Clinical Approach to Acute Arthritis
description
Transcript of Clinical Approach to Acute Arthritis
![Page 1: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/1.jpg)
Clinical Approach to Acute Arthritis
Azam aminiRheumatologist
Boushehr university of medical science
![Page 2: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/2.jpg)
Acute ArthritisThe sudden onset of inflammation of the joint, causing severe pain, swelling, and redness.Structural changes in the joint itself may result from persistence of this condition.
![Page 3: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/3.jpg)
Signs of InflammationSwellingWarmthErythemaTendernessLoss of function
![Page 4: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/4.jpg)
Key PointsDistinguish arthritis from soft tissue non articular syndromes If the problem is articular distinguish single joint from multiple joint involvementInflammatory or non-inflammatory diseaseAlways consider septic arthritis!
![Page 5: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/5.jpg)
Articular Vs. PeriarticularClinical feature Articular PeriarticularAnatomic structure
Painful site Pain on movementSwelling
Synovium, cartilage, capsuleDiffuse, deepActive/passive, all planesCommon
Tendon, bursa, ligament, muscle, boneFocal “point”Active, in few planesUncommon
![Page 6: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/6.jpg)
Inflammatory Vs. Noninflammatory
Feature Inflammatory NoninflammatoryPain (when?)SwellingErythemaWarmthAM stiffnessSystemic featuresî ESR, CRPSynovial fluid WBCExamples
Yes (AM)Soft tissue SometimesSometimesProminent SometimesFrequentWBC >2000Septic, RA, SLE, Gout
Yes (PM)BonyAbsentAbsentMinor (< 30 ‘)AbsentUncommonWBC < 2000OA, AVN
![Page 7: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/7.jpg)
Acute MonoarthritisInflammation (swelling, tenderness, warmth) in one jointOccasionally polyarticular diseases can present with monoarticular onset: (RA, JRA,Reactive and enteropathic arthritis,
Sarcoid arthritis, Viral arthritis, Psoriatic arthritis)
![Page 8: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/8.jpg)
Acute Monoarthritis - Etiology
THE MOST CRITICAL DIAGNOSIS TO CONSIDER: INFECTION !SepticCrystal deposition (gout, pseudogout)Traumatic (fracture, internal derangement)Other (hemarthrosis, osteonecrosis, presentation of polyarticular disorders)
![Page 9: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/9.jpg)
Questions to Ask – History Helps in DD
Pain come suddenly, minutes? – fracture.0ver several hours or 1-2 days? –infectious, crystals, inflammatory arthropathy.History of IV drug abuse or a recent infection? – septic joint.Previous similar attacks? – crystals or inflammatory arthritis.Prolonged courses of steroids? – infection or osteonecrosis of the bone.
![Page 10: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/10.jpg)
Acute Monoarthritis
![Page 11: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/11.jpg)
Indications for Arthrocentesis
The single most useful diagnostic study in initial evaluation of monoarthritis: SYNOVIAL FLUID ANALYSIS1. Suspicion of infection2. Suspicion of crystal-induced arthritis3. Suspicion of hemarthrosis4. Differentiating inflammatory from noninflammatory arthritis
![Page 12: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/12.jpg)
Tests to Perform on Synovial Fluid
Low threshold for doing Gram stain and cultures .Total leukocyte count/differential: inflammatory vs. non-inflammatory.Polarized microscopy to look for crystals.Not necessary routinely: Chemistry (glucose, total protein, LDH) unlikely to yield helpful information beyond the previous tests.
![Page 13: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/13.jpg)
Septic JointMost articular infections – a single joint15-20% cases polyarticularMost common sites: knee, hip, shoulder20% patients afebrileJoint pain is moderate to severeJoints visibly swollen, warm, often redComorbidities: RA, DM, SLE, cancer,etc
![Page 14: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/14.jpg)
Septic Joint - Nongonococcal
80-90% monoarticularMost develop from hematogenous spreadMost common:Gram positive aerobes (80%)Majority with Staph aureus (60%)Gram negative 18%
![Page 15: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/15.jpg)
Septic Joint - GonococcalMost common cause of septic arthritisOften preceded by disseminated gonococcemiaSexually active individual, 5-7 days h/o fever, chills, skin lesions, migratory arthralgias and tenosynovitis persistent monoarthritisWomen often menstruating or pregnantGenitourinary disease often asymptomatic
![Page 16: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/16.jpg)
Disseminated Gonococcemia – Pustules
![Page 17: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/17.jpg)
GoutCaused by monosodium urate crystalsMost common type of inflammatory monoarthritisTypically: first MTP joint, ankle, midfoot, kneePain very severe; cannot stand bed sheetMay be with fever and mimic infectionThe cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis
![Page 18: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/18.jpg)
Acute Gouty Arthritis
![Page 19: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/19.jpg)
Risk FactorsPrimary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis.Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure.
