Seropositive arthritis Rheumatoid and others

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a comprehensive set on all Seropositive arthritides/ arthropathies
mainly discussing the features of Rheumatoid arthritis.

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  • Generalised This may be due to steroids or limitation of
    movement due to pain, or muscle wasting, and occurs later in the
    course of the disease.
  • As in rotator cuff tears allow upward subluxation
    of the eroded humeral head.
    Gross rheumatoid arthritis with ulnar deviation,
    subluxation and joint narrowing at the metacarpophalangeal joints.
    Boutonniere deformities are present at the index and little fingers
  • Progressiv ejoint space narrowing
  • Erosiins typically appear lateral side of 5th metatarsal but the medial side of others.
    Fig very pronounced destructive changes in tarsus and in metatarsal heads

  • Pannus is an abnormal layer of fibrovascular tissue or granulation tissue.
    Geodes in rheumatoid arthritis. There is joint space narrowi
    ng. Osteoporosis is demonstrated. An effusion is present. There are large
    distal femoral geodes which reach the patellofemoral articulation.
  • Caplan syndrome (also known as rheumatoid pneumoconiosis) is the combination of seropositive rheumatoid arthritis and a characteristic pattern of fibrosis.
    5 - 50 mm well-defined nodules in the upper lung lobes / lung periphery.
    nodules may remain unchanged, multiply, calcify, or become thick walled cavities.
    background changes of pneumoconiosis
    may have an accompanying pleural effusion
    features often grow in short bursts
  • Fig 3 shows extensive pulmonary fibrosis with honey combing (rare more commonly assosciated with Progressive massive pulmonary fibrosis)
  • Mediastinal window image showing cavitatory lesions in bilateral upper lobes (arrows) with large fibrotic area in right upper lobe (arrow head) and few subpleural fibrotic lesions 
  • MALAR RASH
    ALSO SEEN IN  Pellagra, dermatomyositis, and Bloom Syndrome.
    This is due to the presence of two X chromosomes in the female as opposed to the one X chromosome present in males. The X chromosome carries immunological related genes, which can mutate and contribute to the onset of SLE. The Y chromosome has no identified mutations associated with autoimmune disease
  • the oblique radiograph of her left hand shows dislocation at the first carpometacarpal joint (arrow) and subluxations in the metacarpophalangeal joints of the index and middle fingers associated with swan-neck deformities

    because the malalignments are flexible and are corrected by the pressure of the hand against the radiographic cassette
  • A 62-year-old woman presented with a 15-year history of systemic lupus erythematosus. Dorsovolar view of both hands shows severe deformities, subluxations, and articular erosions. Note the advanced (generalized ) osteoporosis secondary to disuse of the extremities and treatment with corticosteroids.
  • . Multiple soft tissue calcifications follow muscles planes of thigh
    There is significant osteoporosis.
  • Coronal T1-weighted image of the thighs showing fatty infiltration of the muscles caused by chronic myopathy
  • dilatation of distal 2/3 of the oesophagus 1
    apparent shortening of length due to fibrosis
    Small bowel: uminal dilatation (can be massive)
    reduced peristalsis / delayed contrast transit.
    hidebound bowel sign (crowding of valvulae conniventes): thought to be pathognomonic of scleroderma
    sacculation (antimesenteric border, focal dilatations, pseudo-diverticula)


  • Dermatomyositis
  • Septic arthritis of proximal interphalangeal joint of the fifth finger. Lupus patient with pain and focal increase in volume (A). Coronal and sagittal MRI T2-weighted images with fat suppression (B,C) demonstrating medullary edema in bone borders (black arrow on B) and strain caused by articular capsule fluid in the fifth finger proximal interphalangeal joint (white arrow on C). On the sagittal image, erosion of the corresponding proximal phalanx is also well characterized. Coronal, contrast-enhanced MRI T1-weighted image (D) demonstrating contrast enhancement surrounding the bone, synovia and soft tissues of this area.
