1 diff-diag- Dr. Ahmed El yasaqy

A) Bacterial
Infections
Prof. Ahmed El-Y asaki;
AinShams U.,
The Egyptian Syndicate, KasrAini Hospital
8-1-2015
Prof.Ahmed ElYasaki; AinShams U., Jan, 2015

‫الرحيم‬ ‫الرحمن‬ ‫ال‬ ‫بسم‬‫الرحيم‬ ‫الرحمن‬ ‫ال‬ ‫بسم‬

Clinical Features:
The classic picture of symmetrical polyarthritis in a middle-aged female only
occurs in a proportion of cases.
Onset of Disease:
May be acute or insidious, monarticular or polyarticular. Average age of
onset is 40 years. Prodromal constitutional symptoms frequently precede
joint pain and swelling.
1. Typical onset (50%): Gradual development of symmetrical
polyarthritis involving small joints of hands and feet.
2. Acute polyarthritis (10-20%): May be associated with fever,
sweating and leucocytosis.
RHEUMATOID ARTHRITIS: CLINICAL
FEATURES, COMPLICATIONS,
DIAGNOSIS AND PROGNOSIS

3. Acute mono-articular arthritis (~30%): Sudden painful swelling of
large joint may resemble rheumatic fever or atypical gout. 'Arthritis robusta'
is a rare form o RA with proliferative synovitis, subchondrial cysts (like
geodes) and acute onset, seen in manual workers.
4. Chronic mono-articular arthritis: Insidious painful swelling of a large
joint e.g. knee. Disease may remain localized for years: joint biopsy may
then be necessary to differentiate osteoarthritis and tuberculous arthritis.
Onset of Disease (Cont.):

5. Onset with soft-tissue lesion: RA may be heralded by tenosynovitis
'trigger-finger', rotator cuff lesion in shoulder, or carpal tunnel syndrome.
6. Onset with sensory disturbance: Paraesthesiae due to carpal tunnel
syndrome (established by motor and sensory nerve conduction tests). Some
times associated with vasomotor disturbance (e.g. Raynaud's phenomenon),
or no apparent cause. Carpal tunnel syndrome is often an early feature of
RA, occurring in over 20% of patients at some time, especially where wrists
involved (due to associated flexor tenosynovitis).
7. 0nset with visceral disorder: e.g. pleural effusion.
Onset of Disease (Cont.):

Effect of RA
Early changes Late changes

ACR
Rheumatol
Diff. stages of RA
OP stage Early erosion Late stage

Narrow medial, lateral and PF compartment. Generalized OP. Synovial
cysts (geodes) in the tibial plateau and lateral femoral condyle.

The 1987 ARA revised criteria of RA. It has sensitivity 94% and specificity
89%.

ARA 'exclusions' (any one of which excludes diagnosis of RA) is a
convenient list of conditions which may be confused with the disease.
1. Systemic lupus erythematosus: Arthritis in young female with
severe anaemia and constitutional disturbance, out of proportion to joint
symptoms.
2. Polyarteritis nodosa: Arthritis may resemble RA but radiological
changes are minimal, severe systemic symptoms and evidence of vasculitis
at early stage of disease. (Borderline between 'malignant' RA with
widespread vasculitis and polyarteritis nodosa may be narrow, but joint
erosions and typical rheumatoid deformities are uncommon in the latter).
3. Dermatomyositis: Joint signs are mild, muscle weakness
predominates. Rash is typical.
4. Scleroderma: Typical skin changes, but coexistence with RA is not
uncommon.
5. Rheumatic fever: Main differential features are: migratory joint
involvement myocarditis and/or endocarditis; small subcutaneous nodules
having different histological structure; higher, sustained fever; more specific
Differential Diagnosis of RA

6. Gout: Classical types are straightforward. Acute polyarticular onset of
gout may resemble RA. Response to colchicine is strongly suggestive,
occurrence of tophi are diagnostic, family history and persistently high
serum uric acid level are suggestive.
7. Acute suppurative arthritis: May resemble acute monarticular RA.
Proved by positive synovial fluid culture.
8. Tuberculous arthritis: Often confused with monarticular RA. Synovial
fluid culture only occasionally positive and diagnosis usually rests on
synovial biopsy.
9. Reiter’s syndrome: Presence or history of urethritis and conjunctivitis.
10. Hypertrophic osteoarthropathy: Wrists and ankles involved,
radiograph shows periosteal reaction.
11. Shoulder-hand $ (form of algodystrophy): Swollen, painful hand
resembles RA but frozen shoulder occurs at same time with lack of
constitutional symptoms and normal ESR.
12. Neurogenic arthropathy: Characteristic radiological changes and
associated urological signs.
Differential Diagnosis of RA (Cont.)

13. Ochronotic arthropathy: Homogentisic acid in urine detected on
alkalinization.
14. Sarcoid arthritis: Sarcoid involvement of joints (rare) may resemble
RA but other features of sarcoidosis will be present. Positive Kveim test and
Erythema nodosum and arthritis associated with pulmonary sarcoid
lymphadenopathy) usually involves lower-limb large joints.
15. Myeloma: Increase in plasma cells in marrow, paraprotein or
abnormal immunoglobulin present.
16. Arthritis with erythema nodosum: Usually transient, affecting
joints of lower limb.
17. Arthritis in blood disorders: (especially leukaemia and
haemophilia).
18. Arthritis with hypogammagllobulinemia.

The following are not in ARA list of 'exclusions' but must also be included in
differential diagnosis:
19. Osteoarthritis: Confusion tends to arise especially in (a) acute
episodes of activity in isolated osteoarthritic joints, (b) acute generalized
osteoarthritis with moderately raised ESR in middle-aged females (rare
condition; many turn out to have RA with or without concomitant
osteoarthritis). Differential points are Joints involved (often terminal
interphalangeal and first carpometacarpal joints of hands), Heberden's
nodes, radiological appearance, and lack of subcutaneous nodules and
rheumatoid factor in osteoarthritis.
20. Spondylitis: Large joint involvement in ankylosing spondylitis is not
uncommon but polyarthritis resembling RA is rare. Subcutaneous nodules
and rheumatoid factor are absent.
21. Psoriatic arthritis: Whereas some cases ('indeterminate type')
resemble RA, the presence of psoriasis in patient or a close relative,
predominant involvement of terminal interphalangeal joints and negative
Rose-Waaler tests are suggestive of this diagnosis.

