Step into the Rheum: When to refer to a rheumatologist?
Samah Osman Musa, MD
Consultant Rheumatologist
Aman Hospital
In 2019, 1.71 billion people globally suffered from musculoskeletal conditions (1), and a small proportion of these conditions are due to inflammatory diseases best treated by a rheumatologist. This population can be identified by recognizing inflammatory features when presenting to their primary care physician. Inflammatory joint pain improves with movement and worsens with rest. It is associated with morning stiffness lasting greater than 30 minutes, swelling, and warmth, and may also have systemic features such as fever, weight loss, or fatigue. These features should prompt further investigations and evaluation by a rheumatologist.
Rheumatoid arthritis classically presents as symmetric synovitis of the small joints of the hands and feet lasting longer than six weeks. The presence of rheumatoid factor (RF) and/or anti-cyclic citrullinated protein (anti-CCP) can help diagnose but also plays a role in prognosis. Those with higher titers of RF and anti-CCP tend to have more severe diseases. Prednisone can quickly relieve inflammation, but its use should be limited to short tapers. Prednisone cannot be used in the long term due to risks of hyperglycemia, insulin resistance, osteoporosis, and cardiovascular. People with rheumatoid arthritis should start disease-modifying antirheumatic drugs to prevent the progression of the disease; with correct counseling and monitoring, these medications are effective and safe.
One acute swollen joint can have several different causes. However, this clinical presentation is considered an emergency, as it is important to rule out septic arthritis. Septic arthritis is quite rare, but if not identified as soon as possible or treated correctly, it can cause significant destruction. It can appear very similar to a gouty flare or a flare of rheumatoid arthritis. The most appropriate intervention is arthrocentesis and analysis of joint fluid to quickly identify the cause.
The antinuclear antibody test (ANA) is essential, but its interpretation can be tricky. A retrospective study looking at referrals to a rheumatology clinic showed that the pretest probability of the ANA in this subset was 2.1% for diagnosis of systemic lupus erythematosus (3). This is extremely poor and mainly attributed to tests being ordered for patients without symptoms of an ANA-associated disease. When ordering this test, it is important to identify the complaints that provide the appropriate clinical context for its interpretation. A young woman with photosensitivity butterfly rash, oral ulcers, fevers, and inflammatory joint pain is highly suspicious for SLE, and an ANA would have a higher pretest probability in this case. The ANA by immunofluorescence is the gold standard as it provides additional information for diagnosis.
Body pain and fatigue are common complaints in the primary care setting. All-over body pain lasting for three months or longer without localization and other symptoms such as brain fog, fatigue, and unrefreshing sleep and no discernable cause should prompt consideration of fibromyalgia. Fibromyalgia is due to central sensitization, which results in increased pain signals to the brain and reduced inhibitory signals. Treatment involves graded exercise therapy, psychological therapy, and pharmacotherapy. (4)
Citations:
- Cieza, Alarcos et al. “Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019.” Lancet (London, England) 396,10267 (2021): 2006-2017. doi:10.1016/S0140-6736(20)32340-0
- Kay, Jonathan, and Katherine S Upchurch. “ACR/EULAR 2010 rheumatoid arthritis classification criteria.” Rheumatology (Oxford, England) 51 Suppl 6 (2012): vi5-9. doi:10.1093/rheumatology/kes279
- Abeles, Aryeh M, and Micha Abeles. “The clinical utility of a positive antinuclear antibody test result.” The American journal of medicine 126,4 (2013): 342-8. doi:10.1016/j.amjmed.2012.09.014
- Macfarlane, G J et al. “EULAR revised recommendations for the management of fibromyalgia.” Annals of the rheumatic diseases 76,2 (2017): 318-328. doi:10.1136/annrheumdis-2016-209724