Rheumatological diseases can affect the joints, skin, and internal organs. Some common types include rheumatoid arthritis, osteoarthritis, lupus, Sjogren's syndrome, and spondyloarthropathies like ankylosing spondylitis. Rheumatoid arthritis causes chronic inflammation of the synovium and can lead to joint deformity. Osteoarthritis is characterized by cartilage loss within a joint and associated bone changes. Systemic lupus erythematosus is a multi-system autoimmune disease affecting many organs, with a variety of potential manifestations.

1. Rheumatological diseases

2. Rheumatic Diseases
Common Rheumatic Diseases :
 Rheumatoid arthritis (RA)
 Osteoarthritis
 Systemic lupus erythematous (SLE)
 Sjogren syndrome
 Dermatomyositis/polymyositis
 Scleroderma/systemic sclerosis
 Ankylosing spondylitis.
 Psoriatic arthritis

3. The Most Common Autoimmune Disease
 1% population or 3 per 10,000
 3:1 female to male
 Highest in 3rd and 4th decades
 Two peaks incidence
 Morbid/mortal disease
 Description dates to the 17th century -A New World Disease

4. Rheumatoid arthritis (RA)
 Rheumatoid Arthritis (RA) is a chronic inflammatory disorder that may affect
many tissues and organs, but mainly attacks the joints producing an
inflammatory synovitis.
 RA mainly affects the joints.
 May also produce inflammation in the lungs, pericardium, pleura, and sclera.
 Rheumatoid Arthritis is a chronic disease who’s pain intensity and deterioration
of joint structures progress over time often leading to deformations and
disability.

5. Signs and Symptoms of Rheumatoid Arthritis
 Tender, warm, swollen joints
 Joint stiffness that is usually worse in
the mornings and after inactivity.
 Fatigue, fever and weight loss

6. RA Diagnosis & Tests
 X Rays of hands and feet are generally performed in people with RA.
 Magnetic Resonance Imaging (MRI)
 Ultrasounds
 Blood Tests: Rheumatoid Factor

7. Treatment
 Surgery
• Removal of inflamed synovium
• Arthroplasty
 Physical therapy
 Cortisone Therapy
 Anti-inflammatory Agents
• Aspirin
• Ibuprofen
• Naproxen
 Acetaminophen
• Tylenol

8. Osteoarthritis
 Most common rheumatic disease and is characterized
by progressive loss of cartilage and reactive changes
at the margins of the joint and in the subchondral bone
 Primarily affects weight-bearing joints
such as the knees, hips and lumbosacral spine
 In early disease, pain occurs only after joint use
and is relieved by rest
 As the disease progresses, pain occurs with
minimal motion or even at rest

9. Classification of OA
Primary OA Secondary OA
Etiology is unknown Etiology is known
• More common than secondary OA Due to a predisposing cause such as:
1) Injury to the joint
• Common-in elders where there is no 2) Previous infection
previous pathology 3) RA
4) CDH
• Its mainly due to wear and tear changes 5) Deformity
occurring in old ages mainly in weight 6)Obesity
bearing joints

10. Clinical features of OA
 Pain
 Stiffness
 Muscle spasm
 Restricted movement
 Deformity
 Muscle weakness or wasting
 Joint enlargement and instability
 Crepitus
 Joint Effusion

11. Possible Anatomic Sites Of Pain Generation in OA

12. Special Investigations
 Blood tests: Normal
 Radiological features:
1) Cartilage loss
2) Subchondral sclerosis
3) Cysts
4) Osteophytes

13. Treatment
 Education
 Physiotherapy
– Exercise program
– Pain relief modalities
 Aids and appliances
 Medical Treatment
 Surgical Treatment

14. Systemic Lupus Erythematous (SLE)
 A multi-system inflammatory, autoimmune connective
tissue disease that occurs most commonly in women
during their reproductive age.
 The hallmark of SLE is its variety of presentation &
autoantibodies.
 Essentially any organ system can be affected,
particularly the skin, joints, kidneys, and CNS.

15. Epidemiology of SLE
 More common in urban than in rural areas
 4 -5 cases per 10,000
 Female : male= 9：1 (adult)
 Onset age= 65% between 15-25 ys(late onset ?40-55)
 Identical twin：30%
 First degree relative：5%
 Child of SLE mother has risk of SLE
(with positive anti –Ro/SSA antibody) ≈2%

16. Pathophysiology of SLE
 Systemic lupus erythematous (SLE) is characterized by a global loss of self-
tolerance with activation of auto reactive T and B cells leading to production of
pathogenic autoantibodies and tissue injury.
 Autoimmune reactions directed against constituents of cell nucleus, DNA

17. Clinical Features and Clinical Manifestations
 Clinical Features:
• Musculoskeletal disease
• Mucocutaneous involvement
• Renal Disease
• Central nervous system disease
• Cardiopulmonary disease
• Hematologic abnormalities
• Gastrointestinal involvement
 Clinical Manifestation:
• Severe fatigue
• Fever
• Weight loss
• Anorexia
• Lymphadenopathy

18. Treatment of SLE
 Arthritis, Arthralgias, Myalgias: Glomerulonephritis
NSAIDS, Anti-Malarials (eg. Plaquenil), Steroids
steroids-injections, oral methotrexate Pulse cytotoxic
Mycophenolate mofetil
 Photosensitivity, Dermatitis
Avoid Sun exposure CNS disease
Topical steroids, Plaquenil Anti-coagulants for thrombosis
Steroids and cytotoxic for
vasculitis
 Weight loss and fatigue Infarction
Steroids Steroids
Cytotoxic
 Abortion, Fetal loss Prostacyclin
ASA, Immunosuppression
 Thrombosis
Anti-coagulants

19. Sjogren syndrome
 A chronic, slowly progressive autoimmune
disease characterized by lymphocytic
infiltration of the exocrine glands resulting in
xerostomia and dry eyes
 1/3 have systemic manifestations
 Few develop lymphoma
 Female-to-male ratio, 9:1

20. 2 Forms: Sjogren syndrome
 Primary Sjogren's syndrome
The disease presents alone
 Secondary Sjogren's :
Associated with other autoimmune diseases
• RA
• SLE
• Scleroderma
• Mixed CT disease
• Primary biliary cirrhosis
• Vasculitis
• Chronic active hepatitis

21. Sjogren syndrome: Etiopathology
 Etiology -not well understood
 Findings suggest an on-going interaction between
The innate and acquired immune systems
 Lymphocytic (T,B) infiltration of exocrine glands
+
 B lymphocyte hyper-reactivity
 Inherited susceptibility+ exo /endogenous antigens
 Trigger a self-perpetuating inflammatory response

22. Sjogren’s: Clinical Manifestation
 Medications that cause similar symptoms
• Antidepressants
• Anticholinergic
• Beta blockers
• Diuretics
• Antihistamines
• Women on HRT
• Anxiety
 Glandular: Extra glandular:
• Xerophthalmia • Arthralgias/arthritis
• Xerostomia • Raynaud's phenomenon
• Bilateral parotid swelling • Lymphadenopathy

23. Investigations
 Routine:
• Mild normochromic, normocytic anaemia
• ESR rise- in 70%
 Mouth:
• Sialometry
• Sialography
• Imaging: Ultrasound, MRI or MR sialography of salivary glands.
• Salivary gland Biopsy
 Eye:
• Schirmer test

24. Sjogren’s: Treatment
 Artificial tears, Rx -corneal ulcerations
 Avoid drugs that secretions (Diuretics, anti HTs,anticholinergic &
antidepressants)
 Xerostomia: Best replacement - water
 Vaginal dryness: Propionic acid gels
 Secretagogues: Oral Pilocarpine / Cevimeline
 Arthralgias : HCQ
 RTA: Oral Soda bicarb
 Systemic vasculitis: Steroids,
 immunosuppressives, M Abs
 High-grade lymphomas: Chemo (CHOP) + M Abs

25. Dermatomyositis
 Dermatomyositis is a disease of the connective-tissue which is defined by
swelling of the skin and muscles.
 Dermatomyositis affects adults and children however it is more common in
females than males.
 It mostly affects the skin and muscles, but it may also affect the lungs and
oesophagus

26. Dermatomyositis: Symptoms
 Skin rash
 Symmetric proximal muscle weakness
 Muscle pain
 Temporary paralysis
 Difficulty in swallowing
 Scaly skin eruption
 Flat, erythematous lesion on the shoulders and chest
 Reddish-purple eruption on the upper eyelid
 Erythema
 Psoriasiform scalp changes
 Gastrointestinal infection
 Lung problems

27. Diagnostic Criteria
 Bohan and Peter Criteria: Symmetric proximal muscle weakness
 Typical rash
 Elevated serum muscle enzymes
 Myopathic changes on EMG
 Characteristic muscle biopsy abnormalities and absence of histopathologic signs
of other myopathies

28. Treatment
 Improve muscle strength and avoid development of extra muscular
complications
 Glucocorticoids are the cornerstone of initial therapy
 Typically initiate prednisone at 1 mg/kg to a maximum dose of 80 mg
 Initial treatment with high doses for the first several months to establish
disease control
 Slow taper to the lowest effective dose for total duration of 9-12 months
 First line agents include Azathioprine or methotrexate
 More than 80% of patients will improve with glucocorticoids alone

29. Sclerosis
 Multisystem disorder
 Unknown Etiology
 Thickening of skin caused by accumulation of
connective tissue (collagen types I and III)
 Involvement of visceral organs

30. Sclerosis: Etiology
 Unknown
 Environmental Exposures
• Silica exposure in men conferred increased risk
• Silicone breast implants: no definite risk identified
• Aniline laced Contaminated rapseed oil in Spain
• Vinyl chloride exposure increased risk of SSc like disorder: Eosinophilic
Fasciitis
• Bleomycin
• L-tryptophan: Eosinophilia Myalgia syndrome
 Genetic Factor
Familial Clustering: 1.5-2.5% of those with 1st degree relative

31. Sclerosis: Pathogenesis

32. Forms of Systemic Sclerosis
 Limited Scleroderma
• Crest Syndrome
• Calcinosis
• Raynaud’s
• Esophageal Dysmotility
• Sclerodactyly
• Telangiectasisa
 Diffuse Scleroderma
• Organ Involved
• Skin
• Musculoskeletal
• Pulmonary
• Renal

33. Forms of Systemic Sclerosis
 Limited Scleroderma
• Crest Syndrome
• Calcinosis
• Raynaud’s
• Esophageal Dysmotility
• Sclerodactyly
• Telangiectasisa
 Diffuse Scleroderma
• Organ Involved
• Skin
• Musculoskeletal
• Pulmonary
• Renal

34. Treatment: Sclerosis
 Corticosteroids
 Immunosuppressive Therapy
 Antispasmodics (muscle relaxants)
 Nutritional therapy
 High-protein diet with supplementary vitamins

35. Ankylosing Spondylitis
 A systemic rheumatic disease and is one of
the seronegative spondyloarthropathies
 The typical patient is young, aged 18-30
 Men are affected more than women by
a ratio about of 3:1

36. Signs and Symptoms
 Mild to severe back and buttock pain that is
often worse in the early morning hours
 Continued inflammation of the:
• Ligaments
• Tendons
• Joint capsules
• joints of the spine
 Common symptom is generalized fatigue.

37. Diagnosis
 A blood test for the HLA-B27 gene
 X-ray
 Tomography and magnetic resonance imaging of the sacroiliac joints
 Schober's test

38. Treatment
 Anti-inflammatory drugs
• NSAIDs such as Aspirin, Ibuprofen, Phenylbutazone, Indomethacin, Naproxen
and COX-2 inhibitors.
 DMARDs
• Such as Cyclosporine, Methotrexate, Sulfasalazine, and Corticosteroids
 TNFα blockers (antagonists)
• Etanercept, infliximab and Adalimumab
 Surgical Management
• Osteotomy for marked deformities of the hip/spine.
• Occasionally, hip or knee Arthroplasty is used

39. Psoriatic Arthritis
 Inflammatory arthritis associated with psoriasis
 One of the spondyloarthropathies.
 Males and females are equally affected.
 Psoriatic Arthritis is chronic, progressive
inflammatory disorder affecting the joints and skin
characterized by osteolysis and bony proliferation.

40. Signs and Symptoms
 Morning stiffness lasting >30 min in 50% of patients
 Patients may present with less joint tenderness than is usually seen in RA
 Dactylitis may be noted in >40% of patients2,4
 Ridging, pitting of nails, onycholysis – up 90% of patients vs nail changes in only
40% of psoriasis cases2,3

41. Main Features of Psoriatic Arthritis

42. Clinical Features in Psoriatic Arthritis
Dactylitis Enthesitis

43. Treatment
 NSAIDS
 DMARDS
• MTX
• Leflunomide
• Sulfasalazine
• Cyclosporine
• TNF α inhibitor
 Coordinate b/w Rheumatology and Dermatology