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