  • Seropositive arthritis Rheumatoid and others

    1. 1. SEROPOSITIVE ARTHRITIS
    2. 2. INTRODUCTION  SEROPOSITIVE ? • RA FACTOR • Anti-CCP antibodies  RF assosciations Rheumatology: Rheumatoid Arthritis; SLE; Sjogren’s; MCTD; Myositis; Cryoglobulinemia; Others: SABE; syphilis; Sarcoidosis; cirrhosis; Walden storm's macroglobulinemia; etc ….  RA factor is seen in 5-10% of normal population as well
    3. 3. Rheumatoid Arthritis  Chronic systemic inflammatory disease  Affects many organs  Predominantly attacks the synovial tissues and joints.  Peak 20-55yrs  M:F = 1:3  Clinincally Low-grade fever, fatigue, weight loss, muscle soreness, and atrophy Symmetric peripheral joint pain and swelling, particularly of the hands  Typically involves small joints : metatarsophalangeal and  metacarpo-phalangeal and carpal joints (very often SYMMETRICAL involvement) Axial skeleton involvement n advanced stages
    4. 4. CLINICAL DIAGNOSTIC CRITERIA  American College of Rheumatology revised criteria require that 4 out of 7 of the following are present 4: 1. morning stiffness lasting at least 1 hour before maximal improvement 2. soft tissue swelling of 3 or more joints observed by a physician 3. swelling of the proximal interphalangeal, metacarpophalangeal, or wrist joints 4. symmetric swelling 5. rheumatoid nodules 6. the presence of rheumatoid factor; and 7. radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints.
    5. 5. RADIOLOGICAL FINDINGS  X-RAYS 1. Soft-tissue changes 2. Osteoporosis 3. Joint space changes and alignment deformities 4. Periostitis 5. Erosions 6. Secondary osteoarthritis
    6. 6. SOFT TISSUE CHANGES  More clinical exam than radiological finding  Swelling due to 1. oedema of peri- articular tissues 2. synovial inflammation in bursae, joint spaces and along tendon sheaths. 3. Joint distension increased synovial fluid.  Hands: most commonly seen fusiform swelling metacarpophalangeal joints ulnar styloid (invl of ext carpi ulnaris tendon) radial styloid (invl of radiocarpal synocial hypertrophy)  Foot  Similar fusiform swelling can be found in the 1st and  5th metatarsal heads
    7. 7. At the Achilles tendon insertion When synovitis thickens the bursa , oedema obliterates the local fat and blurs out margins of the tendon Note : the swelling is symmetric but if a rheumatoid nodule Is present at the swelling it may appear eccentric (as in olecranon)
    8. 8. OSTEOPOROSIS  Assessment of osteoporosis depends in part on film quality, and comparison between normal and abnormal joints in the same patient.  Interpretation is subjective and changes arc seen only after loss of 25-50% of mineral density  Types 1. Late/Generalised ( steroid and limitation of movement) 2. Early/ Localized (synovial inflammation and hyperaemia)  In menopausal women , generalized osteoporosis masks the osteoporotic changes due to RA  Generalised or solitary sclerosis one or more distal phalanges is an impoirtan finding
    9. 9.  Terminal phalangeal sclerosis New bone with no ,medullary cavity . IVORY PHALANX
    10. 10. JOINT SPACE CHANGES  EARLY WIDENING due to synovial hypertrophy and Effusion  LATER NARROWING of joint space due to cartilage destruction by pannus  Allignment abnormalities at joint due to weakening of capsule and tendinitis Leads to tendon rupture or improper muscle action The boutonniere deformity results from proximal interphalangeal joint flexion and distal intcrphalangeal joint extension swan-neck deformity proximal interphalangeal joint extension and distal interphalangeal joint flexion. The boutonniere deformity is the more common. Z-deformity radial deviation at the wrist; ulnar deviation of the digits, and often palmar subluxation of the proximal phalanges
    11. 11. JOINT SPACE CHANGES  Swan neck deformity
    12. 12.  Synovitis of the metacarpophalangeal joint.  Longitudinal high-resolution (10.5-MHz) sonogram shows thickened synovial tissue (arrows).
