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MSK Summative > Pathology of Joint Pain > Flashcards

Pathology of Joint Pain Flashcards

1
Q
  • What is a joint?
    • What are two types of joints and what is their function?
A
  • Joint is a connection between two bones
    • Solid joints:
      • tightly connected to provide structal strength (e.g. cranial structures)
    • Synovial joints
      • have joint space to allow for motion
      • Synovium lining the joint capsule scretes fluid rich in hyaluronic acid
      • lubricate joint and facilitate smooth motion
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2
Q
  • Articular surface of adjoining bones is made of?
  • What is it surrounded by?
A
  • Made of hyaline cartilage (type II collagen)
  • Surrounded by joint capsule
    • lined by synovium
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3
Q
  • Osteoarthritis / Degenerative Joint Disease is?
  • Due to?
  • What are major risk factors?
A
  • Progressive degeneration of articular cartilage (layer on top of bone at joint to help with movement)
    • most common type of arthritis
  • Most often due to wear and tear
  • Major risk factor= age
    • Others: obesity and trauma
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4
Q
  • Which joints does osteoarthritis affect?
A
  • Affects limited number of joints (oligoarticular):
    • hips
    • lower lumbar spine
    • knees
    • distal interphalangeal joints (DIP) of fingers
    • proximal interphalangeal joints (PIP) of finger
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5
Q

What is classic presentation of osteoarthritis?

A

Joint stiffness in the morning that worsens during the day

  • when you use the joints you begin to feel the pain
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6
Q

What are 3 pathological findings of osteoarthritis?

A
  1. Disruption of cartilage that lines the articular surface
    • fragments of cartilage floating around in joints pace are called “joint mice”
  2. Eburnation (polishing) of subchondral bone
    • bone rubbing against bone
  3. Eburnation leads to osteophyte formation (reactive bony outgrowths)
    • arise in DIP (Herberden nodes) of joints of fingers
    • PIP (Bouchard nodes) of joints of fingers
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7
Q
  • Rheumatoid Arthritis is what kind of a disease?
    • classically affects?
    • associated with?
A
  • Chronic, systemic autoimmune disease
    • classically arise in women of late childbearing age
  • Associated with:
    • HLA-DR4
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8
Q
  • Although rhematoid arthritis is a systemic autoimmune disease is is characterized by involvement of?
  • What is the hallmark feature?
    • what does it lead to?
A
  • Characterized by:
    • involvement of joints
  • Hallmark feature:
    • Synovitis (inflmmation of joint capsule) that leads to formation of pannus (inflammed granulation tissue)
      • granulation tissue has fibroblast, blood vessels and myofibroblasts
  • Leads to:
    • myofibroblasts cause contraction which lead to:
      • movement of joint in different directions (deformities)
      • destruction of cartilage
      • ankylosis (fusion of joint)
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9
Q
  • Describe the change in pain and stiffness over the day with rheumatoid arthritis?
A
  • Morning stiffness that improves with activity
    • inflammation builds up a night (leads to stiffness in morning)
    • as use the joint it squeezes the joints free of the granulation debris
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10
Q
  • What joints are involved in rheumatoid arthritis?
    • how does it differ from osteoarthritis?
A
  • Symmetric involvement of:
    • PIP joints of the fingers (swan neck deformity)
    • wrist (ulnar deviation)
    • elbows, ankles and knees
  • DIP is usually spared, unlike osteoarthritis
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11
Q

What is seen on X-ray of rheumatoid arthritis?

A
  • Joint space narrowing
    • synovial inflammation
  • Loss of cartilage
    • replaced by granulation tissue
  • Osteopenia
    • wearing away of bone underneath cartilage
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12
Q

What are 5 systemic symptoms of rheumatoid arthritis?

A
  1. Fever, malaise, weight loss, myalgias (muscle pain) (bc autoimmune)
  2. Rheumatoid nodules
    • central zone of necrosis surrounded by epitheliod histiocytes (skin)
  3. Vasculitis
    • multiple organs can be involved
  4. Baker cyst
    • swelling of bursa behind knee
  5. Pleural effusions, lymphadenopathy, interstitial lung fibrosis
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13
Q
  • What are the classic lab findings of rheumatoid arthritis?
    • What are complication of RA?
A
  • Labs:
    • IgM autoantibody against Fc portion of IgG (rheumatoid marker)
      • maker of tissue damage and disease activity
    • neutrophils and high protein in synovial fluid
  • Complications:
    • Anemia of chronic disease
      • chronic inflammation release acute phase proteins, hepcidin—> prevent release of Fe from macrophage
    • Secondary amyloidosis
      • acute phase reactants produce protein SAA in liver—-> converted to AA—> deposits in tissues
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14
Q

Seronegative Spondyloarthropathies are group of joint disorders characterized by what 3 things?

