Rheumatology revison notes

11-03-2018
Rheumatology
TONY SCARIA 2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Homogeneous
• Ab against ds DNA nucleosomes & histone
Peripheral rim
• Ab against ds DNA & to nuclear envelope protein
TONY SCARIA
2010 KMC

11-03-2018
Speckled pattern
• Ab against nuclear non DNA contents
• Sm Ag  SLE
• SSA & SSB sjogren syndrome
• Ribonucleopattern  Mixed connective tissue ds
Nucleolar pattern
• Ab to RNA in systemic sclerosis
Centromere pattern
• Anticentromere Ab in systemic sclerosis
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
SLE
• Differential Diagnosis of Rash over face
(Malar)
• 1. Non erythematous-
• 1. Chloasma
• 2. Erythematous-
• 1. SLE
• 2. Photosensitivity reaction
• 3. Contact dermatitis
Sparing of nasolabial fold
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC

11-03-2018
Renal involvement
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Wire loop lesion
• Formed by subendothelial
deposits
• Seen in class 3,4 and 5
• Most commonly a/w class 4
• It indicates active ds & poor
prognosis
TONY SCARIA
2010 KMC
Adverse prognosis
• Factors associated with Adverse Prognosis and High Risk of Renal
Progression in Lupus Nephritis
• Hypertension
• Hypocomplementemia
• Thrombocytopenia
• High Anti Ds DNA antibody titres
• Pregnancy
• Nephritic urinary sediment
• Azotemia
• Proteinuria
• Decreased GFR
TONY SCARIA
2010 KMC

11-03-2018
Better prognosis
• Presence of anti LA (SSB) indicate lower involvement of kidney in SLE
TONY SCARIA
2010 KMC
• Most common cause of death in SLE with in 10 years is renal failure
(followed by infection)
• But most common over all cause is cardiac failure
TONY SCARIA
2010 KMC

11-03-2018
Muskuloskeletal system
• Mc system to be involved in SLE
• Non erosive arthritis
TONY SCARIA
2010 KMC
CNS
• Psychosis a/w anti P Ab (antiribosomal P Ab)
TONY SCARIA
2010 KMC

11-03-2018
Lungs involvement in SLE
• Pleuritis and pleural effusions (the most common pulmonary
manifestations).
• Alveolar injury (edema and hemorrhage)
• Chronic interstitial fibrosis.
• Shrinking lung syndrome
• The chest radiograph reveals elevated diaphragms, and pulmonary function
tests shows reduced lung volumes
• Diaphragmatic myopathy restricted lung volume
• a/w Anti Ro Ab
TONY SCARIA
2010 KMC
Cardiac Manifestations in SLE
• 1. Pericarditis is the most frequent cardiac manifestation;
• 2. Endocarditis of Libman-sacks
• 3. AR, MR
• 4. Risk for myocardial infarction
• 5. Myocarditis
• 6. Endocarditis
Overall most important cause of death n SLE 
cardiac failure
TONY SCARIA
2010 KMC

11-03-2018
Cutaneous manifestation in SLE
• 1. Systemic rash
• 2. Discoid rash
• 3. Subacute cutaneous lupus erythematosus (LE) Rash is a photosensitive.
• 4. Urticaria
• 5. Lichen planus-like dermatitis
• 6. Bullae.
• 7. Small painful ulcerations on the oral or nasal mucosa are common in SLE.
• 8. Tin-tack sign
• 1. Also known as carpet tack sign , is a useful clinical feature in diagnosing discoid lupus
erythematosus.
• 2. Hyperkeratotic scale extending into the follicular infundibulum creates keratotic spikes
when viewed from the scale’sundersurface, resembling a carpet tack.
TONY SCARIA
2010 KMC
Tin tack sign
TONY SCARIA
2010 KMC

11-03-2018
Hematologic
• 1. Coombs positive hemolytic anemia
• 2. Lymphopenia
• 3. Thrombo cytopenia
• 4. Anti phospholipid syndrome –
• lupus anti coagulant and anti cardiolipin are present. It consists of
thrombocytopenia, recurrent fetal loss, recurrent venous or arterial clotting.
TONY SCARIA
2010 KMC
Not a feature of SLE
• Lung cavitation
• Joint deformity
• Raynauds phenomenon
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Significance of anti Ro Ab
• anti-Ro, which indicates increased risk for
• neonatal lupus,
• sicca syndrome, and
• Sub acute cutaneous lupus erythematosus (SCLE)
TONY SCARIA
2010 KMC

11-03-2018
• Women with child-bearing potential and SLE should be screened for
• aPL to r/o APLA
• anti-Ro to r/o risk for neonatal lupus
TONY SCARIA
2010 KMC
• Complement level are reduced in SLE.
Immune complex diseases associated with hypocomplementemia
• 1. SLE
• 2. Vasculitis
• 1. Hypocomplementemic urticarial vasculitis
• 2. Polyarteritis nodosa (especially hepatitis Bassociated (necrotizing
vasculitis)
• 3. Glomerulonephritis
• 1. Post-streptococcal
• 2. Membranoproliferative
• 3. Cryoglobulinemia (types II and III)
• 4. Bacterial endocarditis
• 5. Serum sickness
TONY SCARIA
2010 KMC

11-03-2018
Drug induced lupus erythematosus
• Procainamide and hydralazine are most common offenders.
• Most patients do not have symptoms of lupus erythematosus.
• high frequency of antihistone antibodies.
• multiple organs may be affected renal and CNS involvement, usually
does not occur.
• Sex ratio is equal (in contrast to idiopathic SLE where females are
affected more commonly)
TONY SCARIA
2010 KMC
Drug induced lupus
• Acebutolol
• Methyldopa
• Asparaginase
• Phenolphthalein
• Barbiturates
• Phenytoin
• Bleomycin
• Procainamide
• Hydralazine
TONY SCARIA
2010 KMC

11-03-2018
Drugs associated with SLE are
• 1. Antiarrhythmics → (Procainamide, disopyramide, propafenone)
• 2. Antihypertensives → (Hydralazine,. ACE inhibitors, and Beta
blockers)
• 3. Antithyroid → (Propylthiouracil)
• 4. An psycho cs → (Chlorpromazine and lithium)
• 5. An convulsant → (Carbamazepine and phenytoin)
• 6. An bio cs → (Minocycline and Macrolides, INH)
• 7. An hyperlipidemic → (Lovasta n, Simvasta n)
TONY SCARIA
2010 KMC
drug induced SLE
• 1. Anti histone antibodies are positive
• 2. Anti dsDNA is usually absent
• 3. Renal involvement is not a feature or very uncommon
• 4. Polyserositis is a feature
• 5. Rash is very common
• 6. Features disappear on discontinuation of drugs.
TONY SCARIA
2010 KMC

11-03-2018
• Medication
• 1. NSAIDs, salicylates (St. Joseph's aspirin (low dose aspirin)
• 2. Topical glucocorticoids
• 3. Topical sunscreens
• 4. Hydroxychloroquine (quinacrine can be added or substituted)
• 5. DHEA (dehydroepiandrosterone)
• 6. Methotrexate (for dermatitis, arthritis)
• 7. Glucocorticoids, oral
• 8. Methylprednisolone sodium succinate, IV
• 9. Cyclophosphamide IV
• 10. Mycophenolate mofetil or mycophenolic acid
• 11. Azathioprine
• 12. Belimumab
• 13. Rituximab
TONY SCARIA
2010 KMC
Rx
• Low dose aspirin (St Joseph aspirin) therapy is used in
• 1. Pre-eclampsia
• 2. Coronary artery disease.
• 3. Anti phospholipid syndrome
• 4. IUGR
• Indication steroid therapy in SLE
• 1. Nephritis
• 2. Thrombocytopenic purpura
• 3. Hemolytic anemia
• 4. Pericarditis
• 5. Convulsion
Low dose aspirin not used in
SLE without APLS
TONY SCARIA
2010 KMC

