Arthritis

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By: gdhpgmi (115 month(s) ago)

excellent presentation for medica graduates

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“Things may come to those who wait, but only the things left by those who hustle.” – Abraham Lincoln : 

“Things may come to those who wait, but only the things left by those who hustle.” – Abraham Lincoln

Pathology of Arthritis: 

Pathology of Arthritis Dr. Venkatesh M. Shashidhar. Associate Professor of Pathology Fiji School of Medicine

Joints:: 

Joints: Mobility - Cranial sutures  Shoulder joint. Articular cartilage – hyaline – friction res. Synovial fluid – lubric/nutri, Type A & B synoviocytes. Hyaluronidase Continuous production and absorption. Affected by Inflammation, immobility. Capsule, ligaments, menisci. Vascular, rich nerve supply – Art. Cartilage*

Joints - Anatomy: 

Joints - Anatomy

Arthritis - Introduction: 

Arthritis - Introduction Inflammation of joints - Common Common site for autoimmune injury Heart valves & Joints - damage – Exposure of hidden antigens. Infections. Degeneration – Age/Stress/life style Use it or Loose it….!

Arthritis – Clinical features:: 

Arthritis – Clinical features: Pain  Inflammation - capsule, synovium, periosteum. Swelling:  inflammation, effusion, proliferation. Restricted movement  pain, fluid, synovial swelling, damage. Deformity  mal-alignment, erosion, ankylosis

Arthritis Clinical Classification:: 

Arthritis Clinical Classification: Monoarthritis: Local, asymmetric, secondary. Acute: Bacterial, Trauma, Crystal, Reactive Chronic :Tuberculosis, Lyme, Fungal, Trauma, Tumors. Polyarthritis: Chronic, symmetric, systemic. Autoimmune, degenerative, Crystal. Rarely infective.

Polyarthritis Classification:: 

Polyarthritis Classification: Autoimmune: Rheumatic, Rheumatoid, Ankylosing spondylitis, Reiter syndrome etc. Degenerative: Osteroarthritis Crystal Deposition: Gout – Monosodium urate CPPD - Pseudo Gout Infective - Septic, TB, Lyme etc. rare.

Rheumatoid Arthritis: 

Rheumatoid Arthritis

Epidemiology of RA: 

Epidemiology of RA Prevalence about 1% of US population Female : Male ratio = 2:1 Strong association with HLA DR4. Concordance in identical twins only 30%

RA - Definition:: 

RA - Definition: Chronic Multisystem autoimmune inflammatory disorder primarily affecting joints producing a proliferative synovitis that often progresses to destruction of the articular cartilage and ankylosis.

Etiology:: 

Etiology: Genetic Susceptibility: HLA DR4, or DR1 in 65% to 80% cases. Microbial inciting agent: Epstein-Barr virus, Borrelia & Mycoplasma Autoimmunity: IGM anti IgG – RA Factor. Helper T cell (CD4) against type II collagen & cartilage glycoprotein-39

Immuno-dysregulation in RA: 

Immuno-dysregulation in RA T lymphocytes  type II collagen & superantigen  releasing cytokines  inflammation. B cells  IgM Rheumatoid factor – anti IgG. Macrophages surround RF factor complex  type III injury (immune complex)  cytokine release  inflammation damage.

Morphology:: 

Morphology: Proliferative synovitis with lymphocytes (CD4), plasma cell & macrophages Pannus. Organizing fibrin (rice bodies). Neutrophils on the joint surface and fluid. Juxta-articular erosions, cysts & osteoporosis Fibrous ankylosis. Skin - Rheumatoid nodules Vasculitis (commonly of digital arteries)

Early Destruction in RA:: 

Early Destruction in RA: Swan Neck Deformity

RA - Clinical Features:: 

RA - Clinical Features: Morning stiffness. Arthritis in 3 or more joint areas. Arthritis of small hand joints. Symmetric arthritis. Rheumatoid nodules. Serum rheumatoid factor. Typical radiographic changes At least 4 features for diagnosis.

N.Synovium - - R.Arthritis:: 

N.Synovium - - R.Arthritis:

RA - Pannus:: 

RA - Pannus:

RA - Pannus:: 

RA - Pannus: Hyperplastic inflammed synovium

Extra-Articular RA: 

Extra-Articular RA Rheumatoid Nodules Vasculitis Pleuritis Pericarditis Tendonitis

Skin RA Nodule:: 

Skin RA Nodule:

Skin RA Nodule:: 

Skin RA Nodule:

Rheumatoid Nodule (skin):: 

Rheumatoid Nodule (skin): Palisading Macrophages Central Fibrinoid Necrosis

Joint involvement in RA:: 

Joint involvement in RA:

Swan Neck Deformity in RA:: 

Swan Neck Deformity in RA:

Joint Destruction in RA:: 

Joint Destruction in RA: Swan Neck Deformity

RA Joint destruction, ankylosis:: 

RA Joint destruction, ankylosis:

Osteoarthritis: 

Osteoarthritis Degenerative arthrosis. (Osteoarthrosis)

Osteoarthritis:: 

Osteoarthritis: Degenerative end result - (ageing) >80% in >65y. Progressive erosion & fibrillation of articular cartilage  forms Loose bodies. Large weight bearing joints. Hardened articular bone – eburnation. & Subarticular cyst formation in bone. Periarticular osteophyte formation. Mild inflammation but painful, morning stiffness. Limited range of movements Heberden nodes (F)

Normal -- Femur Head -- OA: 

Normal -- Femur Head -- OA Normal Osteoarthritis

Femur Osteroarthritis:: 

Femur Osteroarthritis:

Joint Mice or Loose Bodies:: 

Joint Mice or Loose Bodies:

Spine Osteophytes (OA):: 

Spine Osteophytes (OA):

Radiologic Features:: 

Radiologic Features: nonuniform joint space loss, osteophyte formation, cyst formation subchondral sclerosis Sclerosis, ankylosis & deformity.