A
  1. Lack of rheumatoid factor (seronegative)
  2. Axial skeleton involvement (spondylo)
  3. HLA-B27 association
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15
Q
  • Ankylosing spondyloarthritis (seronegative)causes?
    • invovle which joints?
  • Who does it most common affect?
  • What does it present as?
A
  • Inflammatory disease that leads to fusion of vertebrae
    • Involves sacroiliac joint and spine
  • Arise in young adults often males
  • Presents with:
    • low back pain
    • invovlement of vertebral spine eventually arise
      • lead to fusion of vertebrae (“bamboo spine”)
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16
Q

Reactive Arthritis (Reiter Syndrome) is a type of seronegative spondyloarthropathy.

  • Characterized by?
  • Who does it arise in?
  • skin findings?
A
  • Characterized by:
    • triad of arthritis, urethritis and conjunctivis
      • “can’t see, can’t pee, can’t climb a tree”
        • inflammation in multiple DIP and PIP
        • sausage fingers/toes
  • Arise in young adults, usually male
    • weeks after a GI or Chlamydia trachomatis infection
  • Skin findings:
    • keratoderma blenorrhagicum
    • Circinate balanitis
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17
Q
  • Psoriatic arthritis is seen in 10% of cases of?
    • what joints are most commonly affected?
A
  • Associated with psoriasis
  • Joints affected:
    • DIP joints of hands and feet
      • “sausage” fingers or toes
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18
Q
  • Infectious arthritis is due to?
  • What are two common causes and who do they affect?
  • What joint does it affect?
    • What does it present as?
A
  • Arthritis due to infectious agent; usually bacterial
    1. N. gonorrhoeae: young adults, sexually active
    2. S. aureus: older children and adults
  • Involve one joint; usually knee
  • Presents as:
    • warm joint, erythematous
    • limited range of motion
    • fever
    • increased white count
    • elevated ESR
      • measure of inflammation
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19
Q

What are risk factors for acute infectous arthritis?

A
  • Advanced age
  • Co-morbid conditions
    • rheumatoid arthritis
    • Diabetes mellitus
  • Prosthetic joints
  • IV drug abuse
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20
Q
  • What is pathogenesis/how do bacteria cause infectious arthritis?
A
  • Bacteria invade joint
  • Release bacterial products
    • formation of immune complex
    • activate complement
    • inflammation
  • Degredation of cartilage
    • local activation of coagulation
    • Fibrin deposited in joint
  • Nidus (place for bacterial growth) and microvascular obstruction in synovium
    • continued joint damage
    • formation of pannus
      • granulation tissue composed of macrophage and fibroblasts
  • Continued release of MMP and activation of osteoclast
    • continued degredation of cartilage and erosion of subchondral bone (just below cartilage)
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21
Q

HLA-B27 is associated with which 4 diseases?

A

PAIR (also known as seronegative arthritis)

  1. Psoritic arthritis
  2. Ankylosing spondylitis
  3. IBD-associated arthritis
  4. Reactive arthritis (Reiter syndrome)
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22
Q
  • What inflammatory cytokines are big players in rheumatoid arthritis?
    • What do they cause formation of?
A
  • Autoantibodies and CK mediated inflammation
  • Important CK’s:
    • INF gamma and IL-17
    • TNF and IL-1
    • RANKL: activated T cells
  • Infammatory cytokines induce pannus formation
    • erodes articular cartilage and bone
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23
Q

What are 6 predisposing factors of rheumatoid arthritis?

A
  1. Female
  2. HLA-DR4
  3. Smoking
  4. Silica exposure
  5. (+) rheumatoid factor
  6. anti-cyclic citrullinated peptide antibody (more specific)
24
Q

Treatment of Osteoarthritis?