11-03-2018
New diagnostic modalities in SLE
• Cell bound compliment activation product (CB – CAP)
• Platelet bound compliment product (P-C4d)
• Diagnostic marker in Urine.
• 1. Endothelin 1
• 2. Lipocalcin 2
• 3. U-MCP-1
• 4. Hepcidin
TONY SCARIA
2010 KMC
Systemic sclerosis

11-03-2018
Systemic sclerosis (scleroderma)
• F>>M, 30–50 Yrs
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Mirovascular injury  hallmark feature of
SScl
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
• Anti topoisomerase I (Anti Scl 70)
• Widespread skin involvement
• Rapid progression and early visceral involvement
Diffuse
scleroderma
• Anticentromere Ab
• Limited skin involvement, confined to fingers,
forearms
• When skin alone is involved then it is known as
Morphea.
Limited or
localized
scleroderma
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
• CREST syndrome which is a combination of
• 1. Calcinosis: subcutaneous calcifications of fingers and along
extensor surface of forearm
• 2. Raynaud phenomenon
• 3. Esophageal dysmotility
• 4. Sclerodactyly (skin thickening limited to fingers)
• 5. Telangiectasia (dilated capillaries)
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
• 1. Antinuclear antibodies.
• 2. Antibodies to single stranded RNA
• 3. Anti - Scl - 70 (antitopoisomerase) seen in generalize scleroderma.
• a/w pulmonary fibrosis
• Peripheral vascular disease
• 4. Anticentromere antibody. These autoantibodies are seen in patient
with CREST syndrome.
• 5. Antiendothelial cell antibody.
TONY SCARIA
2010 KMC
• 1. RNA polymerase III – Associated with acute onset scleroderma
renal crises & cancer
• 2. U3-RNP
• 3. U1-RNP TONY SCARIA
2010 KMC

11-03-2018
Morphea
• isolated patches of hardened skin
• no internal organ involvement
• Diagnosis is by clinical suspicion, presence of autoantibodies
(especifcally anti-centromere and anti-scl70/anti-topoisomerase
antibodies) and occasionally by biopsy
TONY SCARIA
2010 KMC
C/F

11-03-2018
Raynauds phenomenon present in 80 % of
patients
TONY SCARIA
2010 KMC
• Pulmonary Manifestations
• 1. Pulmonary interstitial fibrosisa/w diffuse scleroderma
• 2. Pulmonary hypertension a/w CREST SYNDROME
• 3. RVF
TONY SCARIA
2010 KMC

11-03-2018
GIT
manifestations
• involvement of the lower two
thirds of the esophagus resulting
in loss of esophageal peristalsis
and dysphagia
• Gastric antral vascular ectasia
(GAVE) in the antrum
• "watermelon stomach" due
to their endoscopic
appearance
• recurrent episodes of
gastrointestinal bleeding,
resulting in chronic
unexplained anemia.
TONY SCARIA
2010 KMC
• Musculoskeletal Manifestations
• arthralgia and a mild non – erosive inflammatory arthritis.
• Inflammation of synovium with hypertrophy and hyperplasia of synovial soft tissues.
• Closely reminiscent of rheumatoid arthritis but joint destruction is not common.
TONY SCARIA
2010 KMC

11-03-2018
• Renal Involvement sudden renal crisis a/w RNA polymerase III Ab
• 1. There is intimal hyperplasia of the interlobular arteries, fibrinoid
necrosis of the afferent arterioles, including the glomerular tuft, and
thickening of the glomerular basement membrane.
• 2. This change results in the development of renin induced
hypertension.
• 3. Sudden renal failure can occur
TONY SCARIA
2010 KMC
Rx
• *Management*
• 1. D – Penicillamine
• 2. Glucocorticoids
• 3. Hypertension,
• alpha – methyldopa, calcium channel blockers or ACEI,
• as these drugs may alleviate Raynaud’s phenomenon.
• Beta – blockers are contraindicated in treating hypertension, as may
precipitate Raynaud’s phenomenon
TONY SCARIA
2010 KMC

11-03-2018
sjogrens syndrome
Sjogren’s syndrome
• chronic, slowly progressive autoimmune disease
• lymphocytic infiltration of the exocrine glands resulting in xerostomia and dry
eyes
TONY SCARIA
2010 KMC

11-03-2018
Triad of sjogrens syndrome
1. Dry eye
2. Dry mouth
3. B/L parotid
enlargement
TONY SCARIA
2010 KMC
Type of sjogrens syndrome
• Idiopathic
• Less common
• associated with: HLA - DR - 3
Primary
• Occurs in a/w AutoImmune d/s
• More common  60 %
• Usually associated with: HLA - DR - 4
Secondary
TONY SCARIA
2010 KMC

11-03-2018
Primary sjogrens syndrome
Glandular involvement
•Involves exocrine
glands
•Xerostomia
•Keratoconjunctivitis
sicca
Extraglandular
•Arthralgia / arthritis
(MC extraglandular
involvement )
•Marginal zone B cell
lymphomaMikulics syndrome 
enlargement of lacrimal &
salivary gland from any
cause
TONY SCARIA
2010 KMC
Features of 1* psjogrens
• 1. Arthralgia/arthritis
• 2. Lung involvement
• 3. Liver involvement
• 4. Peripheral neuropathy
• 5. Raynaud's phenomenon
• 6. Vasculitis
• 7. Lymphoma
• 8. Myositis
• 9. Lymphadenopathy
• 10. Kidney involvement
• 11. Splenomegaly
TONY SCARIA
2010 KMC

11-03-2018
Secondary sjogren
• *Causes of secondary Sjögren’s syndrome*
• 1. Rheumatoid arthritis (most common cause)
• 2. SLE
• 3. Scleroderma
• 4. Mixed connective tissue disease
• 5. Primary biliary cirrhosis
• 6. Vasculitis
• 7. Chronic active hepatitis
• 8. Polymyositis
• 9. Hashimoto's thyroiditis
• 10. Interstitial pulmonary fibrosis
TONY SCARIA
2010 KMC
• RHEUMATOID FACTOR
• Ig M auto Ab that binds self IgG
• presence of autoantibodies to
• Ro/SS – A and
• La/SS – B antigens
• Antibodies to α - fodrin (120kDa),
• a salivary gland- specific protein may be present
TONY SCARIA
2010 KMC

11-03-2018
• Diagnostic Criteria for Sjögren’s Syndrome
• 1. Dry eyes
• 2. Dry mouth
• 3. Positive Schirmer’s I test
• 4. Histopathology - Focus score 1 in a minor salivary gland biopsy
• 5. Reduce salivary flow
• 6. Antibodies to Ro (SS – A) or La(SS – B), antinuclear antibodies, or
rheumatoid factor
• Probable Sjögren’s syndrome : three items are present.
• Definite Sjögren’s syndrome: four or more items are
present.
TONY SCARIA
2010 KMC
Diagnosis
• Biopsy of the lip (to examine minor salivary glands)
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Focus score in sjorens syndrome
• Focus score
• (the number of mononuclear cell infiltrates containing at least 50
inflammatory cells in a 4 mm2 glandular section) of greater than 1 is probably
the single most important test result in the diagnosis of the oral component in
SS
TONY SCARIA
2010 KMC

