Lab: Joint Disease 2 Flashcards
Where is rheumatoid arthritis often seen first?
Small joints of hands and feet
Is rheumatoid arthritis bilateral/symmetrical?
Yes
autoimmune etiology and inflammatory
Are rheumatoid arthritis lesions osteolytic or osteoblastic?
Osteolytic
rheumatoid arthritis
Blue arrows:
Red arrow:
Purple arrows:
Green arrow:
Blue arrows: uniform loss of joint space/fibrous ankylosis
Red arrow: prearticular erosions
Purple arrows: swan neck deformity (fibrous ankylosis)
Green arrow: Boutonniere deformity (fibrous ankylosis)
What are some radiographic features of rheumatoid arthritis?
- Osteolytic lesions (juxta-articular/periarticular)
- Juxta-articular osteoporosis
- Decreased joint space
- Subluxation/dislocation of joints
- Fibrous ankylosis (swan neck and Boutonniere)
What are some symptoms of rheumatoid arthritis?
- Cardinal signs in affected joints
- Tenosynovitis and tendon rupture
- Fibrinoid necrosis (rheumatoid nodules)
- Necrotizing vasculitis (vascular stenosis, ischemia and necrosis in tissues supplied)
Are spondyloarthropathies inflammatory?
Yes
Which joints are primarily involved in spondyloarthropathies?
Primarily spine
Asymmetrical peripheral joint involvement possible
The following are all symptoms of which joint pathology?
- Cardinal signs of inflammation
- Tenosynovitis and tendon rupture
- Fibrinoid necrosis
- Necrotizing vasculitis
Rheumatoid arthritis
Generally, spondyloarthropathies are HLA-B27 ___ and rheumatoid factor ___
HLA-B27 positive and rheumatoid factor negative
spondyloarthropathies are seronegative
Spondyloarthropathies involve ___ ankylosis of affected joints
osseous
What is ankylosing spondylitis?
Progressive ankylosis of the spine beginning in the sacral and lumbar regions
What are some signs of ankylosing spondylitis?
- Postural changes
- Sacroiliitis
- Bamboo sign (radiograph)
- Trolley track sign (radiograph)
- Dagger sign (radiograph)
The following are all signs related to which joint pathology?
- Postural changes
- Sacroiliitis
- Bamboo sign
- Trolley track sign
- Dagger sign
Ankylosing spondylitis
Is psoriatic arthritis more often seen in the spine or extremities?
Frequently extremities
What is noticeable in this radiograph?
What pathology is present?
Reactive bone formation (blue arrows), and osseous ankylosis
Psoriatic arthritis
This pathology likely previously had what visible presentation?
Psoriatic arthritis rash
psoriatic arthritis
Psoriatic arthritis has a similar pathogenesis to, but different presentation from ___
rheumatoid arthritis
How might the spine be affected by psoriatic arthritis?
- May or may not have sacroiliac involvement
- Paravertebral ossifications
What is the triad of symptoms related to reactive arthritis/Reiter’s syndrome?
- Conjunctivitis
- Urethritis
- Arthritis
If a patient presents with the following, what is their most likely diagnosis?
- Conjuctivitis
- Urethritis
- Arthritis
Reactive arthritis/Reiter’s syndrome
Enteropathic arthritis is associated with previous ___ issues such as ___
previous gastrointestinal issues such as ulcerative colitis or Chron’s disease
With enteropathic arthritis, exacerbations of ___ can lead to increased arthritic symptoms
gut symptoms
How many joints are affected by enteropathic arthritis?
Monoarthritic: pain in one joint
What is the nature of the pain associated with enteropathic arthritis?
Migratory and transient pain in one joint
Persistent cases of enteropathic arthritis may resemble changes associated with ___
ankylosing spondylitis
Which joints are most affected by degenerative joint disease?
Which are most affected by rheumatoid arthritis?