22. Arthritis with ulcerative colitis or regional ileitis: Usually large
joints, often with sacro-iliitis.
23. Traumatic arthritis:
24. Polymyalgia rheumatica: Peripheral joint signs are minimal, ESR is
very high, temporal artery biopsy may be normal or reveal arteritis.
However, some cases of RA occurring in the elderly have onset exactly like
polymyalgia.

Approximately 40% of
cases do very well
Course and Prognosis of RA
(5,0)%
(35,0)%
(50,0)%
(10,0)%
Very variable. It is still impossible to predict the outcome of a
case of RA will any degree of certainty. Periods of
exacerbation and remission are the rule.
10% progress
relentlessly towards
marked disability.
50% have persistent activity
with remissions and
exacerbations, with some
deformity.
(5% remit with no
sequelae
35% remit with mild or
moderate sequelae).

I- Mode of onset: Acute onset is usually favorable, insidious onset less
favorable.
2- Sex: Males tend to do better than females. Exception is symmetrical,
insidious arthritis in males which nearly always has a poor prognosis.
3- Age: RA developing in the elderly presenting with large-joint pain and
stiffness resembling polymyalgia tends to do well.
4- Initial joint involvement: Monarticular and atypical cases with
asymmetrical onset in large joints do well.
5- Underweight: weakness and severe limitation of function at onset
herald poor prognosis.
6- High ESR and low haemoglobin: at onset suggest poor
prognosis. Initially high; serum ferritin concentrations are associated with
systemic disease.
Prognostic Factors of RA

7- Persistent rheumatoid activity for more than a year:
uncontrolled by treatment, denotes poor outlook.
8- Early erosive changes: (e.g. within a year of onset) suggest poor
prognosis.
9- Serology: Seronegative cases are thought to have a more favorable
first year after onset. Systemic lesions, particularly vasculitis, are usually
associated with severe seropositive disease.
10- HLA antigens: HLA-DR2 correlates with less severe cases, HLA-
DR3 with severe cases and vasculitis (but not necessarily with
seropositivity).
11- Extra-articular manifestations:
Note:
Death directly related to rheumatoid disease is not common, but may
occur due to a complication such as amyloid, cervical spine subluxation,
or vasculitis. Patients with severe disease tend to die 10 or more years
prematurely, in females, and 4 years in men.
Prognostic Factors of RA (Cont.)

1. Primary Generalized OA: Often
hereditary, especially associated with
Heberden’s nodes.
2. Secondary OA: Secondary to
trauma or previous joint disease.
OA
Classification:
ACR
Primary OA

Due to prior trauma, infection,
inflammation, CPPD or overwork as
in:
•Bus drivers  shoulder.
* Pneumatic drills  Elbows, wrists,
shoulders.
* Footballer and ballet dancer  Talar joints.
Atlas (hasan slama)
Sec. (Atypical) OA.
Distribution of target
joint
Sec.OA

1. Presence of knee pain.
+ 3 items out of the following six items:
a) Age >50y.
b) Stiffness <30min.
c) Crepitation.
d) Bony tenderness.
e) Bony enlargement.
f) No palpable warmth.
OA
ARA criteria for OA:

Causes of pain in OA
knee
Patellofemoral OA
Tense poplit.cyst.
Worn int.structure
(e.g.,Cartilage)
Med.Lig.strain
Cartilage degeneration
Painful geodes
(bone cysts)
Trabic. microfractures
Panniculitis
Synovitis (in acute stage)
Capsular contraction
Loose bodies
Crystal deposition (urate,
Pyrophosphate or
hydroxyapatite

Diag.Rh.(32,33)
A short-stature
patient has knee pain
(the cause is
sec.OA), The cause
of this abnormal bone
shape is childhood
Rickets:
Osteomalacia

1. Gout.
2. Chondrocalcinosis
(a) Pyrophosphate.
(b) Hydroxyapatite.
A) Crystal Induced
Arthritis

Definition:
Metabolic disorder of purine metabolism
characterized by hyperuricaemia and recurring
attacks of arthritis, and in later stages chronic
arthritis, tophi formation and a tendency to renal
failure.
Classification:
1. Primary (genetic) gout: (95% of cases). Patients
usually have genetic tendency
To
A) Impaired uric acid excretion,
B) Overproduction of urate.
1- Gout (Podagra)

Classification (Cont.):
2. Secondary gout (5% of cases):
A) Due to overproduction of uric acid; occurs in:
2.1 Myeloproliferative disorders: (e.g. polycythaemia,
leukaemia, myeloma, reticuloses). Increased nucleoprotein turnover.
2.2 Specific enzyme deficiencies: Several rare congenital.
disorders now identified, e.g. HGPRT deficiency (Lesch-Nyhan $), PRPP
synthetase excess, glucose-6-phosphatase deficiency.
2.3 During treatment of severe pernicious anaemia:
due to ;
maturation of megaloblastic marrow releasing uric acid. from nucleoprotein
breakdown.
Gout (Podagra)

B) Due to under-excretion of uric acid occurs in:
2.4 Chronic renal failure (n.b. rarely): Blood urate does
not rise until GFR falls to below 10ml/min.
2.5 Certain drugs: Salicylates (in low doses), thiazides
other diuretics (except triamterene), pyrazinamide, adrenaline,
alcohol, sulphonamides, mecamylamine.
2.6 Lactic acidosis (e.g. pregnancy toxaemia): Lactic
acid suppresses tubular excretion of uraic, L-dopa (i.e., L-
dopa can causes SLE & Gout).
2.7 Ketosis (as in diabetes, starvation): B-
hydroxybutyric acid suppresses urate excretion.
Gout (Podagra)

B) Due to under-excretion of uric acid occurs in:
2.8 Hyperparathyroidism.
2.9 Some cases of myxoedema.
2.10 Chronic Lead nephropathy ('saturnine
gout‘‫)رصاص‬ (seen in drinkers of 'moonshine' whiskey in
Southern USA prepared in lead vessels —decreases renal
excretion of water).
2.11 Cystinuria.
2.12 Down's syndrome.
2.13 Glycogen storage disease (type L).
Gout (Podagra)

Acute gout = Podagra (Note swelling and
erythema over first MTP and adjacent forefoot)
Gout (Podagra)

Acute gouty arthritis
Swelling and mild erythema in right knee
Gout (Podagra)