11-03-2018
Rx
• 1. Pilocarpine given orally sicca manifestations.
• 2. Hydroxychloroquine arthralgias.
• 3. Glucocorticoids or other immunosuppressive agents (i.e,
cyclophosphamide)
• extraglandular manifestations.
TONY SCARIA
2010 KMC
Inflammatory myopathies

11-03-2018
Inflammatory myopathies
• Immunologically mediated
• Most common a/w systemic sclerosis
TONY SCARIA
2010 KMC
Types of inflammatory myopathies
• dermatomyositis,
• polymyositis,
• inclusion body myositis TONY SCARIA
2010 KMC

11-03-2018
Dermatomyositis
• Diagnostic Criteria:
• (4 out of 5, for dermatomyositis cutaneous changes must present)
• 1. Proximal symmetric progressive muscle weakness
• 2. Elevated muscle enzyme
• CPK, AST, LDH
• 3. Consistent electromyography (EMG)
• to locate the affected muscles
• 4. Consistent muscle biopsy
• Perifasicular atrophy of muscle fibres+ inflammation
• 5. Cutaneous disease
TONY SCARIA
2010 KMC
Perifasicualr atrophy with inflammation
TONY SCARIA
2010 KMC

11-03-2018
Cutaneous features of dermatomyositis
Major cutaneous
criteria
•Gottron’s papule
•Gottron’s sign
•Heliotrope rash
Minor criteria
•V sign
•Shawl sign
• holster sign
TONY SCARIA
2010 KMC
Heliotrope rash
• Violaceous erythema with edema over eyelids, periorbital region
TONY SCARIA
2010 KMC

11-03-2018
Gottrons papule
• lilac or violaceous papules on knuckle, dorsa of hands.
TONY SCARIA
2010 KMC
Gottrons sign
• Violaceous erythema with edema over
shoulder, arms, forearms.
TONY SCARIA
2010 KMC

11-03-2018
Mechanics hand
• Symmetric hyperkeratosis along ulnar aspect of thumb and radial
aspect of fingers
TONY SCARIA
2010 KMC
Shawl sign
TONY SCARIA
2010 KMC

11-03-2018
V sign in dermatomyositis
TONY SCARIA
2010 KMC
• Poikiloderma: -
Atrophy of skin,
hypopigmentatio
n, dilated blood
vessels over
trunk
TONY SCARIA
2010 KMC

11-03-2018
• Holster sign  hip
TONY SCARIA
2010 KMC
Nail-fold telangiectasia
• In dermatomyositis
TONY SCARIA
2010 KMC

11-03-2018
Muscle involvement in dermatomyositis
• Proxmial muscle weakness
• symmetrical and bilateral
• Progressive weakness
TONY SCARIA
2010 KMC
• Calcinosis cutis occurs in juvenile form of dermatomyositis
TONY SCARIA
2010 KMC

11-03-2018
Auto Ab in dermatomyositis
Anti-Jo1 (histidyl tRNA synthetase) antibody • polymyositis with interstitial lung disease,
pulmonary fibrosis
• Nonerosive arthritis
• Skin rash
Anti Mi2 Ab • Gottron papule
• Heliotrope rash
Anti P55/P140 Ab • Paraneoplastic dermatomyositis
• Juvenile dermatomyositis
TONY SCARIA
2010 KMC
Treatment of skin diseases:
• 1. Sun-protection: Topical steroids
• 2. Antimalarials: Hydroxychloroquine (below 6.5 mg/kg/day), same as
for cutaneous LE.
• 3. Systemic steroids are sometimes used but generally more effective
in controlling myositis than cutaneous manifestations Systemic
steroids may cause steroid myopathy with prolonged use, leading to
paradoxical decrease in muscle weakness following steroid dosage
reduction.
TONY SCARIA
2010 KMC

11-03-2018
Inclusion body myositis
TONY SCARIA
2010 KMC
rimmed vacuoles
(basophilic rimming)
TONY SCARIA
2010 KMC

11-03-2018
• MC inflammatory myopathy in patients older than 65 yrs
• Presents with slowly progressive distal muscle weakness
• cN1A antibodies are present in this myositis
TONY SCARIA
2010 KMC
Mixed Connective Tissue Disorder (MCTD)
• overlap syndrome characterized by a combination of clinical features
similar to those of SLE, scleroderma & polymyositis
• high titers of circulating anti U1 RNP antibodies
• Treatment
• 1. Salicylates and other NSAID
• 2. Glucocorticoids
TONY SCARIA
2010 KMC

11-03-2018
Causes of b/l parotid enlargement
Viral
• 1. Mumps
• 2. Influenza
• 3. Epstein Barr virus
• 4. Coxsackie virus A
• 5. CMV
• 6. HIV
Metabolic
• 1. Diabetes mellitus
• 2.
Hyperlipoproteinemia
• 3. Chronic pancreatitis
• 1. Amyloidosis
• 2. Sjögren’s syndrome
• 3. Sarcoidosis
Endocrine
• Gonadal hypofunction
TONY SCARIA
2010 KMC
HLA A3 Hemochromatosis
HLA DR2 • Narcolepsy
• Goodpasture’s syndrome
HLA-DR3 • Autoimmune hepatitis,
• Primary Sjögren syndrome-1,
• Diabetes mellitus type-1,
• Systemic lupus erythematosus
• Dermatitis herpetiformis
HLA- DR4 • Rheumatoid arthritis,
• Diabetes mellitus type 1
• secondary sjoogrens
HLAB5 Behcets
HLAB27 • Ankylosing spondylitis,
• Psoriaticarthritis,
• Reiter's syndrome,
• Reactive arthritis(Yersinia,salmonella,gonococci),
• JRA (pauci articular)
HLA-B47 • 21-hydroxylase deficiency
TONY SCARIA
2010 KMC

11-03-2018
• Multiple sclerosis- HLA DR2
• Narcolepsy- HLA DR2
• Goodpasture’s syndrome- HLA DR2
• Sjogrens- HLA DR3
• Dermatitis herpetiformis- HLA DR3
• Celiac disease- HLA DR3
• Rheumatoid arthritis- HLA DR4
• Behcets disease – HLA B5
• Congenital adrenal hyperplasia - HLA B47
• SLE- HLA DR2,DR3
• Type 1 Diabetes – HLA DR2,DR3,DR4
• Hyperthyroidism – HLA B8,DR3
• Myasthenia gravis- HLA B8,DR3
• Tuberculoid leprosy- HLA B8,DR3
• VKH syndrome- HLA DW 15,DR4
TONY SCARIA
2010 KMC
Synovium

11-03-2018
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Arthritis
Cells of synovium 2 types
TONY SCARIA
2010 KMC

11-03-2018
Type A & B cells of synovium
TONY SCARIA
2010 KMC
Synovial fluid
• Non Newtonian
• Thixotropic fluid
• Hyalouronic acid  viscosity & lubricating property
TONY SCARIA
2010 KMC

11-03-2018
Articular cartilage
• Mainly articular cartilage
• contain type II collagen
• Avascular  nutrition derived from synovium
• No nerve supply
• No perichondrium
• Lacks ability to repair & regenerate
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Superficial zone
• Densely
packed
collagen
• Flattened
ellipsoid
shaped
chondrocytes
with their
major axis
parallel to
joint surface
Transition zone Middle zone
• Radial zone
• Chondrocytes
are
synthetically
most active
Calcified
cartilage
• Low metabolic
activity
TONY SCARIA
2010 KMC
Arthritis