    13. 13.  Coronal contrast- enhanced fat- saturated T1-weighted MR image shows hyperenhancement of small joints in the hand (arrows), a finding that reflects hyperemic synovial tissue. Erosions (arrowheads) and thickened, intensely enhancing synovium are seen at the fifth metacarpophalangeal joint
    14. 14. EROSIONS  Most important diagnostic feature  Incidence rises with duration progresses (<40% at 3months to 90-95% at 10years )  Peri-articular erosion starts in the bare area  In Hand 1. Carpal erosions occur extensively. 2. Ulnar and radial styloid 3. Proximal compartment of distal radioulnar joint. 4. Fusion is inevitable especially in CARPAL joints  In Foot 1. Earlier seen in feet most often 5th metacarpo- phalangeal joint. 2. Apart from posterior and inferior surfaces of 3. CALCANEUM tarsal erosion are uncommon 4. (Tarsal erosion is seen commonly in sero-negative)
    15. 15.  Local Demeneralisation  progressive resorption of Sub-cortical Bone  Pannus sread  Destruction of articular cartilage  Once destroyed the articular cartilage rarely reforns on helaing  Erosive changes are less common in larger joints but bone destruction Is more  intraosseous defects-cysts (Geodes) are seen 3 – 4 cm or more in diameter.  I
    16. 16.  A. Diagram. Three sites for potential erosions to occur are shown.  B. Erosions. Note the erosion from the extensor carpi ulnaris (rat bite lesion) (arrow) and prestyloid recess (arrowhead). Note the adjacent erosion on the triquetral bone (crossed arrow).  C. Erosions. Note the three sites of ulnar erosion: extensor carpi ulnaris (arrow), prestyloid recess (arrowhead), and radioulnar articulation (crossed arrow). Observe the adjacent soft tissue swelling
    17. 17.  RHEUMATOID ARTHRITIS: FEET  A. Diagram, Marginal Erosions. Target sites for marginal erosions lie on the medial surfaces of the metatarsal heads, except for the fifth metatarsal where early erosions can occur on the lateral side.  B. PA Foot. Typical radiographic depiction of the locational predominance on the medial metatarsal surfaces, except at the fifth. Note the phalangeal fibular deviation. (Lanois deformity)
    18. 18.  Coronal contrast-enhanced fat- saturated T1-weighted MR image shows synovitis of the second and third metacarpophalangeal joints. A subcortical cyst (arrowhead) is seen near the bare area  This type of lesion is called a pre- erosion or subcortical erosion
    19. 19.  MR image shows a small effusion of the third metacarpophalangeal joint
    20. 20. PERIOSTEITIS Local periosteal reactions occur either along the midshaft of a phalanx or metacarpal as a reaction to local tendinitis, at the metaphysis near a joint affected by synovitis. Such changes are less common in rheumatoid arthritis than in the seronegative arthropathies
    21. 21. SECONDARY OA CHANGES  Seen in Weight bearing joints  Its seen at Hip joints commonly.  Superimposes the undetected RA  ASYMMETRY IS KEY IN DIAGNOSIS  Reactive sclerosis and new bone formation in osteoarthritis is not marked
    22. 22. INVOLVEMENT OF AXIAL SKELETON  C1 /C2 JOINT  Osteoporosis with disc narrowing  Endplate irregularity.  Little new bone formation  Erosions of facet joints result in Subluxation  Commonly seen in the synovial joint between the odontoid peg and arch of atlas potentiated by laxity of ligaments around the peg.  Separation in flexion of more than 2.5 mm in adults or 5 mm in children is held to be abnormal.  30% of patients with chronic rheumatoid arthritis and is best seen in flexion.  The eroded odontoid may also fracture  Resorption of hone at non-articular surfaces occurs in the cervical spine at the spinous processes, which become short, sharp and tapered in patients with chronic disease
    23. 23.  the translocation of odontoid into and beyond the foramen magnum (arrows) owing to erosion and destruction of the upper two cervical vertebrae
    24. 24. SACRO-ILIAC JOINT  Sacro iliac Joint  Changes are less common and less severe than Spinal changes  More common in seronegative disease but may he seen in up to 30% of those with longstanding disease.  Seen more in women  Usually unilateral and involving the lower two thirds of the joint; erosions present but no sclerosis; rarely, ankylosis.