ABC Rheumatol. ABC Rheumatol.
Chronic gouty arthritis
May resemble other forms of inflammatory synovitis. As here,
dorsal wrist swelling, and bilateral large knee effusions. From both,
urate crystal were identified, and arthritis resolved on appropriate
ttt.
Gout (Podagra)

Atypical gout:
30% of cases get their gout outside the 1st
MTPJ
1. Polyarticular onset: When hands are involved arthritis
may resemble RA; both clinically and radiologically. but joints
usually appear very nodular‫محببة‬ due to tophi.
2. Knee effusions: Usually history of classical acute attack
in big toe can be obtained but sometimes knee swells de
novo. Synovial fluid is of the inflammatory type, cloudy with
high polymorph count, and contains urate crystals.
Pyrophosphate crystals may also occur—gout with
pseudogout is not uncommon.
3. Soft-tissue gout: Onset with, e.g. Achilles tendinitis or
olecranon bursitis. Possibly some cases of 'tennis elbow'.
Gout (Podagra)

Shelf sign (arrow) =
overhanged edge.
This characteristic
radiogrpahic sign of gout
is due to a tophaceous
deposit
Atlas (hasan slama)

Urate: (gout): Negatively birefringent needle-shape
crystals of monosodium urate.
Pyrophosphate (pyrophosphate arthropathy):
Positive birefringent brick-shaped crystals of calcium
pyrophosphate dehydrate, deposited in cartilage.
Hydroxyapatite (apatite deposition disease):
Tiny hexagonal crystals of hydroxyapatite, deposited in
articular or periarticular tissues - seen with light
microscope only if in clumps.
Axis of 1st
-order
red compensator
Axis of 1st
-order
red compensator
(1)
(2)
(3)
Main crystals causing crystal deposition diseases
are:

(A)(A)
Diff.DiaDiff.Dia
g. ofg. of
PolyPoly--
arthritisarthritisText** = Usually mono-arthritis.Text** = Usually mono-arthritis.Prof.Ahmed ElYasaki; AinShams U., Jan, 2015

(1) JCA(1) JCA

Arthritis for >6weeks.Arthritis for >6weeks.
In child <16Yrs.In child <16Yrs.
Exclusion of other causes of childhood arthritis.Exclusion of other causes of childhood arthritis.
ARA Criteria for definition of JCA (1977):ARA Criteria for definition of JCA (1977):
Arthritis is defined as:Arthritis is defined as:
* Joint swelling, or* Joint swelling, or
* Joint effusion, or* Joint effusion, or
* Two of the following:* Two of the following:
1- Joint tenderness, or1- Joint tenderness, or
2- Decreased ROM, or2- Decreased ROM, or
3- pain on ROM, or3- pain on ROM, or
4- Joint warmth.4- Joint warmth.
(1) JCA(1) JCA
D.D. ofD.D. of polypoly-arthritis-arthritis

About 1 child in every 1000 has JCA.About 1 child in every 1000 has JCA.
More than 12,000 affected children inMore than 12,000 affected children in
Britain.Britain.
The peak onset being between 1-3years &The peak onset being between 1-3years &
8-11years.8-11years.
JCA Incidence:JCA Incidence:

JCAJCA
1) Systemic (Still’s dis.)1) Systemic (Still’s dis.)
2) Poly-2) Poly-
3) Pauci-3) Pauci-
4) Mon-4) Mon-
JCA Classification:JCA Classification:
Based on the predominant C.P. during the 1Based on the predominant C.P. during the 1stst
6m.of disease6m.of disease
Young girlsYoung girls
(Uveitis, ANA+ve)(Uveitis, ANA+ve)
Older boysOlder boys
(Sacro-ilitis, HLA-(Sacro-ilitis, HLA-
Systemic Poly- Pauci- &Mono
10-15%10-15%
(Systemic)(Systemic)
15-20%15-20%
(Poly-)(Poly-)
65-75%65-75%
(Pauci-&mono)(Pauci-&mono)

1) Systemic (Still’s disease)1) Systemic (Still’s disease)

 Unknown.Unknown.
 Affects girls > boys.Affects girls > boys.
Aetiology:Aetiology:
1) Systemic (Formerly called Still’s1) Systemic (Formerly called Still’s
disease)disease)

Clinical features:Clinical features:
 Onset often abrupt, with high remitting fever.Onset often abrupt, with high remitting fever.
Onset may be migratory,Onset may be migratory,
resembling Rheumaticresembling Rheumatic
Fever. Knees, wrists andFever. Knees, wrists and
cervical spine in 1/3 ofcervical spine in 1/3 of
patients.patients.
Children with arthritis mayChildren with arthritis may
not complain of pain, butnot complain of pain, but
most do experience somemost do experience some
discomfortdiscomfort..
1- Joint involvement:1- Joint involvement:

Clinical features (Cont.):Clinical features (Cont.):
Rarely occur.Rarely occur.
Histologically,Histologically,
resembling nodules ofresembling nodules of
RF rather thanRF rather than
rheumatoid nodules.rheumatoid nodules.
2- Subcutaneous nodules:2- Subcutaneous nodules:
Nodule on the olecranonNodule on the olecranon
process is a marker of moreprocess is a marker of more
aggressive diseaseaggressive disease

 General failure to grow when the disease is severe.General failure to grow when the disease is severe.
3-Growth disturbance:3-Growth disturbance:
A 2years old boy had active Still’s disease forA 2years old boy had active Still’s disease for
12months, which is diff. to control.12months, which is diff. to control.
 Marked OP, Multiple compression ofMarked OP, Multiple compression of
Th. vert. (V. plana).Th. vert. (V. plana).
 CS administration.CS administration.
 Active Stills + improper CS intake.Active Stills + improper CS intake.

Systemic–onset JCASystemic–onset JCA
Note:Note: MicrognathiaMicrognathia
and mild flexionand mild flexion
deformities of elbowdeformities of elbow
and kneeand knee

Young adult had recovered from JCA at the age of 5 years.Young adult had recovered from JCA at the age of 5 years.
N.B.: Cervical involvement occur in 50%N.B.: Cervical involvement occur in 50%
(At-Ax sublux., disc space narrow, ankylosis)(At-Ax sublux., disc space narrow, ankylosis)
Fusion of apophyseal joints ofFusion of apophyseal joints of
all cervical vert. This is moreall cervical vert. This is more
common in JCA (common in JCA (target areatarget area))
than Adult RA.than Adult RA.