11-03-2018
TONY SCARIA
2010 KMC
• Non inflammatory arthritis
• OA
• Traumatic arthritis
• Pigmented villnodular synovitis
TONY SCARIA
2010 KMC

11-03-2018
Infective arthritis
• Tom smith arthritis
• Septic arthritis
TONY SCARIA
2010 KMC
distinguish b/w transient synovitis & septic
arthritis
• Transient arthritis is non specific inflammation of the synovium,
related to infection or trauma.
• Septic arthritis is bacterial infection of the synovium of the joint.
• Modified Kochers criteria
• Fever > 38.5
• ESR > 40 mm/hr
• WBC > 12,000 cells/mL
• CRP > 20 mg/dL
• Inability to bear weight on the affected limb
• More the features  more chance of septic arthritis
TONY SCARIA
2010 KMC

11-03-2018
Tom smith arthritis
• Septic arthritis of hip in an infant
• Chondrolysis
• Presents with limp & unstable gait
• Shortening of leg  supratrochanteric
shortening
• Telescopy
• Increased movement in all directions
• X ray
• Complete absence of head & NOF
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Septic arthritis
• Pyogenic arthritis
• Mc cause of bony ankylosis
• Mc organism over all  staph aureus by
hematogenous route
• Mc in neonates group B streptococci
• Mc organism in sexually active young adults  N
gonorrhoea
• Chondrolysis is commn in infancy
• Best method of diagnosis  aspiration of foci
• Rx
• Sx  arthroscopy & wash to focus along with IV Abx
TONY SCARIA
2010 KMC
Causes of migratory arthritis
• Lymes disease
• Rheumatic fever
• Disseminated gonococcal infection
TONY SCARIA
2010 KMC

11-03-2018
Causes of polyarticular symmetric arthritis
• Rheumatoid arthritis
• Systemic lupus erythematosus
• Viral arthritis
• Hepatitis,
• parvovirus B19
• In females working in nursery
• EBV
TONY SCARIA
2010 KMC
Causes of monoarticular arthritis
• Osteoarthritis
• Gout
• Pseudogout (Maybe polyarticular)
TONY SCARIA
2010 KMC

11-03-2018
Causes of oligoarticular asymmetric arthritis
• Spondyloarthropathies
• Osteoarthritis
TONY SCARIA
2010 KMC
Osteoarthritis
• Disorder of synovial joint
• Non inflammatory
• Progressive softening & disintegration of articular cartilage
TONY SCARIA
2010 KMC

11-03-2018
OA / advanced degenerative joint ds
• Degenerative
• Asymmetric
• Localised to one part of joint
• c/c non inflammatory progressive softening & disintegration of
articular cartilage
• Destruction of articular cartilage  main event
• Osteophytosis
• Growth of new cartilage & bone @ joint margins
• Capsular fibrosis
TONY SCARIA
2010 KMC
• Most common joint disease
• Vastus medialis (quadriceps)
• Mc involved muscle in OSA
• Wasting of quadriceps
• Etiology
• Excessive loading inspite of normal articular cartilage & subchondral bone
• Normal load inspite of weak cartilage & bone
TONY SCARIA
2010 KMC

11-03-2018
• Mc knee joint is involved
• MC deformity is genu varus
• Sparing of ankle elbow & wrist
TONY SCARIA
2010 KMC
• Age is the most important powerful risk factor
TONY SCARIA
2010 KMC

11-03-2018
• Primary pathological process of OA
involves articular cartilage
TONY SCARIA
2010 KMC
Classification
Primary
• Idiopathic
• Mc involves knee joint
• Localised
• Mono/pauci articular
• Generalised
• Poly articular > 3 joint
Secondary
• Secondary to
• Trauma
• #
• Developmental/congenital
disorders
• Gout / AVN/ endocrine disorders

11-03-2018
• Polyarticular / generalised OA
• Mc form
• Most commonly involves DIP
• Classical monoarticular /pauciarticular OA
• One or two large weight bearing bone
• Knee>>> hip
• Symptomatic OA of knee is more common in men than in women
TONY SCARIA
2010 KMC
• Hip  rare
• More common in older men
• Hand
• More commonly involved in elderly
female
• DIP PIP
• Non nodal erosive IP arthritis
• Carpo metacarpal joint of thumb
TONY SCARIA
2010 KMC

11-03-2018
• OA characteristically involves
• DIP  Heberdens node ***
• PIP  Bouchards node
• H is more distal than B in alphabets
• Base of thumb 1st MCP
• Other MCP & wrist are spared
TONY SCARIA
2010 KMC
• Foot
• Hallux valgus/rigidus
• Hammer toes
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Radiological features of OA
• 'asymmetric narrowing of joint
space‘
• Due to wearing of cartilage
• EARLIEST SIGN
• sclerosis of the subchondral bone
under the area of cartilage loss,
• d/t new bone formation
• cysts close to the joint surface and
• osteophytes at the margins of the
joint
• Loose bodies & deformities
TONY SCARIA
2010 KMC

11-03-2018
• In knee joint  medial joint space is affected first  genu varus
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Osteo arthritis - Womack grading.
• Stage i
• there is softening of the cartilage if the
surfaces of the knee. This may not show on
X-ray.
• Stage ii
• the cartilage starts to wear away and shows
as a narrowed joint space.
• Stage iii
• osteophytes are seen. Stage 2 and 3 may
merge and be difficult to separate.
• Stage iv
• "bone-on-bone" with very narrow joint
space, lots of osteophytes, and distortion of
the joint
TONY SCARIA
2010 KMC
Osteo arthritis - Outerbridge  cartilage
Classification
• Grade 0: normal cartilage;
• Grade I: cartilage with softening and swelling;
• Grade II: a partial-thickness defect with fissures
on the surface that do not reach subchondral
bone or exceed 1.5 cm in diameter;
• Grade III: fissuring to the level of subchondral
bone in an area with a diameter more than 1.5
cm;
• Grade IV, exposed subchondral bone
TONY SCARIA
2010 KMC

11-03-2018
Rx
• i. Initial management of
• 1. Physical therapy
• 2. Bracing, orthoses, ambulatory aids
• 3. NSAID, glucosamine, chondroitin,
intraarticular injections of steroid or
hyaluronic acid, and analgesics.
TONY SCARIA
2010 KMC
• Glucosamine
• Increases lubrication
• Chondroitin sulphate
• Increases lubrication
• Diacerin
• Reduces IL -1 induced cartilage damage
• S – adenosyl methionine(SAM)
• Reduces pain & cartilage damage
• Tetracycline
• Inhibits metalloproteinase
• Not routinely used
TONY SCARIA
2010 KMC

11-03-2018
• Sx
• In severe disabling pain
• Interfering with day to day activities
• Grade 2- 5 radiological evidence
TONY SCARIA
2010 KMC
• ii. Arthroscopic débridement
• active, older adults with mild-to-moderate
OA of the knee after conservative treatment
• Only in presence of mechanical symptom
like locking / loose bodies in X ray
• iii. High tibial osteotomy
• It is a well-established procedure for the
treatment of unicompartmental OA of the
knee.
• To decrease weight distribution in that
compartment
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
• Type I to III conservative management
• Non pharmacological
• Life style modification
/physiotherapy/bracing
• pharmacological
• NSAIDS/intrarticular injection of
steroid
• Type IV & V  surgery
• Arthroscopic wash out / debridement
• Realignment Sx
• High tibial osteotomy
• Unicompartmental arthroplasty
• TKR
TONY SCARIA
2010 KMC

