This issue of Missouri Medicine discusses multiple rheumatologic topics for the Primary Care Provider, written by experts at the University of Missouri - Columbia School of Medicine, Division of Immunology and Rheumatology. From laboratory tests to new information regarding spondyloarthropathies and fibromyalgia, the articles also address ophthalmologic findings associated with rheumatic diseases, and calcium crystal musculoskeletal manifestations round out the series. Understanding the above disease processes, and developing an approach to rheumatologic test ordering will guide the provider in referring patients, help the provider identify diseases, and facilitate the provider in an understanding of therapeutic approaches.
The diagnosis of fibromyalgia, a syndrome of aches and pains and fatigue, in the past, has been based on specific tender point criteria. However, this approach may be changing. It is well established that fibromyalgia includes many additional symptoms including poor sleep, and headache, as well as cognitive and mood changes. Fibromyalgia can be primary or secondary to specific diseases and triggers. Identifying initiating events, diseases or triggers will ultimately influence treatment and outcome. This issue discusses the evolving directions in the criteria and the description of the syndrome, and provides new insights into etiopathogenesis. With a better understanding of the many contributing factors to this diagnosis, new medications and therapeutic options for the treatment have expanded. Deanna Davenport, APRN, FNP, and Celso Velazquez, MD, will introduce you to these new diagnostic concepts and treatments in “New Directions in Fibromyalgia,”
Rheumatologic blood testing and interpretation of results have, at times, perplexed our non-rheumatologist colleagues, and for good reason. Deciding when to order such tests and the interpretation of results may be confusing. Rheumatologic test results, in the end, must be assessed in the context of the clinical picture and of ongoing treatments. While many tests are available, many are not diagnostic and a significant number may be false negative or false positive. In their article “Rational Use of Blood Tests in the Evaluation of Rheumatic Diseases,” Drs. Siva, Larson, and Barnett, will review the approach to ordering and understanding these tests, including antinuclear antibodies (FANA and ANA profile), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-neutrophilic cytoplasmic antibodies (ANCA), HLA-B27, rheumatoid factor (RF), uric acid levels, anti-cyclic citrullinated peptide antibodies (anti-CCP) as well as anti-phospholipid tests including anti-cardiolipin antibodies (ACA), anti-beta 2 Glycoprotein I antibodies, and lupus anticoagulant (LAC).
It is well known that rheumatic diseases are multisystem. While most providers know that aches, pains, rashes, pulmonary findings, and renal manifestations are frequently involved in systemic rheumatic diseases, other symptoms may prevail or herald the onset of autoimmune diseases. Ophthalmologic findings associated with rheumatic diseases are more common than one might think. Indeed the breadth and severity of such manifestations requires the expertise of our ophthalmologic colleagues, for both diagnosis and treatment. In the article, “Ocular Manifestations of Rheumatic Disease: Diagnosis and Management,” Drs. Almony and Petris review the manifestations and give a guide to clinical signs, symptoms, and treatment.
Primary care physicians are often the first line provider in diagnosing gout and gouty arthritis. The classic findings of pain, rubor and swelling are rarely missed. But calcium pyrophosphate (CPPD) musculoskeletal complaints are less well appreciated and can be robust, subtle and varied in presentation. CPPD may manifest as acute, chronic or destructive arthritis, as a radiographic finding or as a soft tissue symptom. And while CPPD disease is most commonly idiopathic it may represent a manifestation of an underlying disease. Drs. Ivory and Velazquez will discuss this interesting disease process, describe the various presentations and provide a guide to diagnosis and treatment in “The Forgotten Crystal: Calcium Pyrophosphate and Arthritis.”
Spondyloarthropathies representing a group of inflammatory arthritic diseases encompassing psoriatic arthritis, ankylosing spondylitis, reactive arthritis and arthritis with inflammatory bowel disease, are less well understood than rheumatoid arthritis. The importance of potential infectious triggers and new pathologic pathways is becoming more apparent. Such triggers in the context of a permissive genetic background have begun to provide a better picture of etiopathogenesis leading to better treatments. With new biologic medications, and new indications for their use, treatment of such diseases has improved in the last decade. Drs. Wilson and Folzenlogen will update you on the new facets of this interesting group of diseases in “Spondyloarthropathies: New directions in Etiopathogenesis, Diagnosis and Treatment.”
Biography
Darcy D. Folzenlogen, MD, FACP, is an Associate Clinical Professor at the University of Missouri School of Medicine Division of Immunology and Rheumatology.
Contact: FolzenlogenD@health.missouri.edu