A
  • NSAIDs
  • glucocorticoids
  • disease modifying agents
    • MTX
    • Sulfasalazine
    • hydroxychloroquine
    • leflunomide
  • Biological agents
    • TNF- alpha inhibitor
25
Compare pathogenesis of osteoarthritis and rheumatoid arthritis?
* _Osteoarthritis:_ * **mechanical** wear and tear destroys articular cartilage * **chondrocytes** mediate degradation and inadequate reapir * _Rheumatoid arthritis_ * Autoimmune * inflammatory cytokines and cells (**CD 4+**) induce **pannus** (proliferative tissue granulation) formation * erodes articular cartilatge and bone
26
What are some common causes of viral arthritis?
* Alpha virus * parvo B19 * rubella * EBV * Hep B and C Damage to direct infection or secondary reaction
27
* Who tends to be more affected by gout? * What are 3 significant risk factors?
* **Men** more affected * _Significant risk factors_ * Obesity * Metabolic syndrome * Excess EtOH
28
* Avascular (Aseptic) necrosis is due to? * Causes include? * Complications?
* **Ischemic necrosis** (lack of blood) of bone and bone marrow * NOT due to bacteria * _Causes include:_ * **trauma or fracture** (most common) * steroids * sickle cell anemia * Cassion disease * _Major complications:_ * osteoarthritis * fracture
29
Treatment for Ankylosing Sponylitis?
* _First line:_ * NSAID * _Second line:_ * Anti-TNF alpha therapy * can have serious side effects such as infection (TB)
30
* What is the general features of ankylosing spondylitis?
* Destruction of articular cartilage, primarily axial skeleton * **Ankylosis**: stiffening of a joint secondary to bone fusion * **Spondylitis**: inflammation of the spine
31
What HLA subtype is associated with rheumatoid arthritis?
**HLA-DR4** "There are 4 walls in a rheum (room)"
32
* What are the three main functions of the complement system? * Activation of complement system is inhibited by?
1. Inflammation * stimulation of histamine release by C3a, C5a, C4a 2. Opsonization of microbes---\> phagocytosis 3. Cell lysis * by membrane attack complex Inhibited by: * C1 INH, DAF, and CD59 on cell membranes
33
Antibody Dependent cellular Cytotoxicity is mechanism by which?
* **Natural killer cells** destroy virally infected or neoplastic cells * express **TLR** on surface * nonspecific recognition of bacterial antigens, expressed proteins on virally infected cells * activates **NFkB** pathway
34
* What is lupus erythematosus? * What kind of antibodies are generated? * Who does it commonly present in?
* Chronic inflammatory disease * flare up and alternating remissions * possible environmental tirgger * Generate autoantibodies (antinuclear antibody; **ANA**) * _Commonly seen in:_ * **females** of reproductive age * **African American** descent
35
Findings of SLE? (RASH OR PAIN)
* **R**ash (malar or discoid) * **A**rthritis (nonerosive) * **S**erositis * **H**ematologic disorder (cytopenias) * **O**ral/nasopharyngeal ulcers * **R**enal disease * **P**hotosensitivity * **A**ntinuclear antibodies * **I**mmunologic Disorder * (anti-dsDNA, anti-Smith antiphospholipid) * **N**eurological disorders (seizures, psychosis)
36
What is the HLA subtype associated with Goodpasture syndrome?
**HLA-DR2**
37
* In Goodpasture's syndrome there are autoantibodies against? * Causes injury where in the body? * Lab findings show?
* Collagen IV * component of the glomular basement membrane * _Causes damage to:_ * lung * kidney (renal) * _​​Lab findings:_ * linear appearance of IgG depsition on glomular and alveolar basement membrane
38
What type of hypersensitivity is Goodpasture syndrome?
* Type II (antibody mediated) * antibodies to glomerular basement membrane and alveolar basement membrane * linear IF
39
* What is type II hypersensitivity reaction? * 3 mechanisms of destruction?
* Cytotoxic (antibody mediated) * IgM, IgG bind to fixed antigen on enemy cells---\> cellular destruction * Antibody and complement lead to MAC * 3 mechanisms: 1. Opsonization and phagocytosis 2. Complement and Fc receptor mediated inflammation 3. Antibody mediated cell dysfunction
40
* What is compartment syndrome? * Due to? * What parts of the body does it usually invovle?
* _*Compartment syndrome* is:_ * After an injury, blood or edema (fluid resulting from inflammation or injury) may accumulate in the compartment. * The tough walls of **fascia** cannot easily expand, and compartment pressure rises * **preventing adequate blood flow** to tissues inside the compartment * Severe tissue damage can result * _Commonly invovles:_ * anterior tibial compartment of leg * volar compartment of forearm * interosseous compartment of hand
41
* What injury most commonly leads to compartment syndrome? * What is the result?
