Osteoarthritis, part III: Differential diagnostics
Differential diagnostics of OA
In typical cases diagnostics of OA is not difficult, however in certain cases, especially at polyarticulary options of defeat, represents a non-trivial task. Most often the differential diagnosis is carried out with revmatoidny, psoriatichesky, microcrystalline, infectious arthritises.
Osteoarthritis, part I: risk factors, classification, clinic>>> Osteoartrit, part II: laboratory, morphology, X-ray>>>
Revmatoidny arthritis (RA)
Revmatoidny arthritis is the most frequent autoimmune disease of the person, the striking not less than 1 % of the population of the globe. Represents chronic progressing синовит, bringing to a gradual destruktsiya of the joints, in some cases being accompanied extra articulate manifestations. The clinical picture of a disease is very various, nevertheless, development of symmetric polyarthritis with primary involvement in a debut of joints of brushes, especially pyastno-phalanx, proksimalny interphalanx and carpal joints is most characteristic. Arthritises of these groups within the first months of a disease are noted at 65-90 % of patients. Arthritises are often accompanied теносиновитами muscles sgibately and especially razgibately, an atrophy of interosseous muscles. Progressing of process leads to deformations of joints typical for this disease. In the OA clinical picture into the forefront defeat large acts (knee, coxofemoral) joints, involvement pyastno-phalanx, luchezapyastny, ankle joints thus is not characteristic. Painful at OA, maximum in the evening, has mainly mechanical character, disappearing or essentially decreasing in rest that is uncharacteristic for RA. Morning constraint – is minimum and as a rule comes to light only at special inquiry of the patient while at RA this symptom correlating with activity of a disease, often changes existence of the patient, compelling it is essential to limit impellent activity in the morning.
The earliest radiological sign of RA is okolosustavny (epifizarny) osteoporosis, uncharacteristic for OA. A key sign of RA is education regional узур and erosion. Uzura at RA have the fragmentary and indistinctly outlined edges that distinguishes them from the cysts opened on an articulate surface at OA which always are surrounded with an osteosclerosis rim. The laboratory signs defining activity of a revmatoidny inflammation, at OA are close to normal values. The greatest value the following laboratory indicators – SOE have, SRB, the Russian Federation, anti-CCP/MCV (including in sinovialny liquid) which identification essentially increases probability of existence of RA. In clinical practice as a rule the greatest difficulties are represented by differentiation of OA and a debut of seronegativny RA with the minimum kliniko-laboratory signs of an inflammation. In difficult cases carrying out MRT of brushes with the contrast strengthening, allowing to define characteristic for RA синовиты is shown.
Psoriatichesky arthritis (PAS)
Psoriatichesky arthritis can become complicated secondary OA. In the presence of a characteristic skin syndrome, diagnostics comes easy. In lack of the last (for the proof of this fact careful studying of an integument of the patient is necessary, including buttock, pakhovy, axillary folds) the importance gets the anamnesis – existence of this or that option of a seronegativny artropatiya at relatives of the patient, and also a genotipirovaniye. The Kliniko-rentgenologichesky picture is the most important link of the differential diagnosis. For PAS it is characteristic asymmetric олигоартрит, with primary involvement of distalny interphalanx joints of feet, the brushes, being accompanied cyanotic-pink reddening of skin over the struck joints. Patognomonichnym a symptom is дактилит – arthritises of the 3rd joints at least one finger of a hand. Accompanying symptoms сакроилеита, ankiloziruyushchy спондилита, defeat of nails (a "thimble" symptom) quite often come to light. The radiological picture also reveals a defeat asimmetrichnost, its "axial" character, erosion of distalny interphalanx joints, proliferativny changes. In the expressed cases osteolytic defeats of phalanxes, and also pyastny and plusnevy bones that leads to shortening and deformation of extremities are noted.
Metabolic arthritises, mainly gout and a pirofosfatny artropatiya can be at the bottom of secondary OA with an identical clinical picture.
Pirofosfatny artropatiya (PFA)
Radiological хондрокальциноз the large joints, looking like the gentle, linear shadow, repeating contours of an articulate surface (a double contour of a joint), comes to light more than at 50 % of people 80 years are more senior and in most cases proceeds bessimptomno. Nevertheless, the so-called psevdoartrozny form of a chronic pirofosfatny artropatiya in character and to a current is extremely similar to OA: stupid constant pains, a small swelling of joints, are more often than the knee. Luchezapyastny, pyastno-phalanx, coxofemoral, humeral, elbow, ankle joints, a backbone can be surprised. On the roentgenogram OA besides хондрокальциноза is similar, narrowing of an articulate crack, остеофиты, a subkhondralny osteosclerosis is noted. At carrying out the differential diagnosis it is necessary to consider that characteristic defeat for PFA of small joints of a wrist and pyastno-phalanx joints, usually is absent at OA for which involvement of mainly proksimalny and distalny interphalanx joints is typical. Also chronic PFA in 50 % of cases proceeds a type of pseudo-gouty attacks, unlike a small jet exudate at OA, developing at an overload of joints. In difficult cases detection in sinovialny liquid of crystals of a dihydrate пирофосфата calcium in polarized light is solving. The combination of these diseases is possible.
Sharp arthritis of the 1st plusnefalangovy joint, being accompanied the expressed pain syndrome, a giperurikemiya, especially against the alcohol intake, some HP (диуретики, aspirin, циклофосфан, etc.), fever, лейкоцитоз – are considered classical for sharp gouty arthritis. Unlike the last, continuously retsidiviruyushchy chronic gouty polyarthritis with clinical and radiological signs of secondary OA demands carrying out the differential diagnosis with a generalizovanny form of primary OA. It is necessary to consider mechanical character of pains at OA. Aggravations синовита proceed essentially easier, than at gout, without considerable hypostasis and a skin giperemiya, quickly abate in rest. On roentgenograms there are no characteristic for the chronic course of gout "punches". Identification in sinovialny liquid of crystals моноурата sodium is defining. Crystals of uric acid in urine of diagnostic value have no.
Osteoarthritis, part IV: Treatment>>>