11-03-2018
Indications for arthroplasty
Total knee replacememt
• Pain in severe OA
• Deformities
• Severe pain from
chondrocalcinosis & pseudogout
& severe patellofemoral OA
• Tricompartmental OA
Total hip replacement
• Alleviation of pain
• Improve function of hip
• Arthritis
• AVN
• Bone tumours involving
acetabulum & proximal femur
Rheumatoid arthritis
• c/c immunologically mediated
• Persistent inflammatrory synovitis
• Symmetrically involving peripheral joints
• Cartilage damage /bone erosion /change in joint integrityTONY SCARIA
2010 KMC

11-03-2018
• Pathogenesis
• Women (30-50 yrs)
• HLA DR4 DW4
• Initial site  synovial membrane
TONY SCARIA
2010 KMC
Stages
• Initiation phase
• d/t non specific inflmn
• Amplification phase
• d/t T cell activation
• c/c inflammatory phase
• Due to cytokines IL- 1 , TNF alpha & IL - 6
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
• Score of > 6 = definite RA
TONY SCARIA
2010 KMC

11-03-2018
Pathogenesis of RA
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Manifestations of RA
• Erosive arthritis
• Joint swelling tenderness & limitation of motion
• Pain aggravated by movement  Mc manifestation
• Axial involvement
• Limited to Atlantoaxial joint (cervical spine)
• Bakers cyst
• Extension of inflamed synovium in to popliteal space
TONY SCARIA
2010 KMC

11-03-2018
Involvement of hand
• Z deformity
• Radial deviation of wrist
• Ulnar deviation of
fingers of hand ***
• pathognomonic
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
At DIP mallet deformity
Rupture of extensor
tendon at DIP
TONY SCARIA
2010 KMC
Swan neck deformity
• Extension of PIP & compensatory
flexion of DIP
TONY SCARIA
2010 KMC

11-03-2018
boutonniere deformity
• Flexion of PIP & extension of DIP
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Intrinsic plus hand
deformity in RA
(d/t contracture
of lumbricals)
Assessed by bunnels test
TONY SCARIA
2010 KMC
• Eversion of hind foot deformity
• @ subtalar joint
• plantar subluxation of metatarsal
head
• Hammer toes
• Widening of forefoot
• Claw toe
TONY SCARIA
2010 KMC

11-03-2018
Windswept deformity
• Valgus deformity of toes in foot &
varus in other
TONY SCARIA
2010 KMC
Hammer toe / contracted toe
• Deformity of 2nd 3rd 4th toe
• Causing it to be permanently bent
• Mallet toe
• Similar condition affecting DIP
TONY SCARIA
2010 KMC

11-03-2018
Claw toe
• Dorsiflexion of proximal phalanx on lesser MTP joint
• Combined with flexion of DIP & PIP
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Rheumatoid arthritis of spine
• Involves usually atlantoaxial joint
• Dens erosion through foramen magnum
• May encroach spine
TONY SCARIA
2010 KMC
Knee joint in RA
• Valgus
• Triple deformity
• Flexion +
• Posterior subluxn +
• External rotation TONY SCARIA
2010 KMC

11-03-2018
Rheumatoid nodules
• in pressure areas such as the
elbow, finger joints, Achilles
tendon and occipital part of scalp
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
rheumatoid vasculitis
• Polyneuropathy
• Mononeuritis multiplex
• Digital gangrene
• MI TONY SCARIA
2010 KMC
Skin involvement in RA
• Vasculitis  skin necrosis
• Malignant rheumatoid arthritis
TONY SCARIA
2010 KMC

11-03-2018
Eye –
• a. Episcleritis
• b. Scleritis
• c. Conjunctivitis
• d. Scleromalacia (Rupture of the Globe) can occurs
Uveitis is not a feature
TONY SCARIA
2010 KMC
Neurological symptoms –
• 1. Peripheral neuropathy – due to vasculitis.
• 2. Cord compression – due to atlanto axial subluxation
• 3. Nerve entrapment – due to proliferative, synovitis
• (Carpal tunnel syndrome due to median nerve compression, tarsaltunnel
syndrome due to Posterior tibial nerve compression).
TONY SCARIA
2010 KMC

11-03-2018
Pleuropulmonary manifestation of RA
• Pleuritis
• Pleural effusion
• Mainly on left side
• Low pleural fluid sugar
• Arteritis
• Pneumonitis
• Pleuropulmonary nodule
TONY SCARIA
2010 KMC
Caplans syndrome
• Pneumoconiosis
• RA
• Lung nodules
TONY SCARIA
2010 KMC

11-03-2018
Multiple Lung
nodules are
also found in
Caplan’s syndrome
Wegeners
granulomatosis
Silicosis
TONY SCARIA
2010 KMC
Pericarditis
• Constrictive pericarditis
• Asymptomatic
TONY SCARIA
2010 KMC

11-03-2018
• RENAL INVOLVEMENT IS NOT A FEATURE OF RA
• EVEN IF OCCURS D/T AMYLOIDOSIS OR DRUG INDUCED
TONY SCARIA
2010 KMC
Radiologic changes in RA
• Soft tissue swelling
• Joint effusion
• Symmetrical involvement
• Juxta aticular osteopenia
• With in weeks
• Loss of articular cartilage & erosion
• Narrowing of joint space
• Subluxation & ankyloses
• Lack of hypertrophic changes
• Like sclerosis / osteophyte
TONY SCARIA
2010 KMC

11-03-2018
Rheumatoid factor
• Is used in diagnosis & prognosis
• Not used for screening
• About 80% of individuals with
rheumatoid arthritis have
autoantibodies to the Fc portion of
autologous IgG (rheumatoid factors).
• These are mostly IgM antibodies
• RF & Ig combine to form d/s process
• correlates with ds activity
• decline in the level of rheumatoid factor
is associated with reduced clinical
disease activity
• RF is also positive in
• 5% healthy people
• SLE
• c/c liver ds
• Sjogrens syndrome
• Pulm fibrosis
• IMN
• Hep B
• TB
• Leprosy
• Syphilis
• SABE
• Leishmaniasis
• Malaria
• schistosomiasis
TONY SCARIA
2010 KMC

11-03-2018
Diagnosis
• Normocytic normochromic anemia
• Raised ESR CRP & ceruloplasmin
• Anti CCP Is positive in RA
• Most specific Ab
• Synovial fluid analysis
• Turbid
• Decreased viscosity
• Increased protein content
• Decreased sugar
• WBC 5000- 50000/ml
TONY SCARIA
2010 KMC
Marker of active ds
• Anemia of c/c ds
• Increased ESR CRP & platelet count
• Decreased synovial fluid viscosity
TONY SCARIA
2010 KMC

11-03-2018
Feltys syndrome
TONY SCARIA
2010 KMC
Feltys syndrome
• Complement level is decreased
•
• Cause of leukopenia in RA is
• 1. Drug induce – most common
• 2. Felty’s syndrome
• 3. T-LGL
TONY SCARIA
2010 KMC

11-03-2018
Causes of leukopenia
• Feltys syndrome
• Drug induced  most common
• T- IGL
TONY SCARIA
2010 KMC
Haematology in RA
• Anemia in RA Normocytic normochromia
• d/t ineffective erythropoiesis
• GI bleed a/w NSAIDs
• eosinophilia in RA
• Severe systemic ds
• Large B cell lymphoma  lymphoma in RA
TONY SCARIA
2010 KMC

