Excerpts from "Diagnostic Pitfalls in Rheumatology"

The Philippine Academy of Family Physicians hosted a very successful annual meeting last February 16- 20. I was invited to do this lecture and  while the title of the talk is "pitfalls", it really talks of misdiagnosis or missed diagnosis. In a nutshell, I identified four states where diagnosis is either difficult to come by, or actually missed, here are some excerpts:


 A. The monoarthritis muddle:

• Gout is commonly overdiagnosed (other arthritis diagnosed as gout)
• Psoriatic arthritis and pseudogout are usually missed for gout
• Crystal arthritis (gout and pseudogout) are settings for misdiagnosis of septic/ bacterial arthritis
• some cases get operated on
• antibiotics are given
• some would recommend management of acute monoarthritis as infectious arthritis until proven otherwise
• Crystal arthritis can be complicated with bacterial arthritis
• TB arthritis diagnosis is usually either delayed or missed. In reports, it is only considered once NSAIDs and antibiotic treatment fail.

B. The polyarthritis puzzle 

• Underdiagnosis of polyarticular gout ("diuretic" gout)
• among elderly females on antihypertensive medications with hydrochlorothiazides ( usually a "co" prefix or"plus"  suffix of common drugs for hypertension),  - for rheumatoid arthritis
• Missed diagnosis of connective tissue diseases where arthritis is initial presentation, and other signs and symptoms take years to manifest
• examples are systemic lupus erythematosus, scleroderma, mixed connective tissue disease

C. The early arthritis enigma - in the advent of technology and concepts of treat to target and personalized treatment, patients with early arthritis (less than 3 months to a year or 2 of arthritis) can be a treatment enigma, and the question is - do we treat aggressively to catch the reversible phase of joint destruction or wait for more symptoms and risk permanent joint destruction?    

• Treatment entails expense and adverse events and these are the known outcomes of early arthritis:
• 1/3 to half of cases resolve
• another third develop to full blown rheumatoid arthirtis
• less than a third of cases become other forms of arthritis

D. The similar sounding diagnoses (lay or medical personnel misuse of terms)

• "rheumatic arthritis", rheumatic fever and rheumatoid arthritis
• osteoarthritis (joint disease with bone thickening and cartilage thinning, etc) vs. osteoporosis (bone thinning, predisposing to fracture)
• rheumatic heart disease vs. rheumatic fever

World political climate and continuing medical education

Just 4 years back, the Asia Pacific League of Associations for Rheumatology (APLAR) picked Syria as the site of the 2012 APLAR Convention. This convention sees rheumatologists -clinicians, researchers and academics, from the region and the rest of the world come and sit around to discuss the future of rheumatology. It is held every 2 years. Hongkong hosted the 2010 meeting, which saw over 2000 delegates from all over the world. The Damascus meeting was much anticipated. There was a special value added to  learning rheumatology in the "seat of civilization".

Then came the Arab spring. There was not the faintest hint to this phenomenon, the extent of the upheaval, the geographic and human toll, and the global economic repercussions it would bring on an already unsettled world. Syria joined the fray, and the APLAR sat and waited for the sand storm to settle. As the rest of the Arab world claps the dust off their backs and tries to stand and get back on track, this would not be in Syria. To date, the internal war rages on, causing literally, internal hemorrhage - as media would show it.

We are in prayer for our friends there, the doctors, the rest of the citizens of Syria, as they go through this painful process of change- prayer for end of conflict so its citizens will again live in peace. We in the rheumatology community feels a special tinge of sadness on what we are seeing in Syria. We continue to hope that in the years to come, we can still get that chance to sit on the "seat of civilization" and learn.