Chapter 44 RHEUMATIC Flashcards
Define osteopenia as it relates to osteoporosis and osteomalacia
-X-ray evidence of decreased bone mineral density (BMD)
OSTEOPOROSIS
-decreased bone density & strength
Fractures d/t
- Loss of trabeculae from cancellous bone
- Thinning of cortex
Postmenopausal Osteoporosis
- Increased osteoclastic activity results in loss of trabeculae
- Microfractures occur, bone compresses
Senile/age-related osteoporosis
-Haversian system widens d/t loss of trabeculae
MANIFESTATION
Silent disorder
Sudden onset fracture (hip, pelvis, humerous, etc.)**
Wedging/collapse of vertebrae (loss of height and kyphosis/dowager hump)
No pain unless fracture
OSTEOMALACIA
- softening of bones d/t inadequate mineralization
- adult condition
CAUSES
- insufficient calcium absorption from intestines
- phosphate deficiency d/t renal losses or decreased intestinal absorption
- Anticonvulsant use
MANIFESTATION
Bone pain, tenderness
Muscle weakness an early sign
Fractures of radius, femur
Not a significant cause of hip fracture
Delated healing of fractures = deformities
Hyperparathyroidism d/t low calcium levels
Describe the risk factors and factors that contribute to the development of osteoporosis and relate them to the prevention of the disorder
Gender Postmenopausal osteoporosis Male hormone declination Genetics Activity level Nutrition Body size Race Age-related changes
Describe the primary features of osteoporotic bone and resulting manifestations of this disease
Fractures d/t
- Loss of trabeculae from cancellous bone
- Thinning of cortex
Postmenopausal Osteoporosis
- Increased osteoclastic activity results in loss of trabeculae
- Microfractures occur, bone compresses
Senile/age-related osteoporosis
-Haversian system widens d/t loss of trabeculae
MANIFESTATION
- Silent disorder
- Sudden onset fracture (hip, pelvis, humerous, etc.)**
- Wedging/collapse of vertebrae (loss of height and kyphosis/dowager hump)
- No pain unless fracture
Compare the pathogenesis and manifestations of osteomalacia and rickets
RICKETS
Inadequate calcium absorption from diet
Lack of vitamin D
Failure/delayed calcification of cartilaginous growth plate =
Over growth
Metaphyseal regions of long bones widen/deform as unmineralized
CAUSES Nutritional deficits Kidney failure Malabsorption syndromes, GI loss Medications (anticonvulsants, aluminum antacids) Genetic
MANIFESTATION Enlarged skull Oversized joints Delayed fontanel closure Slow tooth growth Abnormal shaped thorax Bowed legs Difficult ambulation Stunted growth
OSTEOMALACIA
Softening of bones d/t inadequate mineralization
Adult condition
MANIFESTATION
Bone pain, tenderness
Muscle weakness an early sign
Fractures of radius, femur
Not a significant cause of hip fracture
Delated healing of fractures = deformities
Hyperparathyroidism d/t low calcium levels
CAUSES Insufficient Ca+2 absorption from intestines Lack of intake Vitamin D deficiency Phosphate deficiency d/t Renal losses Poor absorption in GI tract Anticonvulsant use (long term) Renal rickets Occurs with chronic renal failure d/t inability of kidney to activate Vitamin D & excrete phosphate Vitamin D resistant rickets Familial renal tubular defect
Characterize the risk factors, cause and manifestations of Paget disease
Abnormal bone remodelling as a result of
Focal areas of excessive osteoclast-mediated bone resorption followed by
Disorganized osteoblast-mediated bone repair
Unclear patho
Genetic, environmental, ? Virus trigger
RISKS
Mid adulthood, progression
Men = women
Northern European heritage
MANIFESTATION
Isolated lesions or widespread
Long-bone bowing and fractures
Large joint osteoarthritis
Skull, spine, pelvis, femur, tibia are common
“Cement line” from new bone growth over old bone
Discuss the etiology, patho and general manifestations of rheumatoid arthritis
Autoimmune systemic disease
polyarticular
Can affect the organs
CAUSE Uncertain Genetic predisposition Women > men Peak incidence 40-50 years
PATHO
T-cell mediated response to trigger
- Inflammatory mediator released
- Antibodies form against autoantigens
Rheumatoid factor (RF) – which is an antibody – occurs in 70% to 80% of patients (Forms an immune complex)
Synovial inflammation and joint destruction result
Fluid accumulates (inflammatory process)
Neovascularization in synovial membrane
Pannus: vascular granulation tissue is formed is destructive to joint
-Inflammatory erosion of cartilage/bone
MANIFESTATION Symmetrical Polyarticular Diarthodial/synovial Joint pain Joint swelling Limited joint movement Wrist, finger joints common -Pain when turning doorknob, opening jars, buttoning shirts
Feet
- Pain on ball of foot when rising in morning
- Widening of forefoot d/t inflammation
List the extraarticular manifestations of rheumatoid arthritis
Fatigue, weakness, anorexia, weight loss Elevated ESR & C – reactive protein (CRP) Rheumatoid nodules Granulomatous lesions with central necrotic core Tender, or not Moveable, or immoveable Small or large Numerous other but they are more rare
Discuss the parameters for diagnosing rheumatoid arthritis.
Four or more: Morning stiffness of > 1 hour x 6 weeks >3 joint swelling x 6 weeks (simultaneous) Swelling of wrist or finger joints x 6 weeks Symmetric joint swelling x 6 weeks Rheumatoid nodules Serum RF Radiographic evidence
Discuss the risk factors and typical triggers associated with systemic lupus erythematous
RISK Chronic inflammatory disease affecting entire body! Unknown cause Young women (15-40) African, Hispanic, Asian descent Familial Genetic
Type III hypersensitivity response
Formation of autoantibodies and immune complexes which result in immune responses
TRIGGER UV light Chemicals Foods Infectious agents
Describe the immunologic process that occurs in systemic lupus erythematosus.