Brachydactyly of right fourth digit due toBrachydactyly of right fourth digit due to
premature epiphyseal closurepremature epiphyseal closure

4- Fever:4- Fever:
Daily spiking intermittent fever (of 39Daily spiking intermittent fever (of 39oo
or more), whichor more), which
typically manifest in the afternoons or evening, oftentypically manifest in the afternoons or evening, often
associated with rash and arthritis (either poly- or pauci-).associated with rash and arthritis (either poly- or pauci-).
CharacteristicCharacteristic quotidianquotidian fever associated with systemic JCAfever associated with systemic JCA
(in this case, not improved after aspirin or CS, but on indomethacin)

5- Maculo-papular rash:5- Maculo-papular rash:
Seen in most cases,Seen in most cases,
usually together withusually together with
pyrexia.pyrexia.
Lesions are discrete,Lesions are discrete,
nonpruritic, evanescentnonpruritic, evanescent
and migratory.and migratory.
Sometimes confined toSometimes confined to
the axillary region andthe axillary region and
anterior chest wall.anterior chest wall.

In most cases (predilection in cervical, axillary andIn most cases (predilection in cervical, axillary and
epitrochlear areas).epitrochlear areas).
Hepato-splenomegalyHepato-splenomegaly: less common.: less common.
6- Lymphadenopathy:6- Lymphadenopathy:

7- Eye:7- Eye:
Occasionally precede arthritis.Occasionally precede arthritis.
Iritis is common in children, and theIritis is common in children, and the
spectrum is broad (Unlike adult RA).spectrum is broad (Unlike adult RA).
It is initially asymptomatic.It is initially asymptomatic.
All children with JCA should be screenedAll children with JCA should be screened
by slit lamp.by slit lamp.

Irreg. pupilIrreg. pupil
d.t.d.t.
synechiaesynechiae
Hypopyon (uncommon)Hypopyon (uncommon)

Deposit in ant. chamberDeposit in ant. chamber
seen by slit lamp exam.seen by slit lamp exam.
CataractCataract
(> with CS use)(> with CS use)
Band keratopathy: In theBand keratopathy: In the
ant. chamber severelyant. chamber severely
compromise vision.compromise vision.

8- Transient pericarditis:8- Transient pericarditis:
Occasionally otherOccasionally other
types of serositistypes of serositis
(Pleuritic or(Pleuritic or
abd.pain).abd.pain).

2) Poly-articular JCA2) Poly-articular JCA

2) Poly-articular JCA2) Poly-articular JCA
Definition:Definition:
Commoner in girls>boys (2:1).Commoner in girls>boys (2:1).
Age of onset is older than in systemic.Age of onset is older than in systemic.
May be marked joint swelling, or else dry arthritis.May be marked joint swelling, or else dry arthritis.
Growth retardation less likely than in systemic type.Growth retardation less likely than in systemic type.
Cervical spine (rigid neck).Cervical spine (rigid neck).
TMJTMJ  micrognathia commonly involved.micrognathia commonly involved.
Severe hip involvement may cause marked disability.Severe hip involvement may cause marked disability.
10% are IgM RF +ve (here, disease tend to be progressive, erosive and10% are IgM RF +ve (here, disease tend to be progressive, erosive and
need DMRD).need DMRD).
 40% ANA +ve.40% ANA +ve.
Arthritis involvingArthritis involving >>5 joints, without systemic features.5 joints, without systemic features.
Clinical features :Clinical features :

MicrognathiaMicrognathia
Due to under-Due to under-
development of thedevelopment of the
mandible in a ptn. withmandible in a ptn. with
polyartic. JCApolyartic. JCA

Tenosynovitis & synovitis of the hands and wrists are frequent in childrenTenosynovitis & synovitis of the hands and wrists are frequent in children
with the poly-articular JCA. There is marked swelling of the extensor tendonswith the poly-articular JCA. There is marked swelling of the extensor tendons
of the wrists and MCPJ.of the wrists and MCPJ.

3) Pauci- & 4) Mono-articular3) Pauci- & 4) Mono-articular
JCAJCA

3) Pauci- & 4) Mon-articular JCA3) Pauci- & 4) Mon-articular JCA
Clinical features :Clinical features :
 Commoner in girls>boys (2:1).Commoner in girls>boys (2:1).
 Onset often with mono-arthritis, followed by pauci-articularOnset often with mono-arthritis, followed by pauci-articular
((<<4joints) pattern within a year.4joints) pattern within a year.
 Limb growth disturbance d.t. premature fusion of epiphysesLimb growth disturbance d.t. premature fusion of epiphyses
(see Still’s dis.).(see Still’s dis.).
 1/5 of patients develop ch.anterior uveitis.1/5 of patients develop ch.anterior uveitis.
Definition:Definition:
Arthritis involving 1 up toArthritis involving 1 up to <<4 joints, without systemic4 joints, without systemic
features.features.

OligoarticularOligoarticular
disease indisease in
right kneeright knee
showingshowing
flexionflexion
deformitydeformity
Pauciarticular of RtPauciarticular of Rt
knee in 3year old girlknee in 3year old girl

True leg lengthTrue leg length
discrepancy in adultdiscrepancy in adult
with JCA of 21 yearswith JCA of 21 years
durationduration

Investigations in JCAInvestigations in JCA
Often neither specific nor sensitive.Often neither specific nor sensitive.
Should be done to:Should be done to:
1) Rule out other causes for joint symptoms (infection).1) Rule out other causes for joint symptoms (infection).
2) Assess acuity of the disease (in systemic onset)2) Assess acuity of the disease (in systemic onset)
a- Acute phase reactants.a- Acute phase reactants.
b- Anemia.b- Anemia.
c- Serositis.c- Serositis.
3) Assess prognosis:3) Assess prognosis:
a- RF: in <10% indicates worse prognosis.a- RF: in <10% indicates worse prognosis.
b- ANA: +ve indicates increased R.R. of uveitis.b- ANA: +ve indicates increased R.R. of uveitis.
Laboratory:Laboratory:
Radiography:Radiography:
Radiographic changes are associated with worse prognosis.Radiographic changes are associated with worse prognosis.

