Intro to rheumatology Flashcards
What are the functions of connective tissue?
- binds together, supports and strengthens other body tissues
- protects and insulates internal organs
- compartmentalises structures such as skeletal muscle
- the major transport system within the body
- site of stored energy reserves
- main site of immune responses
What are the three classes of components for connective tissue?
- Cells:
- fibroblast
- macrophage
- mast cell
- plasma cell
- lymphocytes
- leukocytes
- adipose cells - Fibres
- reticular
- elastic
- collagen - Ground substance
- macromolecules
- multi-adhesive glycoproteins
What are fibroblasts and what is their function?
- large flat cells with branching processes
- migrate throughout connective tissue secreting the fibres and ground substance
What are mast cells and what is their function?
- alongside blood vessels that supply connective tissue
- produce histamine
What is the function of reticular fibres?
- provide support for the walls of blood vessels
- made of collagen with a glycoprotein covering
What is the ground substance of connective tissues?
- between cells and fibres
- support cells and bind them together
- provide a medium through which substances are exchanged e.g hyaluronic acid
What is the most abundant protein in the body?
-collagen
What is the main function of connective tissue matrix fibres (collagen, elastin, reticular) ?
-provide strength and support to connective tissue
What are the six types of connective tissues ?
(-vary by the fibres, ground substance and cells contained in it)
- loose connective tissue
- adipose tissue
- blood
- fibrous connective tissue
- cartilage
- bone
What is connective tissue proper and what is its function?
- Loose connective tissue:
- areolar
- adipose
- reticular - Dense connective tissue
- regular
- irregular
- elastic
Function:
- binding tissue
- resists mechanical stress especially tension
What cells are present in connective tissue proper and in its matrix?
Cells:
- fibroblasts
- fibrocytes
- defense cells
- fat cells
Matrix:
- gel like ground substance
- collagen, reticular and elastic collagen
What is the function of cartilage, the cells involved and the matrix composition?
-cartilage is avascular and no nerve supply (but perichondrium does)
Function:
- strengthen and support connective tissue
- resists compression
- cushions and support body structures
Cells:
- chondroblasts- in growing cartilage
- chondrocytes
Matrix:
- Gel-like ground substance
- Fibres: collagen, elastic fibres in some
What is perichondrium?
the connective tissue that envelops cartilage where it is not at a joint
What are the three types of cartilage?
- Hyaline cartilage
- Elastic cartilage
- Fibrocartilage
What is hyaline cartilage?
- gel like ground substance
- end of long bones to cushion joints and at epiphyseal plates
- most abundant cartilage in the body
- weakest of the 3 types of cartilage
What is fibrocartilage?
- chondrocytes scattered among visible bundles of collagen fibres
- no perichondrium
- strongest of the 3 types of cartilage
- found in the intervertebral discs
- found in the intervertebral discs
- collagen fibre in matrix
What is elastic cartilage?
- chondrocytes located in a threadlike network of elastic fibres
- provides strength, elasticity and maintains the shape of certain structures (like the external ear)
- elastic fibres in matrix
What is the function of bone tissue, the cells involved and what is the matrix made of?
Function:
- resists compression and tension
- protect and support
Cells:
- osteoblasts
- osteocytes
Matrix:
- gel-like ground substance
- calcified with inorganic salts
- fibres: collagen
What is osseous tissue?
-bone tissue
What are the types of bone tissue?
- Compact:
- osteon- basic unit of compact bone
- lamellae- concentric circles of matrix
- lacunae- spaces in the matrix that house cells
- osteocytes- mature bone cells - Spongy:
- trabeculae- columns of bone with spaces filled with red bone marrow
What is in the lacuna of elastic cartilage?
-chondrocytes
What is in the lacuna of fibrocartilage?
-chondrocytes
What is an osteon?
-basic unit of compact bone
What is lamellae?
-concentric circles of matrix
What is the function of blood, the cells involved and the components of the matrix?