DJD: weight bearing joints
RA: small joints
80% of those with rheumatoid arthritis are positive for RF
66% of those with rheumatoid arthritis are positive for ___
ACPA
What is indicated by the pale areas found in the joint?
Fibrin deposition (nodules)
rheumatoid arthritis
rice bodies when floating in joint
What is evidenced by the brownish color seen in this joint?
Old hemorrhage
rheumatoid arthritis
What is pannus in regard to joint pathology?
Chronically inflamed “frond like” membrane with abnormal layer of fibrovascular/granulation tissue
rheumatoid arthritis
How does this presentation affect structures of the joint?
- Enzymes and proteases increase, thus increasing vascularity of the joint
- Separates articular cartilage from synovial fluid, starving cartilage
- Symptoms of joint stiffness, decreased ROM, and achiness
rheumatoid arthritis pannus
What are the terms for subcutaneous nodules in the following locations? What pathologies are associated with each?
Metacarpophalangeal joint:
Proximal interphalangeal joint:
Distal interphalangeal joint:
Metacarpophalangeal joint: Haygarth, RA
Proximal interphalangeal joint: Bouchard, DJD, psoriatic arthritis, RA
Distal interphalangeal joint: Heberden, DJD, psoriatic arthritis
everything likes the PIP joint
Image B is a histological tissue section of the rheumatoid nodule in image A.
What is seen at the green arrow?
Fibrinous necrosis
characterized by presence of fibrinoid
due to acute necrotizing vasculitis
Which pathologies have we discussed that include vasculitis as part of their pathogenesis?
- Rheumatoid arthritis
- Lupus
- Systemic sclerosis
Inflammatory joint pathologies often have ___ etiologies.
autoimmune
What is the typical etiology of a non-inflammatory joint pathology?
Wear due to biomechanical stress
What type of primary bone changes occur with non-inflammatory joint pathologies?
Lytic change possible, but primarily blastic (subchondral sclerosing and osteophytes)
What type of primary bone changes occur with inflammatory joint pathologies?
Primarily lytic, but some blastic change in the form of ankylosis of joints possible
If a joint pathology is bilateral and symmetrical, is it more likely to be inflammatory or non-inflammatory?
Inflammatory
What are a patient’s symptoms if they have degenerative joint disease, a non-inflammatory joint pathology?
Early may not present with many symptoms
Late can present with cardinal signs and dull aching pain that’s worse with activity
What are a patient’s symptoms if they have an inflammatory joint pathology?
Cardinal signs, including pain, may have remissions and exacerbations
Ankylosis of joint and other systemic symptoms possible
How does ESR/CRP compare between non-inflammatory and inflammatory joint pathologies?
Elevated with inflammation
Normal with non-inflammatory, but may increase later
What are 5 treatment/lifestyle recommendations for someone with an inflammatory joint pathology?
- Low impact activities/exercise
- Anti-inflammatory diet
- Maintain a healthy weight
- Stop smoking
- Drug therapies
Rheumatoid arthritis leads to proliferation of the synovium which will erode joint structures, sometimes with ___ ankylosis.
fibrous
A patient with rheumatoid arthritis has fibrous ankylosis in their fingers. Which deformities have likely occurred?
- Swan neck
- Boutonniere
Which arthritis pathologies have we discussed that are associated with acute necrotizing vasculitis?
- Rheumatoid arthritis
- Lupus
- Systemic sclerosis
What is acute necrotizing vasculitis?
Inflammation of blood vessel walls leading to necrosis
What types of complications are associated with acute necrotizing vasculitis?
- Bone and other tissue infarction
- Conjunctivitis and ulcers
- Ischemia/ichemic stroke
What complication of acute necrotizing vasculitis is shown?
Ulceration
What type of ankylosis is depicted in this radiograph?
Which pathologies that we have discussed will produce this type of ankylosis?
Osseous ankylosis
Long-standing psoriatic arthritis
all seronegative arthritis will do osseous ankylosis; as can rheumatoid arthritis
DIP and PIP affected = psoriatic arthritis
The diagnostic lab results for this patient were RF-factor positive, HLA-B27 negative, ANA positive, and C-reactive protein elevated.