Soft tissue swelling. Osteopenia and severe jointSoft tissue swelling. Osteopenia and severe joint
destruction with loss of cartilage spacedestruction with loss of cartilage space

Course of JCACourse of JCA
Bad Good
75%75%
(Good)(Good)
25%25%
(Bad)(Bad)
Poor prognosis in:Poor prognosis in:
1- Systemic-onset disease.1- Systemic-onset disease.
2- Poly-articular disease.2- Poly-articular disease.
3- +ve RF.3- +ve RF.
4- Need for systemic CS.4- Need for systemic CS.
5- Younger age of onset.5- Younger age of onset.
6- Frequent sec. infection & amyloidosis.6- Frequent sec. infection & amyloidosis.
7- Female gender.7- Female gender.
8- Radiographic changes.8- Radiographic changes.
9- vasculitis9- vasculitis (exceedingly rare in JCA).(exceedingly rare in JCA).

(2) Sero –ve(2) Sero –ve
Spondylo-Spondylo-
arthropathyarthropathy

2- Psoriatic arthritis.2- Psoriatic arthritis.
3- Reactive arthritis.3- Reactive arthritis.
4- Enteropathic.4- Enteropathic.
5- JCA.5- JCA.
(esp. pauci-articular form).(esp. pauci-articular form).
1- Ank. Spondylitis.1- Ank. Spondylitis.
Members:Members:
Diagram showing overlapDiagram showing overlap
among variousamong various
spondyloarthropathies.spondyloarthropathies.
ReiterReiter
PsoriaticPsoriatic
Ul.colitisUl.colitis
-Chron’s-Chron’s
-Whipple’s-Whipple’s
Ulc.colitisUlc.colitis
Chron’s diseaseChron’s disease
Whipple’sWhipple’s
2- Sero –ve spondylo-2- Sero –ve spondylo-
arthropathy:arthropathy:

 Psoriatic arthritis may precede the onset ofPsoriatic arthritis may precede the onset of
psoriasis by many years.psoriasis by many years.
Clues to the diagnosis of Ps.arthritis in the absenceClues to the diagnosis of Ps.arthritis in the absence
of typical psoriatic rash are:of typical psoriatic rash are:
1- Family history of psoriasis.1- Family history of psoriasis.
2- Pitting or onycholysis of nails.2- Pitting or onycholysis of nails.
3- Dactylitis (swelling of one or more digits, usually in an3- Dactylitis (swelling of one or more digits, usually in an
asymmetrical pattern).asymmetrical pattern).
Psoriatic ArthritisPsoriatic Arthritis

A teenage boy presented with heel and ankle pain.A teenage boy presented with heel and ankle pain.
 Soft tissue swelling around the lower portion of the achilles tendon andSoft tissue swelling around the lower portion of the achilles tendon and
its insertion.its insertion.
 Psoriasis with achilis tendinitis.Psoriasis with achilis tendinitis.

Two weeks after an episode of diarr. In a 19y-old man developed knee joint effusionTwo weeks after an episode of diarr. In a 19y-old man developed knee joint effusion
with massive fluid accumulation in suprapatellar bursa. IBD with acute post-with massive fluid accumulation in suprapatellar bursa. IBD with acute post-
dysenteric (reactive) synovitis. The causative organism is Salmonella, Shigella,dysenteric (reactive) synovitis. The causative organism is Salmonella, Shigella,
Yersinia and Campylobacter species.Yersinia and Campylobacter species.
Reactive ArthritisReactive Arthritis

a) SLE +/- ON.a) SLE +/- ON.
b) Scleroderma.b) Scleroderma.
c) PM/DM.c) PM/DM.
d) MCTD & Overlap $d) MCTD & Overlap $
e) Sjogren’s $.e) Sjogren’s $.
(3) Systemi CT Diseases(3) Systemi CT Diseases

The diagnosis is SLE.The diagnosis is SLE.
This is confirmed by:This is confirmed by:
ANA+ve, A-ds-DNA+ve,ANA+ve, A-ds-DNA+ve,
Urine analysis for protein.Urine analysis for protein.
Leucopenia and/orLeucopenia and/or
thrombocytopenia.thrombocytopenia.
We advised the patientWe advised the patient
to apply ultraviolet lightto apply ultraviolet light
screening creams duringscreening creams during
sun-exposure.sun-exposure.
This facial appearanceThis facial appearance
developed while on holiday,developed while on holiday,
in a young woman who onlyin a young woman who only
previous symptom mildprevious symptom mild
intermittent arthralgiaintermittent arthralgia
and hair loss.and hair loss.
3- Systemic CT3- Systemic CT
Diseases:Diseases:

Osteonecrosis:Osteonecrosis: In SLEIn SLE
Collagen/vascularCollagen/vascular

Osteonecrosis:Osteonecrosis: All the spaces are maintainedAll the spaces are maintained
(glenohumeral, subacromial and acromio-clavicular)(glenohumeral, subacromial and acromio-clavicular)
RtRt

Advanced ON. There is combination of OP and sclerosisAdvanced ON. There is combination of OP and sclerosis

The pathological process:The pathological process: Is vasculitis. Digital infarction is theIs vasculitis. Digital infarction is the
commonest necrotising manifestation. Renal vessel involvementcommonest necrotising manifestation. Renal vessel involvement
is ch.ch. By intimal hyperplasia and fibrinoid necrosisis ch.ch. By intimal hyperplasia and fibrinoid necrosis
(nephrosclerosis), but there is no inflam.cell infiltrate.(nephrosclerosis), but there is no inflam.cell infiltrate.
SclerodermaScleroderma

Localized scleroderma of the foot of an 11y old girlLocalized scleroderma of the foot of an 11y old girl

Scleroderma:Scleroderma: AmorphousAmorphous
calcification in the soft tissue.calcification in the soft tissue.
Erosion of the distal tuftErosion of the distal tuft

Gottron’s papules in boy with juvenile DMGottron’s papules in boy with juvenile DM
Juvenile DMJuvenile DM

Dermatomyositis:Dermatomyositis:
Calcification alongCalcification along
intermuscular fascialintermuscular fascial
planes as well asplanes as well as
subcutaneous tissuesubcutaneous tissue

(4) Systemic(4) Systemic
VasculitidesVasculitides

1- Large-sized vessel1- Large-sized vessel (Takayasu’s, etc.).(Takayasu’s, etc.).
2- Medium-sized vessel2- Medium-sized vessel (Wegner’s, etc.).(Wegner’s, etc.).
3- Small-sized vessel3- Small-sized vessel (Henoch-Schonlein purpura).(Henoch-Schonlein purpura).
(rash with purpura over buttocks/knees).(rash with purpura over buttocks/knees).
4- Other4- Other (Behcet’s, etc.).(Behcet’s, etc.).
44- Systemic- Systemic
Vasculitides:Vasculitides:
Members:Members:

A 13-years old girl presented with knee and ankle painA 13-years old girl presented with knee and ankle pain
and swelling and skin rash.and swelling and skin rash.
 Diagnosis: Henoch-Schonlein purpura (Nonthrombocytopenic leucocytoclasticDiagnosis: Henoch-Schonlein purpura (Nonthrombocytopenic leucocytoclastic
vasculitis).vasculitis).
 PPT Cause: Post-streptococcal URTI.PPT Cause: Post-streptococcal URTI.
Ttt: >90% simple symptomatic ttt. is sufficient. CS are used in relapsing and persistentTtt: >90% simple symptomatic ttt. is sufficient. CS are used in relapsing and persistent
casescases

Desquamation of toes of child with Kawasaki diseaseDesquamation of toes of child with Kawasaki disease

(5) Infectious(5) Infectious

1. Acute septic arthritis.
2. Tuberculous arthritis.
3. Gonococcal arthritis.
4. Syphilitic arthritis.
5. Meningococcal arthritis.
6. Arthritis with brucellosis.
7. Arthritis with enteric fever.
8. Musculoskeletal features in leprosy.
A) Bacterial Infections
B) Arthritis Following Virus
Infections.
C) Mycotic Infections.
I- Infective Arthritis
II- Bone Infection

Aetiology:
1. Haematogenous: From focal sepsis (Primary focus not always evident).
2. Local Introduction: Of sepsis (e.g. wound, following aspiration of joint or
intra-articular steroid).
3. Spontaneous sepsis: In joint already affected.
N.B.: Joint sepsis is an “Emergency” and demands urgent attention,
skilled management and specific therapy.
Significant morbidity and mortality are associated with:
(A) Delayed, (B) Inappropriate and (C) Suboptimal therapy
1. Acute Septic Arthritis

Swelling and erythema in patient withSwelling and erythema in patient with
acute staphylococcal arthritis of theacute staphylococcal arthritis of the
ankleankle

release toxins
Cartilage
destruction
Chemotatic factors
Prof.Ahmed ElYasaki; AinShams U., Dec,2014
(Cont.)
Pathogenesis:
PNL
(c) Loss of proteoglycan from
cartilage
Bacteria in synovium
(b) Chondrocytes injured
(a) The Enzymes degrade collagen
Lysozomes release
enzymes
+Synov.Proli
f

-Monarticular arthritis.
-More in weight bearing joints, especially the knee.
C/P:
Normal patient Immunosupp. and
debilitated patient
Onset: Acute --
General
Symptoms:
Severe pain, swinging
fever, malaise
--
Locally: joint is red, hot, swollen,
tender, held immobile and
usually slightly flexed.
There may be few specific
signs of infection, in particular
the temp. and WBCs.
(Cont.)
Clinical Feature:

2. Blood culture: Sometimes
(not always positive, but should always be requested).
3. Synovial fluid:
-High PNL count (often 50-100,000 WBCs/mm3
).
-Positive culture in 50% of cases, high lactic (or
succinic) acid concentration.
-Antibiotic sensitivity can be determined.
4. Raised serum ASOT: (In staphylococcai
infections).
Typical appearanceTypical appearance
of purulent SFof purulent SF
(Staph.aureus)(Staph.aureus)
(Cont.)
Laboratory:
1. CBC: Leucocytosis: With 'shift to left’ (i.e., increased immature forms,
myelocytes & promyelocytes).

Septic arthritis:Septic arthritis:
Cartilage loss in all kneeCartilage loss in all knee
compartments. There iscompartments. There is
loss of the white corticalloss of the white cortical
line. There is evidence ofline. There is evidence of
bone repairbone repair
SepticSeptic

Aetiology and Pathology:
Secondary (blood-borne) infection. Usually affects thora-columbar spine
or hips.
1. Focus in para-articular bone or synovial membrane.
2. Cold abscesses in fascial planes.
3. Fibrous ankylosis.
4. Secondary infection, leading to bony ankylosis.

Clinical Features:
Classically:
-Pain: Worse at end of day. 'Night starts' in children.
-Muscle wasting: Marked around joint, out of proportion to apparent
degree of inflammation.
-Limp: when lower limb joints involved.
-Deformity: (usually flexion) due to pull of stronger muscle groups.
-Swelling: Occasionally effusion.
-Overlying skin: Often tense, shiny and bluish (not in deeply situated joints; such
as hip and shoulder) where pain, stiffness and muscle wasting may be the only clinical
features.
2. TB Arthritis (Cont.)
However, these classic features are not
always present.
For example,
* Spinal tuberculosis: May present as low back pain with
high ESR and a normal radiograph for several months, until
vertebral collapse occurs or paraspinal cold abscess appears.
* Dorsal spine involvement: May present with girdle
thoracic pain.

Evidence of prior TB disease with sinus tract
communicating to the outer thigh
2. Tuberculous
arthritis.

TB arthritis of theTB arthritis of the
knee showingknee showing
complete obliterationcomplete obliteration
of the joint spaceof the joint space
2. Tuberculous
arthritis.

Diagnosis:
Tuberculous arthritis often presents as:
1. Monarticular arthritis with marked muscle wasting and high ESR.
2. Evidence of tuberculosis elsewhere (radiograph chest).
3. Synovial fluid: turbid, high mononuclear cell count. “Typical' or 'atypical'
mycobacterium) in smear, culture or guinea-pig inoculation.
4. Joint biopsy: Characteristic synovial membrane histology (caseation
with giant-cell systems and acid-fast bacilli).

C/P:
General $: Fever.
-Local $: Sometimes severe pain and swelling of joints.
(Cont.)
Gonococcal tenosynovitis
of the extensor tendons of
the left
wrist(Characteristic)
Tenosynovitis: Characteristically occurs frequently
(especially on backs of hands and feet) (probably more
often than in Reiter’s disease).
3. Gonococcal Arthritis:.