11-03-2018
Eye
• Scleritis
• Episcleritis
• Conjunctivitis
• Scleromalacia (rupture of globe)
• Uveitis is not a feature
TONY SCARIA
2010 KMC
Neurological system
• CNS is not directly involved
• Peripheral neuropathy
• d/t vasculitis
• Cord ompression
• d/t atlanto-axial subluxation
• Nerve entrapment
• d/t proliferative + synovitis  carpel tunnel syndrome
• Tarsal tunnel syndrome
• Posterior tibial nerve compression
TONY SCARIA
2010 KMC

11-03-2018
Poor prognosis
• High titres of RF
• C-RP
• Haptoglobulin
• Subcutaneous nodules
• Radiographic evidence
• Life expectancy is decreased by 3-7 yrs
TONY SCARIA
2010 KMC
Complications of RA
• Amyloidosis  NS
• By staph aureus
TONY SCARIA
2010 KMC

11-03-2018
• NSAIDs
• Etodolac  chiral NSAID for Rx of RA
• Licofelone
• Inhibits both lipoxygenase & cyclooxygenase of AA metabolism
• No GI s/e
• Analgesic anti inflammatory /antihistaminic
• Flupirtine
• Selective K+ channel opener
• NMDA receptor antagonist properties
• Non NSAID non opid nonsteroidal analgesic
TONY SCARIA
2010 KMC
DMARDs
• Slow down progression of ds
• Methotrexate ***
• Mc used
• D – pencillamine
• Sulfasalazine
• Gold
• HCQ
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
s/e of DMARDs
• Gold/pencillamine
• NS
• Pancytopenia
• HCQ
• Retinopathy
• Sulphasalazine
• Skin rash
• Methotrexate
• Liver dysfunction
TONY SCARIA
2010 KMC

11-03-2018
Glucocorticoid rx in RA
• Vasculitis
• Mononeuritis multiplex
• Pericarditis
• Perforating eye lesion
• Pleural effusion
TONY SCARIA
2010 KMC
Anti TNF alpha drugs
• Adalimumab
• Certrolizumab
• Etanarcept
• Golimumab
• infliximab
TONY SCARIA
2010 KMC

11-03-2018
s/e anti TNF alpha drugs
• Serious infections
• Disseminated TB
• Pancytopenia
• Demyelination disorders
• Hypersensitivity
• Exacerbation of CHF
• Hypersensitivity
• Severe liver disease
• SLE
• NO INCREASED RISK OF MALIGANANCY
• Avoided in patients with hypersensitivity / active infection
TONY SCARIA
2010 KMC
Tocilizumab
• Monoclonal Ab directed against IL – 6 receptor cell membrane
• IL – 6  involved in pathogenesis of RA  joint inflammation & damage
TONY SCARIA
2010 KMC

11-03-2018
IL-1 receptor antagonist
• ANAKINRA
TONY SCARIA
2010 KMC
Rituximab
• Anti CD – 20 Ab
• Monoclonal Ab
• Attaches to B cell
TONY SCARIA
2010 KMC

11-03-2018
ibritumomab tiuxetan
• Murine monoclonal Ab
labelled with yttrium 90
or indium 111
• In cases refractory to
rituximab TONY SCARIA
2010 KMC
Abatacept  fusion protein
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Trastuzumab
• Anti – HER2 /neu Ab
• Monoclonal Ab directed against HER2 /neu receptor tyrosine kinase
against breast cancer with over expression of this factor
TONY SCARIA
2010 KMC

11-03-2018
Immunosuppressants
• Cyclophosphamide
• Leflunomide
• Azathioprine
• Cyclosporine TONY SCARIA
2010 KMC
Orthopedic procedures in patients with RA
• Tenosynovectomy
• Tendon repair
• Synovectomy
• arthroplasty
• Arthrodesis
TONY SCARIA
2010 KMC

11-03-2018
• 1. Anemia – *Normocytic normochromic anemia* and is due to ineffective
• erythropoiesis
• 2. ESR – It is increased in all patients with active RA.
• 3. C – reactive protein and ceruloplasmin are increased
• 4. Synovial fluid analysis –
• 1. Turbid
• 2. Decreased viscosity ,
• 3. Increase protein content
• 4. Decrease glucose concentration
• 5. WBC count is 5000 – 50000 per ml
TONY SCARIA
2010 KMC
Psoriatric arthritis

11-03-2018
Psoriatic arthritis
• Seronegative polysynovitis erosive
• HLA DR7
• HLA CW6
• Mc presentation  assymmetric oligoarthritis of large joints
• High incidence of sacroilitis & spondylitis
• HLA B27
• RF negative
TONY SCARIA
2010 KMC
Psoriatic arthritis
• In 30% psoriatic patients
• Skin lesions (early) joint involvement (late)
• Nail changes+
• PsA features include
• DIP joint involvement
• Dactylitis (sausage digitals)
• Arthritis mutilans(severe destructive arthritis)
• Corneal nodules
• Liver damage
• Rx
• MTX ,etanarcept
TONY SCARIA
2010 KMC

11-03-2018
CF
• 5 patterns of joint involvement
• Arthritis of DIP joint
• Asymmetrical oligoarthritis  MC
• Symmetrical poly arthritis similar to RA
• Axial involvement  spine & sacroiliac joint
• Arthritis mutilans
TONY SCARIA
2010 KMC
• Shortening of digits (d/t underlying osteolysis)TELESCOPING
• Pencil in cup deformity +
TONY SCARIA
2010 KMC

11-03-2018
• 1. DIP involvement, & classical pencil in cup deformity
• 2. Marginal erosion with adjacent bony proliferation, (whiskering)
• 3. Small joint ankylosis
• 4. Osteolysis of phalangeal and metacarpal bone, with telescoping
of digits
• 5. Periostitis and proliferative new bone at sites of enthesitis
• 6. Severe cervical spine involvement with atlantoaxial subluxation,
but relative sparing of thoracolumbar spine, and paravertebral
ossification.
TONY SCARIA
2010 KMC
Pencil in cup deformity
TONY SCARIA
2010 KMC

11-03-2018
Pencil in cup deformity
TONY SCARIA
2010 KMC
Whiskering +
TONY SCARIA
2010 KMC

11-03-2018
Saucage digitals d/t dactylitis
TONY SCARIA
2010 KMC
arthritis mutilans
TONY SCARIA
2010 KMC

11-03-2018
• Telescoping
• Underlying osteolysis  telescoping
• Nail changes
• Less tender than RA
• Conjunctivitis & Ch uveitis
• Fibrous & bony ankylosis
• PsA>> RA
TONY SCARIA
2010 KMC
Radiological signs
• Opera glass hand (telescoping)
• Telescoping of bones in to its
neighbours with shortening of digits
• Pencil in cup sign
• Tapering of proximal phalanx and
bony prolifern of distal phalanx
TONY SCARIA
2010 KMC

11-03-2018
Radiological signs in PsA
• Whiskering
• Marginal erosions with adjacent bony proliferation
• Mouse ear
TONY SCARIA
2010 KMC
Opera glass hand sign
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Criteria for PsA caspar
TONY SCARIA
2010 KMC

11-03-2018
Rx of PsA
• Methotrexate is drug of choice
• Anti TNF - a agents
• etanercept and infliximab are newer drugs and are effective even in
longstanding resistent PsA cases (to previous therapy) and extensive skin
lesion
• Other effective agents are sulfasalazine, cyclosporine retinoic acid &
psoralen & UV-A (PUVA)
TONY SCARIA
2010 KMC
Seronegative spondyloarthropathies
• Onset <40 years
• HLA B 27 positive
• Presence of uveitis
• Absence of auto Ab
• Inflammatory of arthritis of spine /
large joints
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
AS

