Transcript Rheumatology: RHEUMATOID ARTHRITIS

Rheumatology:
OSTEOARTHRITIS
RHEUMATOID ARTHRITIS
Dr. Meg-angela Christi Amores
OSTEOARTHRITIS
• Most common type of arthritis
• leading cause of disability in the elderly
• Mostly affects >65 yrs old
Osteoarthritis
• Commonly affected joints:
• cervical and lumbosacral
spine, hip, knee, and first
metatarsal phalangeal joint
(MTP)
• distal and proximal
interphalangeal joints and the
base of the thumb
• Usually spared are the wrist,
elbow, and ankle
Osteoarthritis
• Structural changes:
• nearly universal by the elderly years
• cartilage loss (seen as joint space loss on x-rays) and
osteophytes
Severe osteoarthritis in...
• distal interphalangeal joints (Heberden's
nodes)
• proximal interphalangeal joints (Bouchard's
nodes)
Osteoarthritis
• OA is joint failure
– a disease in which all structures of the joint have
undergone pathologic change
– hyaline articular cartilage loss
– increasing thickness and sclerosis of the
subchondral bony plate, by outgrowth of
osteophytes at the joint margin, by stretching of
the articular capsule, by mild synovitis
Joint protective mechanism
• Joint protectors include: joint capsule and
ligaments*, muscle, sensory afferents~, and
underlying bone
• *Fixing the range of joint motion
• ~providing feedback , anticipating joint loading
• Synovial fluid: major protector against
friction-induced cartilage wear
• depends on the molecule lubricin
• concentration diminishes after joint injury
Osteoarthritis
• Major risk factors:
– Joint vulnerability and joint loading
– vulnerable joint whose protectors are
dysfunctional can develop OA with minimal levels
of loading
– in a young joint with competent protectors, a
major acute injury or long-term overloading is
necessary to precipitate disease
Osteoarthritis
• Other risk factors:
– Age (incidence of disease rising dramatically with age)
– hormone loss with menopause
– Highly heritable
– Hip OA is rare in China, Knee OA is frequent
– Major injuries to a joint : e.g. Fracture
– Obesity
– Repeated use of joint : e.g sports, farming, etc
– Malalignment: e.g. varus, valgus
• varus, in which the stress is placed across the
medial compartment of the knee joint, and
valgus, which places excess stress across the
lateral compartment of the knee
Clinical features: OA
• Activity-related joint pain
• during or just after joint use
• knee or hip pain with going up or down stairs
• pain in weight-bearing joints when walking
• for hand OA, pain after cooking
• Brief morning stiffness <30 mins
Treatment
• mild and intermittent symptoms may need
only reassurance or nonpharmacologic
treatments:
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altering loading across the painful joint
avoid activities that precipitate pain
Exercise
Correction of malalignment
• with ongoing, disabling pain are likely to need
both nonpharmaco- and pharmacotherapy
• Acetaminophen, Nonsteroidal Anti-Inflammatory Drugs
(NSAIDs), and COX-2 Inhibitors
Rheumatoid arthritis
Rheumatoid Arthritis
• chronic multisystem disease of unknown
cause
• persistent inflammatory synovitis, usually
involving peripheral joints in a symmetric
distribution
• Hallmark: potential of the synovial
inflammation to cause cartilage damage and
bone erosions and subsequent changes in
joint integrity
Rheumatoid Arthritis
• Epidemiology
– prevalence of RA is ~0.8% of the population
– Women > men ( 3:1 )
– seen throughout the world and affects all races
– onset is most frequent during the fourth and fifth
decades of life
– genetic predisposition
Rheumatoid Arthritis
• Unknown cause
• might be a manifestation of the response to
an infectious agent in a genetically susceptible
host
• Mycoplasma, Epstein-Barr virus (EBV), cytomegalovirus,
parvovirus, and rubella virus
• but convincing evidence that these or other infectious
agents cause RA has not emerged
Rheumatoid Arthritis
• propagation of RA is an immunologically
mediated event
• earliest event appears to be a nonspecific
inflammatory response
• cascade of cytokines produced in the
synovium activates a variety of cells in the
synovium, bone, and cartilage to produce
effector molecules that can cause tissue
damage
Rheumatoid Arthritis
Clinical features
• chronic polyarthritis
• begins insidiously with fatigue, anorexia,
generalized weakness, and vague
musculoskeletal symptoms
• hands, wrists, knees, and feet, become
affected in a symmetric fashion
• by constitutional symptoms, including fever,
lymphadenopathy, and splenomegaly (10%)
Clinical features
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Prolonged morning stiffness (>1 hr)
swelling, tenderness, and limitation of motion
distal interphalangeal joints are rarely involved
Synovitis of the wrist joints is a nearly uniform
feature of RA
Rhuematoid Arthritis- hand
• “Z” deformity
• radial deviation at the wrist with ulnar deviation of the
digits, often with palmar subluxation of the proximal
phalanges
• swan-neck deformity
• hyperextension of the proximal interphalangeal joints,
with compensatory flexion of the distal interphalangeal
joints
• boutonnière deformity
• flexion contracture of the proximal interphalangeal
joints and extension of the distal interphalangeal joints
Extraarticular manifestations
• a systemic disease with a variety of
extraarticular manifestations
– Rheumatoid nodules
– Clinical weakness and atrophy of skeletal muscle
– Rheumatoid vasculitis
– Pleuropulmonary manifestations
– Felty's syndrome
– Osteoporosis
Laboratory tests
• RF (rheumatoid factor)
• 2/3 of patients
• not specific for RA, present in 5% of healthy
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Anti-CCP
Normochromic, normocytic anemia
ESR increased
Synovial fluid analysis
• fluid is usually turbid, with reduced viscosity, increased
protein content, and a slightly decreased or normal glucose
concentration
Treatment
• Goals:
– 1) relief of pain, (2) reduction of inflammation, (3)
protection of articular structures, (4) maintenance
of function, and (5) control of systemic
involvement
• Pain meds:
– First line: NSAIDS
– 2nd line: steroids (glucocorticoids)
– 3rd line: DMARDS (methotrexate, gold)
OA vs RA
OSTEOARTHRITIS
Age frequent
Hand involvement
Wrist involvement
Onset of pain
Morning stiffness
Special features:
RHEUMATOID ARTHRITIS