* _Common cause:_ * **supracondylar fracture** of the humerus * _Results in:_ * obstruction of **brachial artery** * ischemia and necrosis of flexor group of muscles of the forearm
42
* Tennis elbow is due to? * Where is pain most common?
* Repetitive extension (overuse) * pain near **lateral epicondyle**
43
* What is golfer's elbow due to? * Pain is common where?
* Repetitive flexion (forehard shots); overuse of elbow * pain in **epicondyle**
44
* What is De Quervain tenosynovitis due to? * What does it cause? * Where is the pain? * How is this tested for?
* _Due to:_ * overuse of hand and wrist * _Causes_: * a chronic overuse tendon problem resulting consistent overloading of the tendons. * There is **friction** between the tendon and surrounding synovial sheath, causing intense irritation. * In order to function properly, a tendon must be able to glide freely within its synovial sheath. * **stenosis** (narrowing) of fibro-osseous tunnel * _Pain_: * on **radial aspect** of the wrist * _Test_: * Finkelstein test
45
* Carpal tunnel syndrome is the most common ___ syndrome? * Due to compression of which nerve? * Who are more affected? * Bilateral or unilateral?
Most common entrapment neuropathy * Compression of **median** **n**. * **Women** more affected than men * Frequently **bilateral**
46
2 tests for carpal tunnel syndrome?
1. **Phalen maneuver:** * gently flex wrist together as far as possible; hold for 1 min. 2. **Tinel sign:** * light tapp over transverse carpal ligament * produce numbness/tingling in median n.
47
* What is hypoxia? * What does it cause?
Deficiency of O2; reduce aerobic oxidative respiration * _Causes_: * **Ischemia**: reduced blood flow * reduced O2 (no aerobic metabolism) * reduced nutrients (no aerobic glycolysis) * Inadequate blood oxygenation * deceased oxygen carrying capacity of blood NOTE: * ischemia causes more rapid and severe cell and tissue death than hypoxia alone
48
* avascular necrosis (osteonecrosis) is? * common causes?
* *Avascular necrosis:* * necrosis of bone and marrow or infarction from ischemia * _Common causes:_ * alcohol abuse * infection * trauma * radiation therapy * tumors
49
* Raynaud phenomenon is due to? * Most often occurs where?
* _Due to:_ * decreased blood flow to the skin due to arteriolar (small vessel) vasospasm (sudden constriction) in response to cold or stress * color change from **white** (ischemia) to **blue** (cyanosis; hypoxia) to **red** (reperfusion) * _Most often in:_ * fingers and toes
50
Primary vs. Secondary Raynaud?
* _Primary (Raynaud's disease)_ * **idiopathic** * symmetric * _Seondary (Raynaud's syndrome)_ * vascular insufficiency due to arterial disease caused by other entities like: * SLE, sclerodema, Buerger disease * assymmetric
51
* Scleroderma is a triad of? * Results in? * commonly presents where?
* _Triad of:_ * autoimmune (mostly females) (of connective tissue) * noninflammatory vasculopathy * collagen deposition with fibrosis * _Results in:_ * **hardening** of the skin * _Commonly_: * **slcerosis of skin,** manifesting as puffy taut skin without wrinkles * fingertip pitting * also sclerosis of renal, pulmonary, cardiovascular and GI
52
* Diffuse vs. Limited scleroderma? * associated with which autoanitbodies?
* _Diffuse scleroderma:_ * widespread skin involvement * rapid progression with early visceral involvement * associated with **anti-Scl-70** antibody * _Limited scleroderma:_ * limited skin involvement confined to fingers and face * **CREST** syndrome * **C**alcinosis\* * **R**aynaud phenomenon * **E**sophageal dysmobility * **S**clerodactyly * **T**elangiectasia * Associated with **anti-centromere antibody**
53
This is image is comparing a normal patients skin to a patient with?
* Systemic sclerosis * note extensive deposition of collagen in the dermis * virtual absence of appendages (hair follicles) and foci of inflammation
54
* What is fibrosis? * How does it develop in chronic inflammation?
* *_Fibrosis_*= excessive deposition of collagen * deposition of collagen is normal in wound healing * _Fibrosis in chronic inflammation:_ * chronic inflammation activates **macrophages** and **lymphocytes** * lead to **production of GF, cytokines** which increase synthesis of collagen * deposition of collagen is enhanced by decreased activity of metalloproteinases
55
What are extra-articular symptoms of ankylosing spondylitis?
Extra articular manifestation include: * **uveitis** (redness of eye, blindness) * **aortitis** (inflammation of aorta) * weak walls pull of valvle---\> aortic regurgitation

MSK Summative (8 decks)

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