11-03-2018
Ankylosing spondylitis / marie –
strumpell/bechtew ds
• Genetically determined
• Generalised c/c inflammatory ds
• Primarily affects axial skeleton
• With variable involvement of shoulder or hip TONY SCARIA
2010 KMC
• Primary pathology
• Enthesitis
• Site of ligamentous attachment to bone
• Primarily I pelvis & spine
• Prominent edema of adjacent bonemarrow fb ossification
• Peripheral arthritis of AS
• TNF alpha & cytokines
TONY SCARIA
2010 KMC

11-03-2018
• AS
• HLA B27 +ve
• M:F=3:1
• Earliest manifestation  sacroilitis (enthesitis+ synovitis)
• Sacroiliac joint mainly on iliac side
• Extra articular manifestation
• a/c anterior uveitis *** mc
• cardiac manifestation  AR , 3rd degree heart block , conductive defects
• GI involvement  inflammation of colon / ileum (IBD)
• Restrictive lung ds
TONY SCARIA
2010 KMC
• M:F=2:1
• 15 – 25 yrs
• dull pain, insidious in onset, felt deep in lower lumbar or gluteal
region, accompanied by low back morning stiffness of up to few hour
duration that improves with activity and returns following period of
inactivity
TONY SCARIA
2010 KMC

11-03-2018
Musculoskeletal system
• Enthesopathy
• Inflammation of tendon & ligament attached to it
• Synovitis of diarthroidal joints
• Sacroiliac joint
• Facet foint of vertebrae
• Costovertebral joint
• Inflammation of fibroosseous junction of syndesmotic joints
• SI joint ligaments
• Manubrium sternii
• Pubic symphysis
• Intervertebral disc
TONY SCARIA
2010 KMC
1. ? Mark posture
• Hyperkyphosis of thoracic spine & loss of
lumbar lordosis
2. Sacroilitis
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
• Should increase by atleast 5 cm in on fexion
• <5cm  restriction of flexion
TONY SCARIA
2010 KMC

11-03-2018
Shobers test
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Limitation of chest expansion
• d/t costovertebral joint involvement
• <2cm  AS
TONY SCARIA
2010 KMC

11-03-2018
Eye involvement in AS
• Iritis +
TONY SCARIA
2010 KMC
Spine
• Loss of lumbar lordosis (Straightening)
• Enthesitis – Increased Blood ﬂow –
Cause absorption by
• Erosions of anterior corners of
vertebral body causing squaring of
vertebral body.
• Delicate syndesmophyte with “vertical
orientation bridging vertebral bodies”
“(horizontal in degenerative spine
disease)”.
• Bamboo spine, syndesmophytes and
paravertebral ossifcation
TONY SCARIA
2010 KMC

11-03-2018
• Xray
• Loss of lumbar lordosis
• Sclerosis of anterior corners of vertenbral body
• Squarring of vertebrae
• Bamboo spine TONY SCARIA
2010 KMC
Sacro iliac joint
• Blurring of margins
• Juxta-articular sclerosis
• Erosions cause
pseudowidening
• Obliteration of joint (fbrous
followed by bony ankylosis)
TONY SCARIA
2010 KMC

11-03-2018
• Complication
• Mc  spine # even with minor trauma
TONY SCARIA
2010 KMC
• Rx
• Phenylbutazone  most effective drug
• Causes aplastic anemia
• Hence reserved for resistant cases
• indomethacin
• Sulfasalazine + FA antagonist
• Anti TNF alpha therapy
• Infliximab / etanarcept
TONY SCARIA
2010 KMC

11-03-2018
Diffuse idiopathic skeletal
hypertrostosis (DISH)
Ankylosing spondylitis
Syndesmophytes Nonmarginal (paravertebral) Marginal
X ray Flowing candle wax • Bamboo spine
• Squaring of vertebral bodies
Radiodensity Increased Radiolucent
HLA B8 B27
a/w DM + -
Age Elderly Young
TONY SCARIA
2010 KMC
Flowing wax like appearance in DISH
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Neuropathic joint d/s / charcot’s joint
• Progressive destructive arthritis
• d/t loss of sensation & proprioception  repeated trauma  bone &
cartilage damage
• Hence Less pain is experienced than anticipated
• DM ***>>tabes dorsalis
• Radiological features
• Same as OA
• Diagnosis
• MRI & bone scan
• Using indium 111 labelled WBC / IgG (to differentiate from OM increased uptake in
osteomyelitis but not in neuropathic joint)
TONY SCARIA
2010 KMC

11-03-2018
d/s associated with charcots joint
• DM***
• Midtarsal >>tarsometatarsal>>metatarsophalangeal>>ankle >> knee & spine
• Tabes dorsalis
• Associated with lightening pin in lower limbs
• Knee joint is affected
• Meningomyelocele
• Ankle / intertarsal
• Peroneal muscular atrophy
• Syringomyelia
• Shoulder elbow wrist cervical spine
• Leprosy
• Amyloidosis
• c/c alcoholism
• Metatrsophalangeal / IP
TONY SCARIA
2010 KMC
Radiological finding in charcots joint
• Joint space narrowing
• Joint becomes
progressively enlarged
from bony overgrowth
and synovial effusion
• swelling, instability,
laxity & progressive
deformity
TONY SCARIA
2010 KMC

11-03-2018
Tumbling building block spine
• In charcot spine
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Rx of charcots joint
• limitation of joint movements by bracing or casting, joint
debridement (arthrocentesis) and fusion of joint (arthrodesis)
TONY SCARIA
2010 KMC
Hemophilic arthropathy
• Order of joint involvement
• Knee >> ankle >> elbow>> shoulder>>hip
• Position of joint
• Flexion + abduction + external rotation
• Avoid joint aspiration & arthroscopy
TONY SCARIA
2010 KMC

11-03-2018
• Hemophilia
• X-linked recessive disorder
• manifested only in males but females are carriers
• characterized by the absence or
• defciency of factor VIII (hemophilia A or classical hemophilia)  85%
• factor IX (hemophilia B or Christmas disease)
TONY SCARIA
2010 KMC
Haemarthrosis
• Ankle is most commonly involved in children
• Joint assumes position of minimal discomfort and minimal
intra-articular pressure, which is,
• ﬂexion (30–65°) abduction
(15°) and lateral rotation (15°) in hip; and slight ﬂexion in knee.
• Pain, warmth, boggy swelling, tenderness and limited
movements cause it to resemble with low grade infection.
TONY SCARIA
2010 KMC

11-03-2018
• Clotting Factors
• • <1% ~ Spontaneous Hemorrhage
• • 1-5% - Hemorrhage on Mild Trauma
• • >5% Hemorrhage on Signifcant Trauma
TONY SCARIA
2010 KMC
Haemophilic pseudotumour
• In severe haemophiliacs
• Progressive cystic swelling caused by uncontrolled haemorrhage with
in confined space
• Haematoma increases in size  pressure necrosis
• Mc location  thigh >> abdomen > pelvis
• Iliopsoas >>> quadriceps
TONY SCARIA
2010 KMC

11-03-2018
Intramuscular bleeding
• Bleeding into muscle is less common but equally harmful can cause muscle
necrosis, reactive fbrosis and joint contractures.
• Mc site of bleeding in LL
• Quadriceps
• Mc site of bleeding in UL
• Deltoid
• Bleeding into iliopsoas & retroperitoneum
• Resembles APPENDICITIS
TONY SCARIA
2010 KMC
Radiologic features of haemophilic arthritis
• Soft tissue swelling
• Juxtaarticular osteopenia (not sclerosis)
• Overgrowth & osteoporosis of epiphyses
• Marginal erosions
• Subchondral cyst
• Widened intercondylar notch of femur
• Trochlear notch of ulna
• Enlarged proximal radius
• Squarring distal end of patella
• Total loss of joint space
• Fibrous ankylosis
TONY SCARIA
2010 KMC