Osteoarthritis:: 

Osteoarthritis: Narrow joint space Lipping – osteophyte Dislocation Osteoporosis.

Osteophyte formation:: 

Osteophyte formation:

Bone cysts in OA:: 

Bone cysts in OA:

Osteoarthritis: Ankylosis: 

Osteoarthritis: Ankylosis varus deformity of the knee and collapse of the joint space with destruction of the medial cartilage and the subchondral cortex (open arrowheads).

Osteoarthritis:: 

Osteoarthritis: Lateral view of the left knee shows sclerosis with marked osteophyte formation (arrows). The osteophytes are best seen in this view.

Osteoarthritis:: 

Osteoarthritis: Subchondral cysts (solid arrowhead)

OA Fingers:: 

OA Fingers:

OA Hip:: 

OA Hip:

OA Hip: 1997, bilateral, joint space narrowing (arrows) at the hips that is worse on the left side : 

OA Hip: 1997, bilateral, joint space narrowing (arrows) at the hips that is worse on the left side

OA Hip: Subchondral sclerosis (solid arrowhead) and cyst (arrow) formation are also noted on the left side : 

OA Hip: Subchondral sclerosis (solid arrowhead) and cyst (arrow) formation are also noted on the left side

OA Hip:left hip arthroplasty : 

OA Hip:left hip arthroplasty

OA - Clinical Features:: 

OA - Clinical Features: pain worsens with activity & improves on rest. Instability of joints – Knee. Crepitus, limitation of motion. Muscle spasm, and tendon and capsular contractures. Early morning stiffness lasts 1 hour or more. bony overgrowth – interphalangeal joints distal(Heberden's) proximal (Bouchard's).

Differentiating Features:: 

Differentiating Features: Rheumatoid Arthritis: Young, small joints Autoimmune. Synovial Inflammation synovium  Cartilage Osteoarthritis: Old, Large joints Degenerative. Cartilage degeneration. Cartilage  Synovium

Arthritis Other : 

Arthritis Other Infective, traumatic, secondary to systemic diseases.

Seronegative arthropathies: 

Seronegative arthropathies Ankylosing Spondylitis: Adolescent boys, HLA B27, axial joints (sacroiliac) Reiter Syndrome: Triad of arthritis, urethritis/cervicits & conjuctivitis Autoimmune but initiated by bacterial infection. Enteropathic Arthritis: Secondary to bowel infections (salmonella, shigella) HLA B27 positive Psoriatic Arthritis: 5% of patients, starts in DIP joints, similar to RA.

Septic Arthritis:: 

Septic Arthritis:

Gonococcal Arthritis:: 

Gonococcal Arthritis:

Juvenile Rheumatoid Arthritis:: 

Juvenile Rheumatoid Arthritis: Before age 16 Multisystem involement - Spleenomegaly, Starts with systemic involvement unlike RA. No serum RA Factor – Seronegative Antinuclear Antibody (ANA) +ve  autoimmune.

Big Toe in Gout:: 

Big Toe in Gout:

Joint Destruction in Gout:: 

Joint Destruction in Gout:

Gout Tophi:: 

Gout Tophi:

Urate Crystals (Gout):: 

Urate Crystals (Gout):

Pseudo Gout: 

Pseudo Gout Calcium PyroPhosphate Deposition disease CPPD Chondrocalcinosis.

CPPD – (Chondrocalcinosis): 

CPPD – (Chondrocalcinosis) Type A – Pseudo gout – Knee, men Type B – Pseudo rheumatoid - polyarthritis Type C – Pseudo OA + acute attacks, women Type D – Pseudo OA - acute attacks, hands Type E – Asymptomatic Type F – Pseudoneuropathic

CPPD-Arthritis (pseudo gout):: 

CPPD-Arthritis (pseudo gout):

Pseudo Gout – Calcium pyrophoshate: 

Pseudo Gout – Calcium pyrophoshate

Ankylosing Spondylitis: 

Ankylosing Spondylitis Marie-Strumpell Arthritis Young males, 90% HLA B27 + <1% Rheumatoid factor – seronegative. >25% have iritis 10% Aortic insufficiency Strongly familial, 100% concordance in monozygotic twins.

AS - fusion of vertebral bodies due to bridging syndesmophytes.: 

AS - fusion of vertebral bodies due to bridging syndesmophytes.

Scoliosis in Ankylosing Spondylitis: 

Scoliosis in Ankylosing Spondylitis

Organisms in Reiter’s : 

Organisms in Reiter’s Shigella Flexneri Salmonella S.typimurium – others Yersinia enterocolitica Campylobacter Jejuni Chlamydia trachomatis Ureaplasma urealyticum

Arthritis Comparison:: 

Arthritis Comparison:

Slide66: 

"The gem cannot be polished without friction, nor man perfected without trials or problems (or exams)…!." --Chinese proverb

Pathology of Reiter’s Syndrome: 

Pathology of Reiter’s Syndrome Acute Synovitis Chronic changes (in some) Unilateral Sacroilitis Ascending arthropathy Ossification & enthesopathy Ileal, colonic or urethral - non specific mucosal inflammation

Reiter’s Syndrome:: 

Reiter’s Syndrome:

Iritis:: 

Iritis:

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