![Page 20: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/20.jpg)
Urate CrystalsNeedle-shaped
Strongly negative birefringent
![Page 21: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/21.jpg)
CPPD Crystals Deposition Disease
Can cause monoarthritis clinically indistinguishable from gout – Pseudogout.Often precipitated by illness or surgery.Pseudogout is most common in the knee (50%) and wrist.Reported in any joint (Including MTP).CPPD disease may be asymptomatic (deposition of CPP in cartilage).
![Page 22: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/22.jpg)
Associated ConditionsHyperparathyroidismHypercalcemiaHypocalciuriaHemochromatosisHypothyroidismGoutAging
![Page 23: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/23.jpg)
CPPD Crystals
Rod or rhomboid-shaped
Weakly positive birefringent
![Page 24: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/24.jpg)
Other Tests Indicated for Acute Arthritis
1. Almost always indicated: Radiograph, bilateral CBC
2. Indicated in certain patients: Cultures PT/PTT ESR
3. Rarely indicated: Serologic: ANA, RF Serum Uric acid level
![Page 25: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/25.jpg)
PolyarthritisDefinite inflammation (swelling, tenderness, warmth of > 5 jointsA patient with 2-4 joints is said to have pauci- or oligoarticular arthritis
![Page 26: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/26.jpg)
Acute PolyarthritisInfectionGonococcalMeningococcalLyme diseaseRheumatic feverBacterial endocarditisViral (rubella, parvovirus, Hep. B)
InflammatoryRAJRASLEReactive arthritisPsoriatic arthritisPolyarticular goutSarcoid arthritis
![Page 27: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/27.jpg)
Inflammatory Vs. Noninflammatory
Feature Inflammatory Mechanical
Morning stiffnessFatigueActivityRestSystemicCorticosteroid
>1 h
Profound ImprovesWorsensYesYes
< 30 min
MinimalWorsensImprovesNoNo
![Page 28: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/28.jpg)
Temporal Patterns in Polyarthritis
Migratory pattern: Rheumatic fever, gonococcal (disseminated gonococcemia), early phase of Lyme diseaseAdditive pattern: RA, SLE, psoriasisIntermittent: Gout, reactive arthritis
![Page 29: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/29.jpg)
Patterns of Joint Involvement
Symmetric polyarthritis involving small and large joints: viral, RA, SLE, one type of psoriatic (the RA-like).Asymmetric, oligo- and polyarthritis involving mainly large joints, preferably lower extremities, especially knee and ankle : reactive arthritis, one type of psoriatic, enteropathic arthritis. DIP joints: Psoriatic.
![Page 30: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/30.jpg)
Viral ArthritisYounger patientsUsually presents with prodrome, rashHistory of sick contactPolyarthritis similar to acute RAPrognosis good; self-limitedExamples: Parvovirus B-19, Rubella, Hepatitis B and C, Acute HIV infection, Epstein-Barr virus, mumps
![Page 31: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/31.jpg)
Parvovirus B-19The virus of “fifth disease”, erythema infectiosum (EI).Children “slapped cheek”; adults flu-like illness, maculopapular rash on extremities.Joints involved more in adults (20% of cases).Abrupt onset symmetric polyarthralgia/polyarthritis with stiffness in young women exposed to kids with E.I.May persist for a few weeks to months.
![Page 32: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/32.jpg)
Viral Arthritides - Parvovirus
![Page 33: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/33.jpg)
Rubella ArthritisGerman measles.Young women exposed to school-aged children.Arthritis in 1/3 of natural infections; also following vaccination.Morbilliform rash, constitutional symptoms.Symmetric inflammatory arthritis (small and large joints).
![Page 34: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/34.jpg)
Rheumatoid ArthritisSymmetric, inflammatory polyarthritis, involving large and small jointsAcute, severe onset 10-15 %; subacute 20%Hand characteristically involvedAcute hand deformity: fusiform swelling of fingers due to synovitis of PIPsRF may be negative at onset and may remain negative in 15-20%! RA is a clinical diagnosis, no laboratory test is diagnostic, just supportive!