11-03-2018
Rx
• Factor replacement in haemophilia
• Joint aspiration (in severe cases)
• Ice & analgesics  to relieve pain
• Rest
• Compressive bandage
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
TONY SCARIA
2010 KMC
Gout
• 1st MTP  mc involved joint
• Monosodium crystals 
• negatively birefringent
• Needle shaped
• Tophi
• Extensor aspect of elbow
• Pinna
• 1st MTP
TONY SCARIA
2010 KMC

11-03-2018
Polyarticular gout
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Acute gout
• First episode @ night
• With dramatic joint pain & swelling
• Skin is shiny red  similar to cellulitis
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
TOPHI in Xray
TONY SCARIA
2010 KMC
MARTELS SIGN or G (GOUT)
SIGN
• Punched out with over hanging bone
• Chronic tophaceous gout
• -Cystic changes and well-defined erosions
described as punched-out lytic lesions with
overhanging bony edges (Martels sign, or G sign
for gout), associated with soft tissue calcified
masses
TONY SCARIA
2010 KMC

11-03-2018
MSU crystals in polarised light
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Pseudogout
• Calcium pyrophosphate crystals
• Rhomboid /rectangular
• Positively refringent
• Moderate pain
• Large joints  knee joint – mc involved joint
• Chondrocalcinosis on xray
TONY SCARIA
2010 KMC
Pseudogout is a/w
• Hypothyroidism
• Hemochromatosis
• Hyperaprathyroidism (primary)
• Hypomagensemia
• Hypophosphatemia
• Wilsons ds
TONY SCARIA
2010 KMC

11-03-2018
• Chondrocalcinosis
• Radiological hall mark of pseudogout
• Linear /multiple punactate in menisci
TONY SCARIA
2010 KMC
TONY SCARIA
2010 KMC

11-03-2018
Milwaukee shoulder
• More common in female
• With h/o trauma
• d/t deposition of calcium hydroxyapatite crystal
• Mc in shoulder
• Definitive diagnosis of apatite arthropathy depends on
identification of crystals from synovial fluid or tissue
• X ray  multiple loose bodies
• Rx
• Intraarticular steroid
TONY SCARIA
2010 KMC
Reiter syndrome
• Reactive arthritis
• Seronegative spondyloarthropathies
• HLA B27 +
• Classic triad
• Conjunctivitis / uveitis
• Arthritis large joints in LL
• Urethritis
• Circinate balanitis +
• Keratoderma blenorrhagica
TONY SCARIA
2010 KMC

11-03-2018
• Bacteria causing Reactive Arthritis
• 1. Salmonella
• 2. Shigella MC ORGANISM
• 3. Campylobacter
• 4. Yersinia
• 5. Chlamydia. MC cause following urethritis
• Reiter disease can occur in epidemic form
TONY SCARIA
2010 KMC
Rx of reiters ds
• 1. Analgesics
• 2. Local corticosteroids are useful in the case of iritis
• 3. The nonspecific urethritis is treated with a short course of
• Tetracycline. TONY SCARIA
2010 KMC

11-03-2018
Ankylosis
Bony ankylosis
• Pyogenic arthritis of all joints
*** mc cause
• Tuberculous arthritis of spine
Fibrous ankylosis
• Tuberculous arthrotis of hip /
knee /small joints
Transient synovitis of hip
• aka Observation hip
• Self limiting condition usually lasts only a short time
• aka Coxalgia fugax /coxitis serosa
• Mc of hip pain in children < 10 yrs (3-12 yrs of age)
• With rapid onset of pain
• Limited to groin or may be referred to thigh
• limping
• Antalgic gait
• limited range of movement
• Gaurded rotation of hip
• Tenderness at extremes of motion
• Following viral URTI
• Usually u/l
TONY SCARIA
2010 KMC

11-03-2018
FABER  flexion abduction external rotation
TONY SCARIA
2010 KMC
X ray
• Widened joint space
medially
• Bone density is normal
TONY SCARIA
2010 KMC

11-03-2018
USG
• Mild joint effusion
• USG guided aspiration
• For definitive cytological diagnosis
• To r/o septic arthritis
TONY SCARIA
2010 KMC
Rx
• Observation
• Traction
TONY SCARIA
2010 KMC

11-03-2018
Chondrocalcinosis
• Knee joint  MC involved in menisci
• Causes
• All causes Pseudogout  most important cause
• Alkaptonuria
• Wilsons ds TONY SCARIA
2010 KMC
Arthrtis
Erosive arthritis
• RA
• Gout
• Hyperparathyroidiam
Nonerosive
• SLE
• OA

11-03-2018
Spondyloarthrosis
• Aka Seronegative arthritis
• 1. Ankylosing spondylitis
• 2. Reiter’s disease
• 3. Reactive Arthritis
• 4. Psoriatic arthritis
• 5. Juvenile rheumatoid arthritis (JRA)
• 6. Inflammatory bowel disease
TONY SCARIA
2010 KMC
Features of spondyloarthrosis
• 1. Seronegativity (rheumatoid factor –ve)
• 2. HLA B27 associated
• 3. Axial arthritis: Pathology in spine and sacroiliitis.
• 4. Asymmetrical large-joint oligoarthritis (i.e <5 joints) or monoarthritis.
• 5. Enthesitis: Inflammation of the site of insertion of tendon or ligament
into bone, eg. Plantar fasciitis, Achillis tendonitis, costochondritis.
• 6. Extra-articular manifestations eg anterior uveitis, aortic regurgitation
TONY SCARIA
2010 KMC

11-03-2018
Arthritis in children
Acute(<2
weeks )
•Rheumatic
fever
•Septic
arthritis
Sub acute(2-6
weeks)
•Reactive
arthritis
Chronic(>6
weeks)
•JRATONY SCARIA
2010 KMC

11-03-2018
JIA
Juvenile rheumatoid
arthritis
Juvenile psoriatic
arthritis
Juvenile enthesitis
related arthritis
TONY SCARIA
2010 KMC
Juvenile rheumatoid arthritis
• Diagnostic criteria
TONY SCARIA
2010 KMC

11-03-2018
JRA
pauciarticular
Type I
Type II
Polyarticular
Polyarticular
RA positive
Polyartciular
RA negative
Systemic
onset
• ANA +ve
• RF –ve
• Eye involvement with
iridocyclitis glaucoma cataract
• HLA DR5 & DRW8
• ANA –ve
• RF-ve
• Iritis only (not iridocyclitis)
• HLA B27
• ANA –ve
• RF-ve
• Iritis only (not iridocyclitis)
• HLA B27
• Symmetrical joint involvement
with uveitis & rheumatoid nodule
• RA factor +
• ANA +ve
• No rheumatoid nodule
• No RF
• Fever with ras
• lymphadenopathy HSM
• RF –ve
• Uveitis (iridocyclitis ) absent
TONY SCARIA
2010 KMC
RF is positive only in polyarticular
JRA
TONY SCARIA
2010 KMC

11-03-2018
• No iritis or uveitis in
systemic type &
polyarticular RA negative
TONY SCARIA
2010 KMC
Rx
• NSAIDs
• Naproxen
• Ibuprofen
• Indomethacin
TONY SCARIA
2010 KMC

Rheumatology revison notes

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