Which joint pathology best matches the patient’s result?
Rheumatoid arthritis
ANA is usually lupus and systemic sclerosis, but can also be RA
HLA-B27 is usually spondyloarthropathies
What type of ankylosis is depicted in this radiograph?
Which pathologies that we have discussed will produce this type of ankylosis?
Fibrous ankylosis (joint still seen)
Rheumatoid arthritis
wrists and MCPs are most affected
What type of deformity produced by this pattern of ankylosis indicated by the yellow arrow?
What causes the types of deformities seen here?
Boutonniere deformity
Due to tendon/ligament rupture
hitch hiker at red arrow
Boutonniere and swan neck do not indicate specific pathology
What is the name for the reactive bone formation seen at the joint margins at the red arrows?
What pathology is this associated with?
Fluffy periostitis (mouse ear deformity)
Psoriatic arthritis
gout is not bilateral symmetric
rheumatoid does not do periostitis
This patient has psoriatic arthritis.
What is the name for this type of deformity?
Peripheral erosion on proximal bone, central erosion on distal bone: pencil-in-cup deformity
not specific to psoriatic arthritis
aka mortar in pestal appearance
A 35-year-old female presents with cervical spine pain. She has had pain and stiffness in both hands and both feet. She’s been more fatigued lately. She’s felt tired for the past month but has had symptoms for at least several months with several bouts last year.
Based on this case presentation, what would you include on your differential diangosis and why?
- Rheumatoid
- Psoriatic
- Lupus
- Systemic sclerosis
all are inflammatory
A 35-year-old female presents with cervical spine pain. She has had pain and stiffness in both hands and both feet. She’s been more fatigued lately. She’s felt tired for the past month but has had symptoms for at least several months with several bouts last year.
What types of diagnostic tests would you want to order to narrow your differential diagnosis?
- RF (rheumatoid arthritis)
- ANA (nonspecific autoimmune)
- ESR/CRP (nonspecific inflammation)
- HLA-B27 (risk for autoimmune) (overkill)
A 35-year-old female presents with cervical spine pain. She has had pain and stiffness in both hands and both feet. She’s been more fatigued lately. She’s felt tired for the past month but has had symptoms for at least several months with several bouts last year.
What are the relevant radiographic findings for bone or alignment?
- Marginal erosions at MCPs
- Wrist involvement
red arrow
RA likes MCPs and wrists
A 35-year-old female presents with cervical spine pain. She has had pain and stiffness in both hands and both feet.
Blood work reveals the following:
- ANA positive
- ESR elevated
- RF factor positive
- HLA-B27 negative
What is your differential diagnosis?
Rheumatoid arthritis
Will all patients with rheumatoid arthritis have the same lab findings for ANA, ESR, RF, or HLA-B27?
No
RA can be present without RF positive
What percentage of patients with rheumatoid arthritis will show spinal involvement?
What region of the spine is commonly affected?
80%
Cervical involvement
What sort of diet would you recommend for someone with rheumatoid arthritis or a similar diagnosis?
Mediterranean diet:
- Fish
- Nuts and seeds
- Fruits and vegetables
- Olive oil
- Beans
- Whole grains
anti-inflammatory
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn’t had major injuries since.
Does this seem inflammatory or non-inflammatory?
Inflammatory
several joints affected, likely systemic
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn’t had major injuries since.
What conditions would you include on your initial differential diagnosis?
Ankylosing spondylitis: pain pattern, low back, age and gender, shoulder involvement
Enteropathic arthritis: axial and extremity involvement
Psoriatic arthritis: progressive pain, SI involvement, foot involvement
Reactive arthritis: age and gender, lumbosacral pain, SI and distal lower extremity involvement
inflammatory sponydloarthropathies
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn’t had major injuries since.
What feature is indicated by the green arrows?
What produces this feature?