    25. 25. Shoulder joint changes  Uniform loss of glenohumeral joint space, marginal erosions (particularly at the superior lateral portion of the humerus), humerus often subluxated superiorly, tapered distal clavicle, seemingly widened acromioclavicular joint space.
    26. 26. Hip joint changes  RHEUMATOID ARTHRITIS: PROTRUSIO ACETABULI.  A. AP Hip Unilateral. Observe the symmetric loss of joint space and axial migration of the femoral head, creating a protrusio acetabuli (arrow).  B. AP Pelvis Bilateral. Note the uniform loss of joint space, small femoral heads, and protrusio acetabuli, characteristic of long- standing rheumatoid arthritis.  Note: The most common cause for bilateral protrusio acetabuli in the adult is rheumatoid arthritis
    27. 27. Knee joint changes A. Uniform Loss of Joint Space. Despite the loss of joint space, the distinct absence of subchondral sclerosis and diffuse osteopenia. B. Suprapatellar Effusion. Observe the bulging soft tissue density owing to effusion (arrows). A patellar erosion can also be appreciated. C. Baker’s Cyst. Note that on arthrography the extent of the cyst is defined extending into the popliteal space (arrows). Observe the rupture and dissection of the rheumatoid cyst into the posterior calf.
    28. 28. BONE SCAN Whole-body radioisotope scan showing areas of increase in uptake in the neck, both shoulder joints, the elbow joints, the left hip, both knees and ankles The distribution of disease is shown, but the changes on this scan are not specific.
    29. 29. NON-RHEUMATOLOGIC FEATURES  cardiovascular disease 1. accelerated coronary artery and cerebrovascular atherosclerosis which contribute significantly to the excess mortality of RA 2. pericarditis 3. vasculitis : occurs more commonly with severe erosive disease, rheumatoid nodules, high RF titres.  cutaneous involvement • rheumatoid nodules are usually seen in pressure areas : elbows, occiput, lumbosacral3. They generally occur in RF positive patients 9.  ocular involvement 1. keratoconjunctivitis sicca 2. uveitis 3. Episcleritis  Respiratory system: parenchymal or pleural diseases ; manifests as pleural thickening or Effusion, ground glass opacities Bronchiolitis , bronchienctasis (advanced stages), nodules – cavitation is seen commonly.
    30. 30. CAPLAN’S SYNDROME  Caplan syndrome (also known as rheumatoid pneumoconiosis) is the combination of seropositive rheumatoid arthritis and a characteristic pattern of fibrosis.  5 - 50 mm well-defined nodules in the upper lung lobes / lung periphery.  nodules may remain unchanged, multiply, calcify, or become thick walled cavities.  background changes of pneumoconiosis  may have an accompanying pleural effusion
    31. 31. SLE  chronic, inflammatory, connective tissue disorder of unknown cause  Common in young females  Classical Butterfly Rash over face.  SLE, like many autoimmune diseases, affects females more frequently than males, at a rate of almost 9 to 1.  RA factor , ANA  Unlike rheumatoid arthritis, lupus arthritis is less disabling <10% lupus arthritis will develop deformities of the hands and feet  present with a symmetrical peripheral arthropathy  Soft tissues swelling with calcification around joints and in blood vessels  Erosion is minimal and usually does not cause severe destruction of the joints.
    32. 32. SLE  Most deformities as in swan neck , ulnar deviation are reversible and arise due to tendon or ligament laxity  Avascular necrosis is common  In lateral radiograph 1. Mal-alignments, most commonly at the metacarpo-phalangeal and proximal inter-phalangeal joints of the fingers and the carpometacarpal, 1. metacarpophalangeal and the interphalangeal joints of the thumb Note : in an AP view most of the time these will be less apparent ….?
