatic arthritis is related to the skin condition psoriasis. It occurs more commonly in patients with tissue type HLA-B27. There are five clinical patterns of psoriatic arthritis. First is Asymmetrical mono- and oligoarticular arthritis (30-50% of cases) is the most common presentation of psoriatic arthritis. Second is symmetrical polyarticular arthritis (30-50% of cases) is ultimately the most common form of psoriatic arthritis. Third is distal interphalangeal (DIP) joint involvement (25% of cases) is nearly always associated with nail manifestationsm. Fourth is Arthritis mutilans is affects less than 5% of patients and is a severe, deforming and destructive arthritis. This condition can progress over months or years causing severe joint damage. Fifth is Axial arthritis (30-35% of cases) may be different in character from ankylosing spondylitis, the prototypical HLA-B27-associated spondyloarthropathy. It may present as sacro-iliitis, which may be asymmetrical and asymptomatic, or spondylitis, which may occur without sacro-iliitis and may affect any level of the spine in “skip” fashion. Genetic factors appear to play an important role. There is a 70% concordance for psoriasis in monozygotic twins. There is a 50-fold increased risk of developing psoriatic arthritis in first-degree relatives of patients with the disease. Environmental factors have been implicated. Streptococcal infection can precipitate the development of guttate psoriasis. HIV infection can present with both psoriasis and psoriatic arthritis, as well as worsen existing disease.

Gout is one of the most painful types of arthritis. Gout was once incorrectly thought to be a disease of the rich and famous, caused by consuming too much rich food and fine wine. Gout is a disease due to a congenital disorder of uric acid metabolism. Uric acid is produced when purines are broken down by enzymes in the liver. Purines can be generated by the body itself (via the breakdown of cells in normal cellular turnover) or can be ingested in purine-rich foods (e.g. seafood, beer). Gout usually attacks the big toe (approximately 75% of first attacks), however it can also affect other joints such as the ankle, heel, instep, knee, wrist, elbow, fingers, and spine. In some cases the condition may appear in the joints of the small toes which have become immobile due to impact injury earlier in life, causing poor blood circulation that leads to gout. Chronic gout can lead to deposits of hard lumps of uric acid in and around the joints, decreased kidney function, and kidney stones. An acute attack of gout is a highly inflammatory arthritis often with intense swelling, redness and warmth surrounding the joint. The inflammatory component is so intense, an acute attack of gout is often mistaken for a bacterial cellulitis. Gout is mainly treated with anti-inflammatory drugs. Corticosteroids (also called steroids), may be prescribed for people who cannot take NSAIDs. Steroids also work by decreasing inflammation. Steroids can be injected into the affected joint or given as pills. Colchicine is often used to treat gout and usually begins working within a few hours of taking it.

Septic arthritis also known is Pyogenic arthritis. Septic arthritis is infection, usually bacterial, in the joint cavity. Septic arthritis usually affects just one joint, though occasionally it may occur in more than one joint at a time. It is the most dangerous form of acute arthritis. The joint cavity is usually a sterile space, with synovial fluid and cellular matter including a few white blood cells. Many different types of bacteria (germs) can cause septic arthritis. Infection with a bacterium called Staph. aureus is the most common cause. Septic arthritis is inflammation of a synovial membrane with purulent effusion into the joint capsule, usually due to bacterial infection. This disease entity also is referred to in the literature as bacterial, suppurative, purulent, or infectious arthritis. The most common bacterial isolates in native joints include gram-positive cocci, with S. aureus found in 40% to 50% of the cases. Septic arthritis is uncommon from age 3 to adolescence. Children with septic arthritis are more likely than adults to be infected with group B streptococcus and Haemophilus influenza. Young children and older adults are most likely to develop septic arthritis. As the population ages, doctors are finding that septic arthritis is becoming more common. Symptoms of septic arthritis occur suddenly and are characterized by severe pain, swelling in the affected joint along with acute pain. Chills and fever are also common symptoms. Chronic septic arthritis (which occurs less frequently) is caused by organisms such as Mycobacterium tuberculosis and Candida albicans. The knee and the hip are the most commonly infected joints.



Thanks to Juliet Cohen for contributing this article to our Arthritis blog:

Juvenile Rheumatoid Arthritis

More than 21 million Americans have osteoarthritis. Approximately 2.1 million Americans suffer from rheumatoid arthritis.

The causes of arthritis depend on the form of arthritis. Causes include injury (leading to degenerative arthritis), abnormal metabolism (such as gout and pseudogout), inheritance (such as in osteoarthritis), infections (such as in the arthritis of Lyme disease), and an overactive immune system (such as rheumatoid arthritis and systemic lupus erythematosus). Treatment programs, when possible, are often directed toward the precise cause of the arthritis.

