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
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 rhematoid 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 negative and rheumatoid factor negative
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
these are 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
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
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 leading to erosion of 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 does osseous ankylosis
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
Boutonniere and swan neck do not indicate specific pathology, they are due to tendon/ligament rupture
hitch hiker at red arrow
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
Based on this case presentation, what would you include on your differential diangosis and why?
- Rheumatoid
- Psoriatic
- Lupus
- Systemic sclerosis
all are inflammatory
RF
ANA
ESR CRP
HLA-B27 (overkill)
Marginal erosions are MCPs
Rheumatoid arthritis
you can have RA without RF positive
80% of RA have cervical involvement
