Rheumatology

Question 1

The specialty of Rheumatology

Answer 1

deals with pain and inflammation of the musculoskeletal system and autoimmune diseases.

Question 2

Arthritis

Answer 2

Means inflammation in joints. Most common disease causing morbidity in the elderly. Over time, inflammation in a joint can lead to deformity

Question 3

Arthralgia

Answer 3

joint hurts, but there is no evidence of inflammation. May represent early form of arthritis.

Question 4

Periarticular pain

Answer 4

Refers to pain arising from structures around the joint such as tendons or bursae. This type of joint pain can be distinguished from true arthritis by the lack of effusion, the frequent presence of point tenderness over the immediate area of inflammation, and joint pain made worse with active motion (when the patient moves the joint) compared to passive motion (when the joint is moved by the examiner)

Question 5

Soft Tissue Pain

Answer 5

Pain is pain which may be perceived as arising from the joint, but which actually arises elsewhere such as in the muscle, in nerves adjacent to the joint, or pain referred from a distant site.

Question 6

Swelling

Answer 6

Swelling in a joint can be a particularly helpful finding to determine if a patient has arthritis. Since the joint represents a potential space, swelling can present as a joint effusion. Therefore, an important objective finding of joint inflammation is a joint effusion. Also, because the problem is in the joint itself, BOTH passive and active motion causes pain

Question 7

Arthritis distribution: Monoarticular arthritis

Answer 7

Arthritis involving one joint. This form of arthritis is most often seen in infections, crystal-induced arthritis, or trauma.

Question 8

Arthritis distribution: Oligoarticular arthritis

Answer 8

Arthritis seen in several joints (2-4). This form of arthritis is often associated with the axial arthropathies such as ankylosing spondylitis, psoriatic arthritis, or reactive arthritis. This arthritis is often asymmetrical and involves the large joints (although not invariably).

Question 9

Arthritis distribution: Polyarticular arthritis

Answer 9

Often more than 5. Involves multiple joints, often symmetrically, and usually affects both the small and large joints. Classic examples of this form of arthritis include rheumatoid arthritis, systemic lupus erythematosus, and certain viral syndromes.

Question 10

Types of Joints: Synarthrosis

Answer 10

where bones essentially come together and interlock, such as the skull.

Question 11

Types of joints: Amphiarthrosis:

Answer 11

Where bones are joined by a segment of flexible fibrocartilage such as in the rib cage where costal cartilage joins the ends of each rib to the sternum.

Question 12

Types of joins: Diarthrosis

Answer 12

the most common type of joint. Bone articulates, is cushioned by hyaline cartilage, stabilized by ligaments, actively moved by muscles and tendons, and nourished and lubricated by synovial tissues.

Question 13

Diarthrosis Joint movements.

Answer 13

1) Uniaxial or hinge joints move along one plane such as the elbow or knee.
(2) Polyaxial Joints move in multiple axes such as the ball and socket joint of the shoulder.

Question 14

Tissues around joints: Ligaments

Answer 14

bundles of parallel Type I collagen which connect bone to bone. These serve to prevent inappropriate motion. Hinge joints are commonly bordered by collateral ligaments to limit flexion and extension of the joint.

Question 15

Tissue around joints: Tendons

Answer 15

Resemble ligaments but connect muscle to bone. Tendons are active drivers of joint motion whereas ligaments are passive restraints.

Question 16

Tissues around joints: Entheses

Answer 16

are where ligaments and tendons insert into bone. These are metabolically active sites different from tendon or bone. They are of particular interest in the seronegative spondyloarthropathies because they can become inflamed, cause erosions, and eventually calcify.

Question 17

Tissues around joints: Bursae

Answer 17

are synovial lined sacks or pillows supported by dense regular connective tissue designed to slide and cushion tissues that are less forgiving during movement. Each bursa contains a lubricating film of synovial fluid. The majority of bursae occur between tendon and bone, tendons or ligaments, or between tendons

Question 18

Joints: Axial arthropathy:

Answer 18

Arthritis involving the spine

Question 19

Joints: Ankylosis

Answer 19

fixation of a joint as the result of a disease process, with fibrous or bony union across the joint.

Question 20

Joint: Sacroiliitis

Answer 20

Inflammation of the sacroiliac joint.

Question 21

Joints: spondylitis

Answer 21

inflammation of one or more vertebrae of the spine

Question 22

Joints: Osteophyte

Answer 22

A bony outgrowth of bone.

Question 23

Joints: Syndesmophyte

Answer 23

calcification of a ligament or tendon at site of bony insertion.

Question 24

Joint: Synchondrosis

Answer 24

A union btwn 2 bones formed by cartilage. Ex) pubic symphysis.

Question 25

Diarthrodial Joint - internal structure

Answer 25

articular surface of bone covered by hyaline cartilage (firm and resilient tissue). Predominantly Type II collagen. Also has proteoglyans (which are highly negative charged and have coiled spring effect). Mayjor component of cartilage is water. WATER+COLLAGEN+PROTEOGLYCANS form a turgid gel, which is not a static structure. Chondrocytes produce bth collagen and proteoglycans. No vessels or nerves in joints - get NUTRIENTS FROM SYNOVIUM by way of synovial fluid.

Question 26

Synovium

Answer 26

a thin layer of cells and capsule that covers are synovial lined sacks or pillows supported by dense regular connective tissue designed to slide and cushion tissues that are less forgiving during movement. Each bursa contains a lubricating film of synovial fluid. The majority of bursae occur between tendon and bone, tendons or ligaments, or between tendons

Question 27

Subchondral bone

Answer 27

Under the cartilage. Commonly becomes dense or sclerotic in osteoarthritis. In inflammatory arthritis, the periarticular bone can become ess dense or osteopenic due to the inflammation and increased blood floow

Question 28

Categorization of arthritis. Monoarticular vs. Polyarticular.