-complex cell formation and differentiation
Function:
-transport oxygen, carbon dioxide, nutrients, wastes and other substances
Cells:
- erythrocytes (RBC)- transport oxygen
- leukocytes (WBC)- function in immunity
- platelets- blood clotting
Matrix:
- liquid
- plasma
- no fibres
What are the two main types of connective tissue proper?
-loose and dense
Which type of cartilage are you most likely to find at the epiphyseal (growth) plate?
-hyaline cartilage
Which of the three types of cartilage is the strongest?
-fibrocartilage
Which substance is house in the trabecular of spongy bone?
-red bone marrow
What are the three rheumatological disorders?
- rheumatoid arthritis RA
- systemic lupus erythematosus SLE
- vasculitis
What is rheumatoid arthritis?
- autoimmune disorder primarily affecting joints resulting in warm swollen painful joints
- symptoms are worse following rest
What is systemic lupus erythematous?
- autoimmune disorder of connective tissue
- affects multiple organ systems and joints
Which is vasculitis?
-a group of disorders that destroy blood vessels by inflammation
What are the general macroscopic and microscopic changes in rheumatoid?
Macroscopic:
- synovitis
- bone
- cartilage
- erosion
- angiogenesis diagram
Microscopic:
- cells
- IL
- ANF
- synoviocytes
- osteoclasts
- proteases
- CD4 cells
- plasma cells
- neutrophils
What are the joint changes in rheumatoid?
- bone erosion
- swollen inflamed synovial membrane
- cartilage wears away
- reduced joint space
What causes inflammation in RA?
- Th17 cells produce IL-17
- IL-17 acts on synovial lining cells, these release IL-6, IL-8, MCP-1, GRO-alpha, GM-CSF =inflammation
-IL-17 acts on macrophages, these release IL-1, TNF-alpha, IL-6 =inflammation
What causes cartilage destruction in RA?
- Th17 cells produce IL-17
- IL-17 acts on chondrocytes, these release NO = cartilage destruction
- IL-17 action macrophages, these release MMPs = cartilage destruction
What causes bone destruction in RA?
- Th17 cells produce IL-17
- IL-17 acts on osteoblasts, these release RANKL = bone destruction
( What are the three key symptoms of RA? )
- joint pain
- stiffness
- swelling
What are the key features of RA?
- symptoms last > 6 weeks
- often lasts the remainder of patients’ life - inflammatory synovitis:
- palpable synovial swelling
- morning stiffness > 1hr, fatigue - symmetrical and polyarticular (>3 joints):
- typically involves wrists, MCP, PIP joints
- typically spares certain joints; thoracolumbar spine, DIPs of the fingers and IPs of the toes - may have nodules: subcutaneous or periosteal at pressure points
- marginal erosions and joint space narrowing on x-ray
- ulnar deviation
Compare and contrast rheumatoid versus osteoarthritis?
Rheumatoid:
- inflammatory
- autoantibodies
- small joints affected
- rapid onset
- bilateral, symmetrical pattern
- morning stiffness
- ESR
Osteoarthritis:
- degenerative
- no antibodes
- large weight bearing joints affected
- slow onset
- asymmetric
- uncommon stiffness in morning
What is ESR?
-erythrocyte sedimentation rate
What is CRP?
-C-reactive protein
What is PIP?
-proximal interphalangeal joint
What is MCP?
-metacarpophalangeal joint
What is DIP?
-distal interphalangeal joint
What is CMC?
-carpometacarpal joint
What is RF?
-rheumatoid factor
What happened to ESR and CRP levels in RA?
-elevated
What happened to ESR and CRP levels in OA?
-normal
Tell me about finger PIP swelling in RA?
- swelling is confined to the area of the joint capsule
- synovial thickening feels like a firm sponge
What are you looking for in x-rays of RA?
-soft tissue swelling
-erosions
-joint space loss
-subluxation-partial dislocation
-
What is the typical course of RA?
- damage occurs early in most patients
- lowered life expectancy:
- women 10 years less, men 4 years
What is the typical pattern of pain and stiffness in RA?
