Ch 52: Rheumatic Disorders

What is the most common disabling musculoskeletal disorder in the US?

Arthritis

What is the most common arthritis?

Osteoarthritis

What is osteoarthritis characterized by?

• Loss of articular cartilage

• Cartilage calcifies

• Wear of underlying bone

• Formation of bone spurs

• Noninflammatory

• Weight-bearing joints

What is osteoarthritis caused by?

Abnormal “wear and tear” on joints

What are the factors that increase the abnormal wear and tear in joints?

• Obesity

• Joint trauma

• Congenital disorders

  • Genu Valgus/Varus

• Lifestyle and occupation (abnormal stress to joints)

• Genetic predisposition

• Hormonal status

  • Postmenopausal

Is osteoarthritis degenerative?

Is osteoarthritis inflammatory or not?

Noninflammatory

Is osteoarthritis local or systemic?

Localized

For osteoarthritis, what does the initial injury cause?

• Chondrocytes release of enzymes

  • Proteolytic and collagenolytic (Breakdown of the matrix of proteoglycan and collagen)

• Collagen fatigue and microfractures

For osteoarthritis, what does the progressive injury cause?

• Structural breakdown of cartilage

• Osteophyte spur formation

• Joint effusion

• Inflammation of synovial membrane → joint distention

List the clinical manifestations of osteoarthritis.

Localized

• Joint pain

• Crepitus with movement

• Bony enlargement

• Morning stiffness

• Hand deformity

  • Heberden

  • Bouchard nodes

What are the radiologic changes seen with osteoarthritis?

• Bony proliferation at the joint margins (bone spurs)

• Asymmetric narrowing of the joint space

• Subchondral bone sclerosis

• Malalignment of joints

• Cyst formation

How is osteoarthritis treated?

• Acetaminophen → reduce pain

• NSAID drug therapy → decrease swelling and pain

• Selective NSAID → COX-2 inhibitor (Celebrex)

  • Inhibit cyclooxygenase-2 enzyme

  • Fewer gastrointestinal side effects

• Intraarticular injection of hyaluronan or derivatives

  • Increase joint lubrication

  • Reduce inflammation

• Physical therapy

  • Improve range of motion, muscle strength, and joint conditioning

• Surgery

What is rheumatoid arthritis?

Systemic autoimmune inflammatory disease

What is rheumatoid arthritis triggered by?

Bacterial or viral antigen in genetically susceptible individuals

Describe each phase of rheumatoid arthritis.

Initial phase

• Immune response localizes in synovial tissue

• Activation of B cells, T cells, and macrophages

  • Activated B cells produce auto-antibodies

What are the clinical manifestations of rheumatoid arthritis? (Think cardiac, pulmonary, and ophthalmic)

• Cardiac →

• Pulmonary →

• Ophthalmic →

Which body parts are usually involved in rheumatoid arthritis?

• Hands

• Wrists

• Knees

• Feet

How is rheumatoid arthritis diagnosed?

• Based on guidelines from:

  • The American College Rheumatology

  • European League Against Rheumatism

• The patient must have

  • At least one documented swollen joint

  • Absence of alternative diagnosis that better explains the joint swelling

  • A total score on the criteria scale of ≥6

What is the goal of treatment for rheumatoid arthritis?

• Alleviation of pain and swelling

• Prevention of structural damage

• Preservation of function

How is rheumatoid arthritis treated?

• Anti-inflammatory medication (NSAIDS, COX-2 inhibitors, corticosteroids)

• Disease-modifying antirheumatic drugs (biological agents, tyrosine kinase inhibitors)

Joint dysfunction is secondary to what other diseases?

Neurovascular, hematologic, and metabolic disorders

What is gouty arthritis?

Heterogenous disorder in which disturbance of uric acid metabolism → deposition of uric acid crystals in joints

What is gouty arthritis characterized by?

• Hyperuricemia

• Urate crystal → induced arthritis

• Recurrent attacks of articular and periarticular inflammation

• Accumulation of tophi

• Renal impairment

  • Uric acid calculi

List the clinical manifestations for all four phases of gouty arthritis.

Asymptomatic hyperuricemia → no treatment required

• No clinical signs

• Serum urate levels are elevated

Acute gouty arthritis

• Weight-bearing joints most commonly affected

• Warm, red, and tender

• Great toe most often involved

• Initial attacks can last 1-14 days

• Later attacks tend to become more frequent

Intercritical gout

• Intervals between acute attacks, no symptoms

Which of the phases of gouty arthritis have no symptoms?

Asymptomatic hyperuricemia

Gouty arthritis is most common in ___ men and ___ women.

Middle-aged; postmenopausal

When does tophi appear and what tissue can it affect?

• About 10 years after initial onset of gout

• Affects tissues of the ears and eyes, and cardiac and renal structures

How is gouty arthritis diagnosed?

• Joint fluid (synovial) test

• Blood test

  • Uric acid and creatinine

• X-ray imaging (can be helpful to rule out other causes of joint inflammation)

• Ultrasound (detects urate crystals in a joint or in a tophus)

What is the treatment of gouty arthritis?

• Colchicine

• NSAIDs

• Corticosteroids

• Medications to correct hyperuricemia and prevent gout flares

  • Uricosuric agents or block uric acid production