Answer 28

(1) Monoarticular diseases - characteristic presentation of septic arthritis, gout, pseudogout, traumatic arthritis, mechanical derangement of joint, osteochondritis dissecans, etc.
(2) Polyarticular diseases - characteristic presentation of rheumatoid arthritis, systemic lupus erythematosus (SLE), psoriatic arthritis, Reactive arthritis, hepatitis B, etc.
(3) Polyarticular diseases which can present as a Monoarticular disease - juvenile rheumatoid arthritis, Reactive arthritis, Sarcoid arthritis, psoriatic arthritis, pseudogout, etc

Question 29

Joint distribution

Answer 29

Symmetric (RA or systemic lupus) vs. Asymmetric (osteoartritis, gout, or spondyloarthropathies)

Question 30

Distribution (continued)

Answer 30

(a) Large joints: axial arthropathies.
(b) Small joints: rheumatoid arthritis, systemic lupus erythematosus.
(c) Joints involved in osteoarthritis - distal interphalangeal joints (DIP), proximal interphalangeal joints (PIP), first carpometacarpal joint (CMC), cervical spine, lumbosacral spine, hips, knees, first metatarsophalangeal joint (MTP).

Question 31

Migratory versus additive

Answer 31

(a) Migratory - rheumatic fever, disseminated gonococcemia.

(b) Additive - rheumatoid arthritis, axial arthropathies.

Question 32

Rapidity of onset

Answer 32

Hours = septic joints and crystal disease (gout and pseudogout)
Dys - chronic inflammatory dieases.

Question 33

Response to rest and activity

Answer 33

worse with rest or in morning (RA, axial arthropathies)

Worse with use (osteoarthritic)

Question 34

Age and sex

Answer 34

(a) Presentation at a young age - rheumatoid arthritis, axial arthropathies. systemic lupus erythematosus.
(b) Presentation in the elderly: gout, polymyalgia rheumatica, pseudogout.
(c) Male - gout, axial arthropathies, hemochromatosis.
(d) Female - rheumatoid arthritis, scleroderma, systemic lupus erythematosus.

Question 35

Family history

Answer 35

(a) Rheumatoid arthritis (HLA-DR4)
(b) Axial arthropathies (HLA-B27)
(c) Systemic lupus erythematosus (HLA-DR2, HLA-DR3. C4A null allele)
(d) Gout
(e) Osteoarthritis (Heberden’s – DIP, and Bouchard’s - PIP nodes)

Question 36

Synovial fluid analysis

Answer 36

can be helpful in categorizing a joint as normal, non-inflammatory (type I), inflammatory (type II) or septic (type III).

Question 37

Degenenerative Joint Disease

Answer 37

Osteoarthritic - a cartilage based process. With advanced disease, no cartilage remains. Can be caused by Biochemical changes, Metabolic changes, Etiologic factors

Question 38

Inflammatory joint diseases

Answer 38

Rheumatoid arthritis, the axial arthropathies, and septic joints. Have inflammation primarily in the synovium causing secondary destruction of the cartilage and bone. The jointy typically has one or more signs of inflammation (swelling, warmth, redness, and pain)

Question 39

Rheumatoid arthritis

Answer 39

is the classic example of an inflammatory arthritis. Although rheumatoid arthritis can involve a variety of major organ systems, it is primarily a disease of the joints. One key to understanding RA is to comprehend why key inflammatory cells, cytokines, chemotactic agents and receptors are focused in the joints.

Question 40

Metabolic joint disease

Answer 40

gout or monosodium urate disease, pseudogout or calcium pyrophosphate dihydrate disease, hydroxyapatite deposition disease or basic calcium phosphate deposition disease). There is typically a metabolic process causing crystals to form and be deposited in joints. These can cause intermittent signs of inflammation. They may be associated with systemic symptoms. They can cause bone erosions without cartilage loss.

Question 41

Gout

Answer 41

Episodic - comes and goes. More painful than RA.
occurs after a prolonged period of supersaturation of monosodium urate in the serum and synovial fluid. The mechanism whereby crystals precipitate in joints and induce inflammation is complex. Urate crystal formation is regulated by many factors including lower intraarticular temperature, the presence of proteoglycans, changes in pH, reduced binding of urate to plasma protein, trauma, aging, and connective tissue turnover.

Question 42

Autoimmunity

Answer 42

the generation of an immune response directed against self. Systemic lupus erythematosus (SLE) is the classic autoimmune disease that can affect multiple organ systems. Autoimmunity is usually thought of as a derangement of the adaptive immune system, although there is recent evidence that the innate immune system may play a part in the pathogenesis.

Question 43

General measurements of inflammatory response are

Answer 43

are the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP). The ESR is the most widely used measure of an acute-phase inflammatory response.

Question 44

Organ specific autoimmunity

Answer 44

immune response directed against a single autoantigen or restricted group of autoantigens

Question 45

Vasculitis

Answer 45

vasculitides are a heterogenous group of diseases that are usually categorized by the SIZE of the vessels that are involved

Question 46

Some info about lab tests

Answer 46

H&H go down with inflammation. Platelet and ferretin go up with inflammation.

Question 47

Knowledge bomb…

Answer 47

One inflammed joint is infected until proven otherwise!

Question 48

Heberden’s and Bouchard’s Nodes

Answer 48

Bouchards are “Before”… the proximal one.

Question 49

Rheumatoid arthritis note

Answer 49

…. No T/L spine involvement! Look fro small joints except DIP joints.

Question 50

secondary osteoarthritis

Answer 50

can be from end stage inflammatory disease like hemochromatosis and wilson’s disease (this was brought up in small group session)