If joint pain, swelling, stiffness, redness, loss of motion or deformity occurs, medical evaluation by a health-care professional is warranted. Even minor joint symptoms that persist unexplained for over one week should be evaluated. For many forms of arthritis, it is essential that patients have an early evaluation as it is clear that this can both prevent damage and disability as well as make optimal treatment easier.

Arthritis is a joint disorder featuring inflammation. A joint is an area of the body where two bones meet. A joint functions to allow movement of the body parts it connects. Arthritis literally means inflammation of one or more joints. Arthritis is frequently accompanied by joint pain. Joint pain is referred to as arthralgia.

Arthritis is classified as one of the rheumatic diseases. These are conditions that are different individual illnesses, with differing features, treatments, complications, and prognosis. They are similar in that they have a tendency to affect the joints, muscles, ligaments, cartilage, and tendons, and many have the potential to affect internal body areas as well.

There are many forms of arthritis (over 100 have been described so far, and the number is growing). The forms range from those related to wear and tear of cartilage (such as osteoarthritis) to those associated with inflammation as a result of an overactive immune system (such as rheumatoid arthritis). Together, the many forms of arthritis make up the most common chronic illness in the United States.

For many patients with arthritis, mild pain relievers such as aspirin and acetaminophen (Tylenol) may be sufficient treatment. Studies have shown that acetaminophen given in adequate doses can often be equally as effective as prescription anti-inflammatory medications in relieving pain in osteoarthritis.

Since acetaminophen has fewer gastrointestinal side effects than NSAIDS, especially among elderly patients, acetaminophen is often the preferred initial drug given to patients with osteoarthritis. Pain-relieving creams applied to the skin over the joints can provide relief of minor arthritis pain. Examples include capsaicin, salycin, methyl salicylate, and menthol.

Arthritis sufferers include men and women, children and adults. Approximately 350 million people worldwide have arthritis. Over 40 million people in the United States are affected by arthritis, including over a quarter million children! More than half of those with arthritis are under 65 years of age. Nearly 60% of Americans with arthritis are women.

Symptoms of arthritis include pain and limited function of joints. Inflammation of the joints from arthritis is characterized by joint stiffness, swelling, redness, and warmth. Tenderness of the inflamed joint can be present. Loss of range of motion and deformity can result. Certain forms of arthritis can also be associated with pain and inflammation of tendons surrounding joints.

Some forms of arthritis are more of an annoyance than a serious medical problem. However, millions of people suffer daily with pain and disability from arthritis or its complications.

Moreover, many of the forms of arthritis, because they are rheumatic diseases, can cause symptoms affecting various organs of the body that do not directly involve the joints. Therefore, symptoms in some patients with certain forms of arthritis can also include fever, gland swelling, weight loss, fatigue, feeling unwell, and even symptoms from abnormalities of organs such as the lungs, heart, or kidneys.

The treatment of arthritis depends on which particular form of arthritis is present, its location, severity, persistence, and any underlying background medical conditions of the patient. Each treatment program must be customized for the individual patient.

Treatment programs can incorporate home remedies, nonprescription and prescription medications, joint injections, and surgical operations. Some treatment programs involve weight reduction and avoiding activities that exert excessive stress on the joint. The goal of treatment of arthritis is to reduce joint pain and inflammation while preventing damage and improving and maintaining joint function.

Not every person with arthritis requires medical attention. For example, some patients with osteoarthritis have minimal or no pain and may not need treatment. However, for those with persisting joint symptoms, the ideal steps to take should lead to a proper diagnosis and an optimal long-term treatment plan. This plan must be customized for each person affected, depending on the joints involved and the severity of symptoms.

Surgery is generally reserved for those patients with arthritis that is particularly severe and unresponsive to the conservative treatments. Surgical procedures can be performed to relieve pain, improve function, and correct deformity. Occasionally, joint tissue is surgically removed for the purpose of biopsy and diagnosis. Doctors who specialize in joint surgery are orthopedic surgeons.

Currently, prevention of arthritis focuses on avoiding joint injury and early diagnosis and treatment. Research clearly demonstrates that early diagnosis and treatment can result in less damage, deformity, disability, and even mortality in rheumatoid disease.

The treatment of rheumatoid disease is not only more effective but easier when administered early.

Additionally, maintaining overall good health and strength with exercise and good nutrition can be helpful in preventing joint disease.



Thanks to Alisha Dhamani for contributing this article to our Arthritis blog:

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