- Skin lesions: are common (macules becoming vesicular
then pustular with surrounding erythema).
(Cont.)
Dissiminated
Gonorrheal
pustule

(Cont.)
Resolving stage of
gonococcal dermatitis
Gonococcaemia, showing
typical vesicopustular lesion
on erythematous base

Arthritis or arthralgia are usually reactive, but may be due to:
Direct infection of synovium by virus (e.g. following vaccination).
Immunological response of synovium (reactive arthritis) (e.g., following
mumps, rubella).
Synovitis due to virus replication elsewhere (e.g., arbovirus).
Synovitis as part of general immunological process (e.g., hepatitis-B).
B) Arthritis Following Virus
Infection

Examples are:
Actinomycosis.
Coccidioidomycosis.
Histoplasmosis.
Blastomycosis.
Aspergillosis.
Cryptococcosis (torulosis).
Sporotrichosis.
Treatment:
Amphotericin B (but actinomycosis is sensitive to penicillin).
C) Mycotic Infections

Infantile osteomyelitis: May be due to staphylococcus or
streptococcus. Massive oedema of part of a limb, rapid separation of large
sequestrum.
Adolescent osteomyelitis: Acute and subacute forms, especially in
lower femoral epiphysis. Difficult diagnosis in early stages - pyrexia and
high ESR, but normal radiograph, little or no leucocytosis, may be
negative blood culture. However bone scan is abnormal within a few days
and should always be done if X-ray negative. Tagged leucocytes using
radioactive iridium may also be helpful.
Adult osteomyelitis: Especially in debilitating conditions such as
diabetes. May cause chronic back pain. Radiograph showing involvement
of contiguous vertebrae and intervening discs, only later paravertebral
abscess.
1- Osteomyelitis
II- Bone Infection

Bone scan with gallium 67 (expensive) to detect active infection (taken by
PNL) in 24hours. So scan is done in 1d, 2d, 3d (not like Tc bone scan
used for tumours, done at 0, 1h, 2h, and 3hours).
1- Osteolyelitis

(6) Post-Infectious(6) Post-Infectious

1- Rheum. Fever.1- Rheum. Fever.
2- Lyme disease.2- Lyme disease.
6- Post-6- Post-
Infectious:Infectious:
Members:Members:

A young teenager presented with acutely painfulA young teenager presented with acutely painful
swelling of several large joints in migratory pattern.swelling of several large joints in migratory pattern.
 E.Marginatum (due to RF).E.Marginatum (due to RF).
Diagnosis: ASOT (rising titre), CRP, TLC ECGDiagnosis: ASOT (rising titre), CRP, TLC ECG 11stst
degree H. block.degree H. block.

(7) Other systemic(7) Other systemic
illnessillness

1- Chronic active hepatitis.1- Chronic active hepatitis.
2- FMF.:2- FMF.: +ve FH, episodes of abd.pain & rashes.+ve FH, episodes of abd.pain & rashes.
3- Sarcoidosis.3- Sarcoidosis.
7- Other systemic7- Other systemic
illness:illness:
Members:Members:
EN in acuteEN in acute
sarcoidosissarcoidosis
Rashes + nodules (EN), uveitis, arthritisRashes + nodules (EN), uveitis, arthritis
of wrists and knees, lung changes.of wrists and knees, lung changes.

4- Pigmented V.N. synovitis**.4- Pigmented V.N. synovitis**.
7- Other systemic7- Other systemic
illness:illness:
Members:Members:
Synovial hemangioma and pigmented villonodular synovitis
may present with intermittent and recurrent hemarthrosis,
simulating monoarticular JIA. They usually affect both
females and males in the second decade of age, and
typically result in a sudden onset of painful swelling of
knee. Aspiration of synovial fluid at the onset of swelling
yields frank blood.
Magnetic Resonance Imaging, and occasionally
arthroscopy may be needed to make the definitive
diagnosis

A 35year old woman with 18-month history of painful swellingA 35year old woman with 18-month history of painful swelling
in the right shoulder, believed to be post-traumatic. On aspiration, there was dark brownin the right shoulder, believed to be post-traumatic. On aspiration, there was dark brown
fluid suggesting old blood. There was no other evidence of bleeding disorder.fluid suggesting old blood. There was no other evidence of bleeding disorder.
Pig. V.N.synovitis. 80% involve one knee.Pig. V.N.synovitis. 80% involve one knee.
The synovium is red-brown, markedly thick, matted masses of villous projectionsThe synovium is red-brown, markedly thick, matted masses of villous projections
and sessile or pedunculated nodules.and sessile or pedunculated nodules.

(8) Peri-articular(8) Peri-articular
(Metabolic)(Metabolic)

1- Bone marrow expansion1- Bone marrow expansion (leukaemia, sickle cell, etc.).(leukaemia, sickle cell, etc.).
2- Metastatic disease2- Metastatic disease (eg, neuro-blastoma).(eg, neuro-blastoma).
3- Primary bone/cartilage tumours**.3- Primary bone/cartilage tumours**.
4- Hypertrophic osteoarthropathy.4- Hypertrophic osteoarthropathy.
8- Periarticular :8- Periarticular :
Metabolic:Metabolic:
Members:Members:

This bone marrow smear shows the diagnosis of Sickle cell disease.This bone marrow smear shows the diagnosis of Sickle cell disease.
This patient is more prone to develop Infectious arthritis, or acute osteomyelitisThis patient is more prone to develop Infectious arthritis, or acute osteomyelitis
(Salmonella is often involved).(Salmonella is often involved).
The cause of joint pain in these patient may be:The cause of joint pain in these patient may be:
* Infection with salmonella. * Avascular necrosis of bone.* Infection with salmonella. * Avascular necrosis of bone.
* Short lived polyarthralgia during acute crisis (subsynovial capillary blockage).* Short lived polyarthralgia during acute crisis (subsynovial capillary blockage).
* gout.* gout. * Haemoarthrosis (rare).* Haemoarthrosis (rare).

