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Edit Comment Close Premium member Presentation Transcript “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 MedicineJoints:: 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 - AnatomyArthritis - 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, ankylosisArthritis 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 ArthritisEpidemiology 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-39Immuno-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 DeformityRA - 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 synoviumExtra-Articular RA: Extra-Articular RA Rheumatoid Nodules Vasculitis Pleuritis Pericarditis TendonitisSkin RA Nodule:: Skin RA Nodule: Skin RA Nodule:: Skin RA Nodule: Rheumatoid Nodule (skin):: Rheumatoid Nodule (skin): Palisading Macrophages Central Fibrinoid NecrosisJoint 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 DeformityRA 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 OsteoarthritisFemur 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 SpondylitisOrganisms in Reiter’s : Organisms in Reiter’s Shigella Flexneri Salmonella S.typimurium – others Yersinia enterocolitica Campylobacter Jejuni Chlamydia trachomatis Ureaplasma urealyticumArthritis Comparison:: Arthritis Comparison:Slide66: "The gem cannot be polished without friction, nor man perfected without trials or problems (or exams)…!." --Chinese proverbPathology 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 inflammationReiter’s Syndrome:: Reiter’s Syndrome:Iritis:: Iritis: You do not have the permission to view this presentation. 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Arthritis Bianca Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINTLite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2095 Category: Education License: All Rights Reserved Like it (5) Dislike it (0) Added: February 27, 2008 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: gdhpgmi (16 month(s) ago) excellent presentation for medica graduates Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript “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 MedicineJoints:: 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 - AnatomyArthritis - 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, ankylosisArthritis 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 ArthritisEpidemiology 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-39Immuno-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 DeformityRA - 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 synoviumExtra-Articular RA: Extra-Articular RA Rheumatoid Nodules Vasculitis Pleuritis Pericarditis TendonitisSkin RA Nodule:: Skin RA Nodule: Skin RA Nodule:: Skin RA Nodule: Rheumatoid Nodule (skin):: Rheumatoid Nodule (skin): Palisading Macrophages Central Fibrinoid NecrosisJoint 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 DeformityRA 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 OsteoarthritisFemur 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 SpondylitisOrganisms in Reiter’s : Organisms in Reiter’s Shigella Flexneri Salmonella S.typimurium – others Yersinia enterocolitica Campylobacter Jejuni Chlamydia trachomatis Ureaplasma urealyticumArthritis Comparison:: Arthritis Comparison:Slide66: "The gem cannot be polished without friction, nor man perfected without trials or problems (or exams)…!." --Chinese proverbPathology 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 inflammationReiter’s Syndrome:: Reiter’s Syndrome:Iritis:: Iritis: