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Chapter 59
Disorders of Musculoskeletal
Function: Rheumatic Disorders
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Arthritis
• Primary arthritis
– Affecting body systems in addition to the musculoskeletal
system
– Results from an immune response
• Secondary arthritis
– Rheumatoid conditions limited to a single or few
diarthrodial joints
– Results from a degenerative process and the ensuing joint
irregularities that occur as the bone attempts to remodel
itself
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Systemic Autoimmune Rheumatic
Diseases
• Rheumatoid arthritis
• Systemic lupus erythematosus
• Systemic sclerosis/scleroderma
• Polymyositis
• Dermatomyositis
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Characteristics of Rheumatoid Arthritis
• Associated with extra-articular as well as articular
manifestations
• Usually has an insidious onset marked by systemic
manifestations such as fatigue, anorexia, weight loss,
and generalized aching and stiffness
• Characterized by exacerbations and remissions
• May involve only a few joints for brief durations, or it
may become relentlessly progressive and debilitating
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Results of Progressive Joint Destruction
• May lead to subluxation (dislocation of the joint, resulting
in misalignment of the bone ends)
• Instability of the joint
• Limitation of movement
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Symptoms of RA
• Fatigue
• Weakness
• Anorexia
• Weight loss
• Low-grade fever
• Anemia
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Systemic Autoimmune Rheumatic
Diseases
• A group of chronic disorders characterized by diffuse
inflammatory lesions and degenerative changes in
connective tissue
– These disorders share similar clinical features and
may affect many of the same organs.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
American Rheumatism Association
Criteria for Rheumatoid Arthritis
• Morning stiffness at least 1 hour present for at least 6 weeks
• Swelling of three or more joints for at least 6 weeks
• Swelling of wrist, metacarpophalangeal, or proximal
interphalangeal joints for 6 or more weeks
• Systemic joint swelling
• Hand roentgenogram changes typical of RA
• Rheumatoid nodules
• Serum rheumatoid factor
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Treatment Goals for a Person With RA
• Reduce pain
• Minimize stiffness and swelling
• Maintain mobility
• Become an informed health care consumer
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement true or false?
• Rheumatoid arthritis is a condition of individual joint
deterioration and breakdown.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• False: RA usually has an insidious onset marked by
systemic manifestations such as fatigue, anorexia,
weight loss, and generalized aching and stiffness. It may
involve joints sporadically or progressively.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Characteristics of Systemic Lupus
Erythematosus (SLE)
• Formation of autoantibodies and immune complexes
• B-cell hyperreactivity
• Increased production of antibodies against self
(autoantibodies) and non-self antigens
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Characteristics of Systemic Lupus
Erythematosus (SLE) (cont.)
•
The autoantibodies can directly damage tissues or combine
with corresponding antigens to form tissue-damaging
immune complexes
−Types of autoantibodies
• Antinuclear antibodies
• Other antibodies
• Platelets
• Coagulation factors
• Red blood cell surface antigens
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Categories of Clinical Manifestations of
SLE
• Constitutional
• Musculoskeletal
• Dermatologic
• Cardiovascular
• Pulmonary
• Renal
• Neuropsychiatric
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Systemic Sclerosis
• Autoimmune disease of connective tissue
characterized by excessive collagen deposition in
the skin and internal organs
• Diffuse or generalized form
– Skin changes involve the trunk and proximal
extremities.
• Limited or CREST variant
– Hardening of the skin (scleroderma) is limited to the
hands and face.
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Manifestations of the CREST Syndrome
• Calcinosis (calcium deposits in the subcutaneous tissue
that erupt through the skin)
• Raynaud phenomenon
• Esophageal dysmotility
• Sclerodactyly (localized scleroderma of the fingers)
• Telangiectasia
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Types of Seronegative
Spondyloarthropathies
• Inflammation and involvement of the peripheral joints
with an absence of rheumatoid factor
– Ankylosing spondylitis
• Juvenile ankylosing spondylitis
– Reactive arthritis, enteropathic arthritis (i.e.,
inflammatory bowel disease)
– Psoriatic arthritis
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Methods of Assessing Mobility and
Detecting Sacroiliitis
• Pressure on the sacroiliac joints with the person in a
forward-bending position elicit pain and muscle spasm.