- characterized by the formation of autoantibodies and immune complexes (type 3 hypersensitivity)
- person with SLE have defective elimination of self-reactive B cells that results in an increase in production of antibodies that damages tissues
-Chronic inflammatory disease affecting entire body! Unknown cause Young women (15-40) African, Hispanic, Asian descent Familial Genetic
Triggers
- UV light
- Chemicals
- Foods
- Infectious agents
Common complaints
- Arthralgia
- Myalgia
- Fever
- Malaise, fatigue
- Temporary loss of cognitive abilities
Identify and discuss the major organ systems that may be involved in systemic lupus erythematosus.
Skeletal
Arthralgias/arthritis common early symptom
Most often hands, wrists, knees
Ligaments/tendons/joint capsule also
No articular destruction like other arthritis
Avascular necrosis (femoral head)
Contractures, tendon rupture, subluxation
INTEGUMENTARY Butterfly rash on nose/cheeks Fingertip lesions Hair loss Mucous membrane lesions Sunlight sensitivity
RENAL Glomerulonephritis Interstitial nephritis Pulmonary Pleural effusion Pleuritis
CARDIAC Pericarditis Heart block Hypertension Ischemic heart disease (chronic SLE)
CNS Photosensitivity Hemorrhage – stroke Thrombus Seizures More frequent with renal disease Psychotic symptoms Depression Euphoria Confusion
Describe the etiology and manifestations of limited and diffuse systemic sclerosis.
Autoimmune disease of connective tissue Widespread fibrosis Thickened skin Organ involvement Cause is poorly understood More women than men, but men have more serious progression
Fingers, forearms, face
CREST syndrome is not uncommon Calcium deposits on skin/soft tissue Raynaud phenomenon Esophageal dysmotility Sclerodactyly Telangiestasias
Pulmonary arterial hypertension is also common
DIFFUSE Widespread, rapidly progressive fibrosis of skin with early movement to organs (kidneys, esophagus, heart, lungs) Stone face Hair loss Telangiestasis on face, chest, hands Reynaud phenomenon is common Arthralgia, myalgia Malabsorption Pulmonary fibrosis Malignant hypertension Pericarditis, heart blocks, myocardial fibrosisa
Manifestations
Limited (most common)
Diffuse
Describe ankylosing spondylitis in terms of cause, pathogenesis, and clinical manifestations.
ANKYLOSING SPONDYLITIS
Chronic systemic inflammatory disease of joints
Late adolescence/early adulthood
Men > women
Etiology is unclear
Genetic
Immune response that destroys joints and fuses adjacent bones
Begins in sacroiliac joint, moves to spine and up
MANIFESTATION Pain -Persistent or intermittent -Can imitate sciatica pain -Worse when immobile Enthesitis -Juncture of tendon/ligament to bone
Progressive stiffening/osteoporosis of spine
Loss of lumbar lordosis
Kyphosis of thoracic spine and neck
Difficulty maintaining balance when walking (leaning forward)
Degeneration of hips, knees d/t altered center of gravity
Difficulty looking up and ahead
Heart and lung are constricted
Uveitis (30%) (inflammation of the middle layer of the eye)
Weight loss, fatigue
Fever
Compare rheumatoid arthritis and osteoarthritis in terms of joint involvement, level of inflammation, and local and systemic manifestations
RHEUMATOID ARTHRITIS
-synovial inflammation and destruction of the joint
-inflammatory process progresses, synovial cells and subsynovial tissue undergoes hyperplasia
-Fluid accumulates (inflammatory process)
Neovascularization in synovial membrane
Pannus: vascular granulation tissue is formed is destructive to joint
Inflammatory erosion of cartilage/bone
MANIFESTATION Symmetrical Polyarticular Diarthodial/synovial Joint pain Joint swelling Limited joint movement Wrist, finger joints common Pain when turning doorknob, opening jars, buttoning shirts Feet Pain on ball of foot when rising in morning Widening of forefoot d/t inflammation
Ankles, knees, elbows, shoulders, spine
Subluxation
Joint instability
Swelling and thickening of synovium stretches joint capsule and ligaments
- Deformities
- Muscle imbalances
- Swan neck deformities of hand
EXTRA-ARTICULAR MANIFESTATION
Fatigue, weakness, anorexia, weight loss Elevated ESR & C – reactive protein (CRP) Rheumatoid nodules -Granulomatous lesions with central necrotic core -Tender, or not -Moveable, or immoveable -Small or large Numerous other but they are more rare
OSTEOARTHRITIS
Degenerative changes to articular cartilage of joints
-Loss of cartilage
-Thickening of subchondral bone
-Osteophyte bone outgrowths at joint margins
-Mild synovial inflammation
Any synovial joint in the body
Manifestations Insidious Joint pain, stiffness, motion limitations Crepitus, grinding Instability and deformity can occur
Describe the pathologic joint changes associated with osteoarthritis.
Degenerative changes to articular cartilage of joints
Loss of cartilage
Thickening of subchondral bone
Osteophyte bone outgrowths at joint margins
Mild synovial inflammation
Any synovial joint in the body
Risk Factors
Genetic
Environmental
CAUSE
Primary: ideopathic
Seconary
Genetic or acquired joint disease
MANIFESTATION Insidious Joint pain, stiffness, motion limitations Crepitus, grinding Instability and deformity can occur