Marginal syndesmophytes due to process of osseous ankylosis
bamboo spine pictured
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn’t had major injuries since.
What feature is indicated by the yellow arrows?
What produces this feature?
Dagger sign: ossification of supraspinous and interspinous ligaments due to osseous ankylosis
bamboo spine pictured
aka trolly track or rail road sign
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn’t had major injuries since.
Besides the elements of the “bamboo spine” pictured, are there any other relevant findings on this radiograph?
What pathologies are associated with all of these radiographic findings?
Osseous ankylosis of SI joints bilaterally and symmetrically
Ankylosing spondylitis and enteropathic arthritis
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn’t had major injuries since.
Patient adds that he does not remember a rash or a fever, nor any digestive issues.
Which diagnosis would be more likely if he had presented with chronic digestive issues?
Enteropathic arthritis
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn’t had major injuries since.
Patient adds that he does not remember a rash or a fever, nor any digestive issues.
With this added information, which of your differential diagnoses is most likely?
Ankylosing spondylitis
Given that this is ankylosing spondylitis, what would be the expected blood results for the following?
- ESR
- Rheumatoid factor
- HLA-B27
ESR: elevated
RF: negative
HLA-B27: positive
What is the impact if the costotransverse ligaments are affected by ankylosing spondylitis?
Decreased chest expansion leading to a decrease in normal breathing without a history of smoking
What treatment options would you recommend for this patient with ankylosing spondylitis?
- Low impact, regular activity
- Anti-inflammatory diet
- NSAIDs early, maybe DMARDs
This patient has ankylosing spondylitis.
What will eventually happen to this patient’s joints?
Osseous ankylosis with complete loss of ROM
A 12-year-old male is taken to the ER. He fell the day before and has pain in his right elbow with a visible wound in the skin. The joint is swollen and very sensitive to touch. His temperature is 100.2 F. He cannot move the elbow well and reports further pain. Radiographs are unremarkable.
What are the patient’s relevant signs and symptoms?
- Fever
- Cardinal signs of inflammation
- Decreased ROM
A 12-year-old male is taken to the ER. He fell the day before and has pain in his right elbow with a visible wound in the skin. The joint is swollen and very sensitive to touch. His temperature is 100.2 F. He cannot move the elbow well and reports further pain. Radiographs are unremarkable.
What conditions would you include on your initial differential diagnosis?
- Lyme disease
- Acute pyogenic osteomyelitis
- Septic arthritis
- Seronegative pauciarticular juvenile idiopathic arthritis
A 12-year-old male is taken to the ER. He fell the day before and has pain in his right elbow with a visible wound in the skin. The joint is swollen and very sensitive to touch. His temperature is 100.2 F. He cannot move the elbow well and reports further pain. Radiographs are unremarkable.
Blood work comes back:
- Alkaline phosphatase normal
- HLA-B27 negative
- RF negative
Assuming ESR/CRP is elevated, what two diagnoses are at the top of your differential list?
- Acute osteomyelitis
- Septic arthritis
What would you do to differentiate between osteomyelitis and septic arthritis?
- Gold standard for septic arthritis is joint aspiration
- Osteomyelitis needs a bone biopsy to confirm
- Further imaging may be needed
send to rheumatologist
A 45-year-old male with slightly high blood pressure was treated with antibiotics recently for a chlamydia infection. He is experiencing more than his usual amount of back pain and chiropractic appointments aren’t relieving him as much as usual. His eyes are unusually red.
What condition could be associated with his case based on this information?
Reactive arthritis
20s-30s; almost exclusively men
A 45-year-old male with slightly high blood pressure was treated with antibiotics recently for a chlamydia infection. He is experiencing more than his usual amount of back pain and chiropractic appointments aren’t relieving him as much as usual. His eyes are unusually red.
What tests or additional information would you recommend he get?
- Ask about urinating and lower extremity involvement
- Need radiographs of spine and SI joints
- CBC with diff and chem profile
- ESR/CRP
- Blood test for HLA-B27