    33. 33. Dermatomyositis  Calcinosis Interstitialis Universalis  Degeneration of collagen tissue  diffuse subcutaneous plaques or nodules of calcium or reticular calcification often with overlying ulceration.  In addition with progression, calcified masses or sheets of calcium and phosphate metabolism. Seen in quadriceps, deltoid , calf muscles , elbows, kness, hands, abdominal wall, chest wall  Pointing and resorption of terminal tufts  Bone erosions are not a feature of these diseases.  Progressive disease is invariably fatal  High incidence of malignancy is seen
    34. 34. POLYMYOSITIS  Polymyositis (PM) refers a rare autoimmune (at times considered paraneoplastic) inflammatory myositis. It is considered a form of idiopathic inflammatory myopathy.  The condition is closely related to dermatomyositis and the term “polymyositis” is applied when the condition spares the skin.
    35. 35. Progressive systemic sclerosis (SCLERODERMA)  CREST SYNDROME ( Calcinosis Raynauds phenomenon : episodes of intermittent pallor of the fingers and toes on exposure to cold, secondary to vasoconstriction of the small blood vessels) Esophageal abnormalities: dilatation and hypoperistalsis Sclerodactyly Telengiectasia  30% to 40% of patients have a positive serologic test for rheumatoid factor and a positive antinuclear antibody (ANA) test.
    36. 36. Progressive systemic sclerosis  Bone changes 1. acro-osteolysis (resorption of the distal phalanges) 2. periarticular osteoporosis 3. joint space narrowing 4. erosions  Soft tissue changes 1. subcutaneous and periarticular calcification 2. atrophy especially at tips of fingers 3. With retraction of skin 4. flexion contractures  Other less common documented musculoskeletal findings 1. rib resorption, mandibular angle resorption, radius and ulna resorption 2. terminal phalangeal sclerosis
    37. 37.  Corroborative findings are seen in the gastrointestinal tract, where dilatation of the esophagus and small bowel  Pseudo diverticula of colon is also seen  In lungs Either UIP or NSIP pattern Most predominant feature will be fibrosis  early stages may show ground glass changes  later stages may show honeycombing and evidence of lung volume loss  lung bases and sub-pleural regions typically involved 4  cysts may be present measuring 1-5cm in diameter 4  pleural effusions are usually not a feature  ESOPHAGEAL DILATATION IS PATHOGNONOMIC
    38. 38. MCTD  MIXED CONNECTIVE TISSUE DISEASE  Overlap syndrome ( mix of Rheumatoid arthritis, dermatomyositis, SLE, Progressive systemic sclerosis)  The distribution may mimic rheumatoid arthritis, but distal interphalangeal joints may be affected and the peripheral arthropathy may be asymmetrical.  Osteoporosis (JUXTA ARTICULAR)  Soft tissue swelling and Joint space narrowing.  Erosive changes are not frequent as in RA  Distal phalanges show soft tissue loss, distal tuft bone resorption and calcification is feature of Progressive systgemic sclerosis
    39. 39. Sjogren’s syndrome  Chronic Autoimmune disease  Primarily affect Salivary and lacrimal glands resulting in XEROSTOMIA and keratoconjuctivtis sicca  Secondary Sjogren’s seen most commonly in people with diagnosed with RA  And SLE As a single entity sjogren’s doesn’t involve the joints. But definitely aggravates the primary Rheumatologic Arthropathy therby increasing the Morbidity and Mortality
    40. 40. SPOTTERS
    41. 41. THANK YOU
    42. 42. Jaccoud’s arthropathy  This condition is characterized by subluxation of metacarpophalangeal joints, “swan-neck” and Boutonniere deformities, besides “Z” deformity of thumb  CAN also occur in shoulder, knee and joints of feet.
    43. 43. Hidebound bowel sign  The hidebound bowel sign refers to an appearance on a barium study of the small bowel in patients with scleroderma. The sign describes the narrow separation between the valvulae conniventes which are of normal thickness despite dilatation of the bowel lumen.  Although the term hidebound is used specifically to describe scleroderma, the same appearance can be present in sprue. Stack of coins is an alternate descriptive term that can be used for both conditions.
    44. 44. case of persistent monoarticular arthritis  Because of the chronic use of corticoids in such patients, the signs and symptoms of infection are frequently masked and the process generally presents a chronic and indolent course.  In, the absence of a clinical response to the therapy with corticoids or other immunosuppressive drugs should raise the suspicion of an underlying infectious process.

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