 Systemic complications of Hemophilia may involve manySystemic complications of Hemophilia may involve many
areas of the body. One of them is the joint that may manifestareas of the body. One of them is the joint that may manifest
itself in the early course of the disease.itself in the early course of the disease.
 The signs and symptoms may vary from child to child. AlsoThe signs and symptoms may vary from child to child. Also
other forms of arthritis may also be found in hemophilicother forms of arthritis may also be found in hemophilic
patients, so, it carries difficult diagnostic dilemma.patients, so, it carries difficult diagnostic dilemma.
 Among them are diseases with polyarticular presentation;Among them are diseases with polyarticular presentation;
and diseases with monoarticular forms.and diseases with monoarticular forms.
 Doctors should collect necessary information to enableDoctors should collect necessary information to enable
them to have a correct diagnosis of the cause of arthritis, itsthem to have a correct diagnosis of the cause of arthritis, its
activity and severity and the subsequent effects of arthritis onactivity and severity and the subsequent effects of arthritis on
the patient’s life.the patient’s life.
HemophiliaHemophilia

(9)(9) Peri-articularPeri-articular
(Mon-metabolic)(Mon-metabolic)

1- Overuse syndrome.1- Overuse syndrome.
2- Growing pains.2- Growing pains.
3- Fibromyalgia & stress associated conditions:3- Fibromyalgia & stress associated conditions:
ch.ch. By easy fatigability, poor attendance at school, non-ch.ch. By easy fatigability, poor attendance at school, non-
restorative sleep pattern and fatigue.restorative sleep pattern and fatigue.
9- Peri-articular: Non-metabolic:9- Peri-articular: Non-metabolic:
Members:Members:

A teenager presented with knee painA teenager presented with knee pain
during ex. no evidence of synovitis could be demonstrated.during ex. no evidence of synovitis could be demonstrated.
His X-ray showedHis X-ray showed
fragmentation of the tibialfragmentation of the tibial
tuberosity at the patellartuberosity at the patellar
tendon attachment, withtendon attachment, with
some separation of thesome separation of the
ossification centreossification centre (Osgood-(Osgood-
Schlatter disease).Schlatter disease). This isThis is
common in age (11-15y) d.t.common in age (11-15y) d.t.
sporting activity and rapidsporting activity and rapid
growth. The condition isgrowth. The condition is
usually unilateral.usually unilateral.

(10) Traumatic(10) Traumatic

PA of metacarpals fails to reveal # seen in lateral viewPA of metacarpals fails to reveal # seen in lateral view
(# through the proximal end of the shaft of the 3(# through the proximal end of the shaft of the 3rdrd
metacarpal)metacarpal)

12- Transient synovitis of the hips.12- Transient synovitis of the hips.
11- Inflamm. Myopathies.11- Inflamm. Myopathies.

Especially in post-pubertal girlsEspecially in post-pubertal girls
13- Arthralgia accompany(pre-icteric) inf.hepatitis (A or B):13- Arthralgia accompany(pre-icteric) inf.hepatitis (A or B):
14- Juvenile sero +ve rheumatoid arthritis:14- Juvenile sero +ve rheumatoid arthritis:

15- Farber’s disease:15- Farber’s disease:
Deficiency of acid ceramidase: arthritis withDeficiency of acid ceramidase: arthritis with
hoarseness in babies.hoarseness in babies.
Especially in girls, pain localizedEspecially in girls, pain localized
in few joints.in few joints.
Also, Ehler-Danlos syndrome.Also, Ehler-Danlos syndrome.
16- Hypermobility syndrome:16- Hypermobility syndrome:
Marfan’s syndromeMarfan’s syndrome

A short-stature patientA short-stature patient
has knee painhas knee pain (the cause(the cause
is sec.OA),is sec.OA), The cause ofThe cause of
this abnormal bone shapethis abnormal bone shape
is childhood rickets.is childhood rickets.
17- Rickets:17- Rickets:

An Asian girl presented with tender, bony swelling atAn Asian girl presented with tender, bony swelling at
wrists and ankles.wrists and ankles.
 Rickets. Diagnosed by Calcium(Low), Phosphate(low), Alk.Ph (high) 25-Rickets. Diagnosed by Calcium(Low), Phosphate(low), Alk.Ph (high) 25-
hydroxycholecalciferol (low), PTH (high), ttted: Therapeutic trial of Vit-D.hydroxycholecalciferol (low), PTH (high), ttted: Therapeutic trial of Vit-D.

A young woman became stunted duringA young woman became stunted during
childhood due to bone damage and became deaf in her early teens.childhood due to bone damage and became deaf in her early teens.
Additional C/P:Additional C/P:
* blue sclera, thin translucent* blue sclera, thin translucent
* skin with wide scars,* skin with wide scars,
* stunting and discoloration* stunting and discoloration
of teeth,of teeth,
* occasional aortic* occasional aortic
and/or mitral valveand/or mitral valve
regurgitation.regurgitation.
This is due to defect in:This is due to defect in:
collagen synthesis.collagen synthesis.
18- Osteogenesis Imperfecta:18- Osteogenesis Imperfecta:

a) Hypertrophic b) Atrophic c) Combined.a) Hypertrophic b) Atrophic c) Combined.
19- Neuropathic arthropathy19- Neuropathic arthropathy

(B)(B)
Diff.DiaDiff.Dia
g. ofg. of
AcuteAcute
MonoMono--

& C.M. Patellae (knees).& C.M. Patellae (knees).
2- Acute septic:2- Acute septic:
Often staphylococcal, including TB. SuspectOften staphylococcal, including TB. Suspect
hypogammaglobulinemia if there are several septic joints.hypogammaglobulinemia if there are several septic joints.
3- Acute osteomyelitis:3- Acute osteomyelitis:
4- Osteochondritis dessicans:4- Osteochondritis dessicans:
(reactive sterile effusions in adj. joints).(reactive sterile effusions in adj. joints).
1- Traumatic arthritis:1- Traumatic arthritis:
Diff.Diag. of AcuteDiff.Diag. of Acute MonoMono-arthritis-arthritis
All previously under poly- can start as acute mono-.All previously under poly- can start as acute mono-.
5- Malignant bone tumors:5- Malignant bone tumors:
Ewing’s sarcoma and osteosarcoma.Ewing’s sarcoma and osteosarcoma.
D.D. ofD.D. of MonoMono-arthritis-arthritis

A child started to limb with thigh painA child started to limb with thigh pain
 Legg-Perthes disease.Legg-Perthes disease.
 Idiopathic osteo-necrosis=O-chondritis dissec.Idiopathic osteo-necrosis=O-chondritis dissec.
 Avascular necrosis.Avascular necrosis.
 Young male (7years).Young male (7years).
 * Relief from Wt-bearing (use Snyder sling for ambulation). * Maintain the* Relief from Wt-bearing (use Snyder sling for ambulation). * Maintain the
femoral head within the acetabulum (by plaster or surgery).femoral head within the acetabulum (by plaster or surgery).
PerthesPerthes
D.D. ofD.D. of MonoMono-arthritis-arthritis

Thank YouThank You

1 diff-diag- Dr. Ahmed El yasaqy

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