Inflammatory pattern:
-worse when resting (therefore moving stiffness) and improves with activity
What are the key x-ray changes found in rheumatoid arthritis?
- loss of joint space
- juxta-articular bone erosions
- soft tissue swellings
- osteopenia
- subluxations
What are the treatment principles for RA?
- Diagnosis
- Severity
- Treatment:
- when damage begins early, start aggressive treatment
- use the safest treatment plan that matches the aggressiveness of the disease - Monitor:
- treatment for adverse effects
- disease activity, revise Rx (prescription) as needed
What are the elements of the assessment for RA?
Assess current activity:
-morning stiffness, synovitis, fatigue, ESR
Document the degree of damage
- ROM and deformities
- joint space narrowing and erosions on x-ray
- functional status
Document extra-articular manifestations
-nodules, pulmonary fibrosis, vasculitis
Asess prior Rx responses and side effects
What are the critical elements of therapy for RA?
- Education:
- build a cooperative long-term relationship
- use materials from the arthritis foundation and the ACR
- assistive devices - Exercise:
- ROM, conditions, strengthening exercises - Medications:
- analgesic and/or anti-inflammatory
- immunosuppressive, cytotoxic, biologic
- balance efficacy and safety with activity
What are the drug treatment options for RA?
- NSAID:
- symptomatic relief, improved function
- no change in disease progression - Low-dose prednisone (<10mg QD):
- may substitute for NSAID
- used as bridge therapy
- if used long term, consider prophylactic treatment for osteoporosis - Intra-articular steroids:
- useful for flares - DMARDs- disease modifying drugs
- minocycline- modest effect, may work best early
- sulfasalazine, hydroxychloroquine- moderate effect, low cost
- intramuscular gold- slow onset, decreases progression, rare remission, requires close monitoring - Immunosuppressive drugs:
- methotrexate- most effective single DMARD, good benefit to risk ratio
- Azathioprine- slow onset, reasonably effective
- Cyclophosphamide- effective for vasculitis, less so for arthritis
- Cyclosporin- superior to placebo, renal toxicity - New DMARDs
a) Leflunomide:
- pyrimidine inhibitor
- effect and side effects similar to those of MTX
b) Ethanercept:
- soluble TNF receptor, blocks TNF
- rapid onset, quite effective in refractory patients in short-term trials and in combinations with MTX
- injection site reactions, long-term effects unknown, expensive
What is monitoring of treatment with DMARDs?
- these drugs need frequent monitoring
- blood, liver, lung, and kidney are frequent sites of adverse effects
- interval of laboratory testing varies with the drug (4-8 week interval commonly needed)
- most patients need to bee seen 3-6 times a year
What are the extraarticular manifestations of RA?
- liver
- cardiovascular
- neurological
- musculoskeletal
- bone marrow
- spleen
What are the manifestations of SLE?
- alopecia
- malar rash
- arthralgia
- oral ulcers
- photosensitivity
What is UCTD?
-undifferentiated connective tissue disease
What is scleroderma and what are its manifestations?
-chronic autoimmune disease that affects the skin, connective tissue and internal organs
- reflux
- Raynaud’s
- digital ulcerations
What are sicca symptoms?
-dryness of exocrine glands, e.g dry eyes, skin, mouth
lecture slides
https://d3c33hcgiwev3.cloudfront.net/6a4GAB1BTdGuBgAdQW3RGw_2d8c3a2535d34867862b89587fc10744_SV_Final_MSK_LE07Introduction_to_Rheumatology.pdf?Expires=1580860800&Signature=CXo0ClidAKZ9p~Hc3z39BALYKQ6FxWvAQwr1q0J1J~OMdy2S1GxR3dhnkiUNhzU5D4E1~XHakXeZ9dNHuQl3j0IC1Fmh6aCy6Vi-tjib60ZR9Fcj-LYW6KfrwYsA-pUOenWzrxmY6fb7Lmb4DOIMxoSUjhfXVA5NqHOpfxFJLRI&Key-Pair-Id=APKAJLTNE6QMUY6HBC5A
