Rachmat Gunadi Wachjudi

Divisi Reumatologi – Departemen Ilmu Penyakit Dalam

FK Universitas Padjadjaran/ RSUP Dr. Hasan Sadikin
 Musculoskeletal pain
 Diagnosis of inflammatory arthritis
 Clinical features
 Role of laboratory parameters
 Role of radiographic examination
Pain involving bone and adjacent structure
(muscle, ligament, joint, and nerve)

Acute vs chronic

Local vs widespread

Mechanical vs inflammatory
 Rheumatic ailments
4% 2% 3%

1% Pre JKN
1%
6% Osteoarthritis
SLE
4%
Rheumatoid Artritis
Gout
Spondyloarthritis
Systemic Sclerosis
10%
Osteoporosis
Soft Tissue Rheumatism
69%
other type

Rheumatology data on
file 2014
 Rheumatic ailments
Post JKN
3% 2% 2%
10%
5%
2%
3% Osteoarthritis
SLE
Rheumatoid Artritis
Gout
Spondyloarthritis
Systemic Sclerosis
27%
46%
UCTD
Soft Tissue Rheumatism
other type

Rheumatology data on
file 2016
 Rheumatic pain

Inflammatory vs Non-
inflammatory

RA
JIA Inflammatory AS
arthritis
ReA PsA

Specific treatment/
management
 Musculoskeletal pain
Articular Non-articular
Characteristic Diffuse
Artikular Focal Non-articular
W/ movement Active-passive Active Trauma
6 weeks
Septic Motion Multi-planar Uni-planar Fibromyalgia
Acute Chronic Bursitis
Gout
Swelling Inflammatory
++ Non-inflammatory
+ Tendinitis
Pseudogout
Reactive Pain at rest ++ - Polymyalgia rheumatica
Inflammatory Non-inflammatory
Early phase chronic
Morningarthritis
stiffness > 30 mins < 30 mins
3 joints DIP, CMC1, hip, knee
<3 NO - YES 
Systemic symptoms
Indolent infection +
Osteonecrosis Osteoarthritis
Inflammatory > 3
Psoriatic arthritis Increase
Charcot arthritisNormal
Reactive arthritis
marker
Pauciarticular JA
ASSYMETRIC SYMMETRIC
Psoriatic arthritis PIP, MCP, MTP  Rheumatoid arthritis
Reactive arthritis SLE
Scleroderma
Polymyositis

Harrison’s Principles of Internal Medicine 17th Ed

 Arthritis
 Joint distribution

RA PsA AS
  Systemic symptoms (eg. spondyloarthropathy)

van Tubergen, Nat. Rev. Rheumatol. 2014

 Kaku sendi pada pagi
hari, berlangsung > 30  Mudah lelah
menit  Anemia
 Sendi simetris
 Pembesaran kelenjar
bengkak secara getah bening
 Terdapat benjolan /
simultan / serentak
 Nyeri tidak berkurang
nodule
 Fenomena Raynaud’s
dengan istirahat
 Demam
 Penurunan berat
badan
(Arthritis Foundation, 2012; Day et al., 2010; American College of Rheumatology, 2009)
Systemic involvement?

RA dapat menyebabkan
1. Synovitis
2. Serositis
3. Nodules
4. Vasculitis
5. Autoantibodies
Enthesitis Peripheral arthritis Dactylitis

58 % pasien kemungkinan erosi

50% pasien AS
tulang lebih tinggi
dengan entesitis
pada pasien dengan
daktilitis
 EAM Prevalence in AS
Patients (%)
Anterior uveitis 30-50
IBD 5-10
Anterior uveitis Subclinical inflammation of the gut 25-49
Cardiac abnormalities
Conduction disturbances 1-33
Aortic insufficiency 1-10
Psoriasis 10-20 Terminal ileitis
Renal abnormalities 10-35
Lung abnormalities 40-88
Airways disease 82
Interstitial abnormalities 47-65
Cardiac Emphysema 9-35
abnormalities Bone abnormalities
Osteoporosis 11-18
Osteopenia 39-59

Elewaut D & Matucci MC. Rheumatology 2009;48:1029-1035

 Hematology
 Acute hase reactant
 Synovial fluid exam
 Serology : RF, anti CCP / ACPA/Anti MCV
 B 27 HLA
 Vitamin D ?
Arend, Rev Bras Reumatol 2013
 Synovitis
Hypervascularization (Power Doppler)

Rheumatoid arthritis

Rowbotham, et al. AJR 2011

 Sacroiliitis
Syndesmophyte
Bone marrow edema (MRI T2)

Ankylosing spondylitis

Østergaard, et al, Kelley and Firestein’s Textbook of Rheumatology 10th Ed

 Deformity
Bone erosions

Rheumatoid Arthritis

Østergaard, et al, Kelley and Firestein’s Textbook of Rheumatology 10th Ed

“RHEUMATOID LUNG “
Rheumatoid Arthritis

Ankylosing Spondylitis
 ACR 20081 ACR 20122 ACR 20153
Factors affecting Disease duration* Disease duration** Disease duration**
treatment options Disease activity Disease activity Disease activity***
Poor prognostic features Poor prognostic features
First line cDMARD monotherapy cDMARD monotherapy cDMARD monotherapy
cDMARD combination cDMARD combination
Recommended MTX, LEF, HCQ, MIN, SSZ MTX, LEF, HCQ, MIN, SSZ MTX, LEF, HCQ, SSZ
cDMARD
Recommended Anti-TNF Anti-TNF (+) + Tofacitinib
bDMARD • Adalimumab • Certolizumab pegol
• Etanercept • Golimumab
• Infliximab + Tocilizumab
Abatacept
Rituximab
*< 6 mo; 6 – 24 mo; > 24 mo; ** < 6 mo; ≥ 6 mo; 1. Saag KG, et al. Arthritis & Rheumatism 2008 Vol. 59, No. 6,
***different recommendation 2. Singh JA, et al. Arthritis Care & Research 2012 Vol. 64, No. 5
3. Singh JA et al. Arthritis Care & Research 2015
cDMARD: conventional Disease Modifying Anti Rheumatic
Drugs; MTX: methotrexate; LEF: leflunomide; HCQ:
hydroxycloroquine; MIN: minocycline; SSZ: sulfasalazine
Singh JA et al. Arthritis Care & Research 2015
 Singh JA et al.
Arthritis Care &
Research 2015
Singh JA et al. Arthritis Care & Research 2015
 Singh JA et al.
Arthritis Care &
Research 2015
 Management of Ankylosing Spondylitis

Ward, et al. Arthritis & Rheumatology. 2015

 Management of Ankylosing Spondylitis

Ward, et al. Arthritis & Rheumatology. 2015

 Establishing a diagnosis of inflammatory arthritis is
important.
 Detailed anamnesis and physical exam can guide to a
definite diagnosis of inflammatory arthritis.
 Inflammatory arthritis often associated with systemic
symptoms/ involvement/ manifestation.
 Abnormalities detect by radiographic examination
indicating late phase of the disease.
 Management including symptomatic treatment with
NSAIDs, remission induction with DMARD, physical
treatment to prevent complication, and corrective
surgery to manage severe deformities.