![Page 35: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/35.jpg)
Acute Polyarthritis - RA
![Page 36: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/36.jpg)
Acute Sarcoid ArthritisChronic inflammatory disorder – noncaseating granulomas at involved sites15-20% arthritis; symmetrical: wrists, PIPs, ankles, kneesCommon with hilar adenopathyErythema nodosumLöfgren’s syndrome: acute arthritis, erythema nodosum, bilateral hilar adenopathy
![Page 37: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/37.jpg)
Acute Polyarthritis in Sarcoidosis
![Page 38: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/38.jpg)
Reactive ArthritisInfection-induced systemic disease with inflammatory synovitis from which viable organisms cannot be cultured Association with HLA B 27 Asymmetric, oligoarticular, knees, ankles, feet40% have axial disease (spondylarthropathy)Enthesitis: inflammation of tendon-bone junction (Achilles tendon, dactylitis)Extraarticular: rashes, nails, eye involvement
![Page 39: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/39.jpg)
Asymmetric, Inflammatory Oligoarthritis
![Page 40: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/40.jpg)
Enthesitis in Reactive Arthritis
![Page 41: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/41.jpg)
Keratoderma Blenorrhagica – Reactive
Arthritis
![Page 42: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/42.jpg)
Reactive Arthritis - Conjunctivitis
![Page 43: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/43.jpg)
Reactive Arthritis – Palate Erosions
![Page 44: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/44.jpg)
Psoriatic ArthritisPrevalence of arthritis in Psoriasis 5-7%Dactilytis (“sausage fingers”), nail changesSubtypes: Asymmetric, oligoarticular- associated dactylitis Predominant DIP involvement – nail changes Polyarthritis “RA-like” – lacks RF or nodules Arthritis mutilans – destructive erosive hands/feet Axial involvement –spondylitis – 50% HLAB27 (+) HIV-associated – more severe
![Page 45: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/45.jpg)
Acute Polyarthritis - Psoriatic
![Page 46: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/46.jpg)
Dactylitis “Sausage Toes” – Psoriasis
![Page 47: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/47.jpg)
Psoriasis
![Page 48: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/48.jpg)
Arthritis Of SLEMusculoskeletal manifestation 90%.Most have arthralgia.May have acute inflammatory synovitis RA-like.Do not develop erosions.Other clinical features help with DD: malar rash, photosensitivity, rashes, alopecia, oral ulceration.
![Page 49: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/49.jpg)
Butterfly Rash – SLE
![Page 50: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/50.jpg)
Photosensitivity
![Page 51: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/51.jpg)
Alopecia - SLE
![Page 52: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/52.jpg)
Arthritis of Rheumatic Fever
Etiology: Streptococcus pyogenes (group A); there is damaging immune response to antecedent infection – molecular cross reaction with target organs “molecular mimicry”.Migratory polyarthritis, large joints: knees, ankles, elbows, wrists.Major manifestations: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules.
![Page 53: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/53.jpg)
Erythema Marginatum – Rheumatic Fever
CircinateEvanenscentNonpruritic rash
![Page 54: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/54.jpg)
Rheumatic Fever – Subcutaneous Nodes
![Page 55: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/55.jpg)
Gouty Arthritis
![Page 56: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/56.jpg)
Skin Lesions Useful in Diagnosis
Psoriatic plaquesKeratoderma Blenorrhagicum (reactive arthritis)Butterfly rash (SLE)Salmon-colored rash of JRA, adult Still’sErythema marginatum (Rheumatic Fever)Vesicopustular lesions (gonococcal arthritis)Erythema nodosum (acute sarcoid, enteropathic arthritis)
![Page 57: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/57.jpg)
Disseminated Gonococcemia – Pustules
![Page 58: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/58.jpg)
Keratoderma Blenorrhagica – Reactive
Arthritis
![Page 59: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/59.jpg)
Erythema Marginatum – Rheumatic Fever
CircinateEvanenscentNonpruritic rash
![Page 60: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/60.jpg)
Adult Still’s Disease and JRA Rash
Salmon or pale-pink BlanchingMacules or maculopapulesTransient (minutes or hours)Most common on trunkFever related
![Page 61: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/61.jpg)
SLE – Face Rash
![Page 62: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/62.jpg)
SLE – Interarticular Rash Hands
![Page 63: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/63.jpg)
Keratoderma Blenorrhagicum
![Page 64: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/64.jpg)
Erythema Nodosum
Sarcoidosis
Inflammatory Bowel Disease – related arthritis
![Page 65: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/65.jpg)
Tenosynovitis and Usefulness in DD
Inflammation of the synovial-lined sheaths surrounding tendons.Exam: tenderness and swelling along the track of the involved tendon between the joints.Characteristic of: Reactive arthritis, Gout, RA, gonococcal arthritis, psoriatic.
![Page 66: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/66.jpg)
Tenosynovitis in JRA
![Page 67: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/67.jpg)
Dactylitis “Sausage Toes” – Psoriasis, Reactive,
Enteropathic
![Page 68: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/68.jpg)
Enthesitis
![Page 69: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/69.jpg)
Extraarticular Features Helpful in DD
Eye involvement: conjunctivitis in reactive arthritis, uveitis in enteropathic and sarcoidosis, episcleritis in RAOral ulcerations: painful in reactive arthritis and enteropathic, not painful in SLENail lesions: pitting (psoriasis), onycholysis (reactive arthritis)Alopecia (SLE)
![Page 70: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/70.jpg)
Reactive Arthritis - Conjunctivitis
![Page 71: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/71.jpg)
Episcleritis
![Page 72: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/72.jpg)
Reactive Arthritis – Palate Erosions
![Page 73: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/73.jpg)
Alopecia - SLE
![Page 74: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/74.jpg)
Nail Pitting - Psoriasis
![Page 75: Clinical Approach to Acute Arthritis](https://reader036.fdocuments.in/reader036/viewer/2022062811/56815f82550346895dce87ac/html5/thumbnails/75.jpg)
Nail Changes in Reactive Arthritis