• Measurement of the distance between the tips of fingers
and the floor in a bent-over position with straight knees
• Modified Schöber’s test, in which contralateral flexion of
the back is measured
• Measurement of chest expansion may be used as an
indirect indicator of thoracic involvement
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Reiter Syndrome
• Clinical manifestation of reactive arthritis
• Accompanied by extra-articular symptoms such as
uveitis, bowel inflammation, carditis
• Develops in a genetically susceptible host after a
bacterial infection due to Chlamydia trachomatis in the
genitourinary tract
• Salmonella, Shigella, Yersinia, or Campylobacter in the
gastrointestinal tract
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Subgroups of Psoriatic Arthritis
• Oligoarticular or asymmetric (48%)
• Spondyloarthropathy (24%)
• Polyarticular or symmetric (18%)
• Distal interphalangeal (8%)
• Mutilans (2%)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Which of the following conditions is caused by collagen
deposition?
a. Rheumatoid arthritis
b. Systemic lupus erythematosus
c. Psoriatic arthritis
d. Systemic sclerosis
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Answer
a. Rheumatoid arthritis
b. Systemic lupus erythematosus
c. Psoriatic arthritis
d. Systemic sclerosis: Systemic sclerosis is an autoimmune
disease of connective tissue characterized by excessive
collagen deposition in the skin and internal organs.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Osteoarthritis
• Degenerative joint disease
• Primary variants of OA occur as localized or generalized
syndromes
• Secondary OA has a known underlying cause such
– Congenital or acquired defects of joint structures,
trauma, metabolic disorders, or inflammatory
diseases
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Causes of Osteoarthritis
• Postinflammatory diseases
• Post-traumatic disorders
• Anatomic or bony disorders
• Metabolic disorders
• Neuropathic arthritis
• Hereditary disorders of collagen
• Idiopathic or primary variants
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Osteoarthritis-Induced Joint Changes
• Progression
• Manifestations
– A progressive loss
of articular cartilage
– Synovitis
– Osteophytes
• Bone spurs
– Joint pain
– Stiffness
– Limitation of motion
– Joint instability
– Deformity
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Metabolic and Endocrine Diseases
Associated With Joint Symptoms
• Amyloidosis
• Gout syndrome
• Osteogenesis imperfecta
• Diabetes mellitus
• Hyperparathyroidism
• Thyroid disease
• AIDS
• Hypermobility syndromes
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Gout Syndrome
• Acute gouty arthritis with recurrent attacks of severe
articular and periarticular inflammation
• Tophi or the accumulation of crystalline deposits in
articular surfaces, bones, soft tissue, and cartilage
• Gouty nephropathy or renal impairment
• Uric acid kidney stones
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Types of Gout
• Primary gout
– Designate cases in which the cause of the disorder is
unknown or an inborn error in metabolism
– Characterized primarily by hyperuricemia and gout
• Secondary gout
– The cause of the hyperuricemia is known, but the
gout is not the main disorder
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Objectives for Treatment of Gout
• Termination and prevention of the acute attacks of gouty
arthritis
• Correction of hyperuricemia
• Inhibition of further precipitation of sodium urate
• Absorption of urate crystal deposits already in the tissues
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Juvenile Idiopathic Arthritis (JIA)
• JIA categories of diseases
with three principal types of
onset:
• Systemic symptoms
1. Systemic onset disease
– Stunted growth
2. Pauciarticular arthritis
– Weight loss
3. Polyarticular disease
– Malaise
– Low-grade fever
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Juvenile Rheumatoid Arthritis (JRA)
• Definition
– A chronic disease characterized by synovitis
• Manifestations
– Can influence epiphyseal growth by stimulating
growth of the affected side
– Generalized stunted growth also may occur
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Manifestations of Children With SLE
• Constitutional symptoms
– Fever, malaise, anorexia, weight loss
• Symptoms of the integumentary, musculoskeletal,
central nervous, cardiac, pulmonary, and hematopoietic
systems are similar to those of adults.
• Endocrine abnormalities include
– Cushing syndrome from long-term corticosteroid use
– Autoimmune thyroiditis
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Signs and Symptoms of Giant Cell Arteritis
• Constitutional symptoms
– Malaise, fatigue, fever, weight loss, cough, sore
throat
• Polymyalgia rheumatica syndrome
• Manifestations related to vascular involvement
• Ischemic optic neuropathy
• Claudication of jaw or arm
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Uric acid accumulation is involved in which condition?
a. Amyloidosis
b. Gout syndrome
c. Osteogenesis imperfecta
d. Diabetes mellitus
e. Hyperparathyroidism
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Answer
a. Amyloidosis
b. Gout syndrome: Gout is the result of hyperuricemia.
c. Osteogenesis imperfecta
d. Diabetes mellitus
e. Hyperparathyroidism
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