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1

osteoarthritis

aka degenerative joint disease
characterized by degeneration of cartilage, failure of repair -> failure of synovial joints

2

osteoarthritis morphology

water content increases, proteoglycans decrease
granular soft articular surface
pieces break off- joint mice
bone eburnation

3

osteoarthritis clinical

usually doesn't become symptomatic until >50
deep, achy pain, worsens with use, morning stiffness, crepitus, limited ROM
impingement of spinal foramina -> nn compression
usually only a few joints involved

4

heberden nodes

prominent osteophytes at distal interphalangeal joints common in women, not men

5

RA

chronic inflammatory disorder of autoimmune origin
principally attacks joints producing nonsuppurative proliferative and inflammatory synovitis

6

common hand presentation of RA

ulnar deviation and large knuckles

7

CD4 cells and RA

T helper cells may initiated autoimmune response in RA by reacting with an arthritogenic agent (microbial or selfAg?)

8

TNF and RA

most firmly implicated mediator of the disease
TNF antagonists very effective Tx

9

Germinal centers

found in synovium of RA pts with secondary follicles and abundant plasma cells producing Abs (some are against selfAgs)

10

pannus

mass of edematous synovium, inflammatory cells, granulation tissue, and fibroblasts that grow over articular cartilage and causes erosion -> fibrous ankylosis which eventually ossifies -> bony ankylosis
specific to RA

11

RA and skin

RA subQ nodules are most common cutaneous lesions
ulnar aspect of forearm, elbows, occiput, lumbosacral area,
can form in lungs, spleen, heart

12

Rheumatoid nodules

firm nontender, round-oval
microscopically resemble necrotizing granulomas with central zone of fibrinoid necrosis surrounded by macros, Ts, and Bs

13

RA and blood vessels

vasculitis
high rheumatoid factor correlates with risk of vasculitis

14

what should you check synovium sample for before Dx RA

acid fast stain for mycoplasm (both cause necrotizing granulomas)

15

RA clinical

50% have insidious onset with malaise, fever, fatigue, after several months joints involved
generally symmetrically and smaller joints first

16

Dx of RA

X-RAY
sterile, turbid, synovial fluid, decreased viscosity, poor mucin clot formation, inclusion bearing neutrophils
combination of Rheumatoid factor and anti-CCP Ab

17

juvenile idiopathic arthritis

presents <16 and persists for at least 6wks

18

JIA vs RA

In JIA:
-oligoarthritis is more common
-systemic disease more frequent
-large joints are affected more then small
-rheumatoid nodules and rheumatoid factor are usually absent
ANA Ab is usually +

19

spondyloarthropathies

ankylosing spondyltis
psoriatic arthropathy
juvenile anklosing spondylitis
sacroilitis
intestinal arthropahty, UC, Chrons
reactive arthropathy, reiter syndrome

20

spondyloarthropathies general characterisitics

pathologic changes in ligamentous attachments rather then synovium
involvement of SI w/or w/o other joints
absence of rheumatoid factor
HLA-B27

21

Ankylosing spondyltis

destruction of articular cartilage and bony ankylosis especially at SI and apophyseal joints
symptomatic 2nd-3rd decade of life as lower back pain and spinal immobility
90% are HLA-B27+

22

reactive arthritis

arthritis, nongonococcal urethritis/cervicitis and conjunctiviits
ususally men 20-30
80% HLA-B27+
also seen in HIV

23

what organisms are linked to reactive arthritis

chlamydia
shigella
salmonella
yersina
campylobacter

24

enteritis associated arthritis

yersinia, salmonella, shigella, campylobacter
appears abruptly usually at knees and ankles, but sometimes also wrists, finger, toes
lasts for 1yr, generally clears rarely accompanied by ankylosing spondylitis

25

psoriatic arthritis

chronic inflammatory arthropathy associated with psoriasis that affects peripheral and axial joints and entheses (ligs and tendons)
30-50
usually develops concurrently or after skin disease onset

26

joints of psoriatic arthritis

SI 20%
usually hands and feet
distal interphalangeal joints are usually first affected with characteristic pencil in cup deformity

27

psoriais of psoriatic arthritis

in unusual locations or not symmetrical

28

infectious arthritis

aka suppurative arthritis
bacterial infections usually enter joints via hematogeneous spread

29

classic presentation of infectious arthritis

sudden development of acutely painful and swollen joints with restricted ROM
fever, leukocytosis, elevated sed rate common
gonococcal infections are more subacute
usually only 1 joint (knee most common, axial joints in drug users)

30

Dx infectious arthritis

joint aspiration