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Differential Diagnosis
Immunologic Disorders
Organs of the Immune system
Tonsils Thymus gland Lymph nodes Bone marrow Spleen Peyer’s patches (Intestinal lymph tissue)
Immune system disorders
Due to dysfunction of immune response mechanism
Causes overresponsiveness or blocked, misdirected or limited responsiveness to antigens
Many immune system disorders are genetically linked
Immunodeficiency Immune system is compromised Commonly seen after chemotherapy
Hypersensitivity Autoimmunity
Immune system fails to recognize self from nonself and misdirects immune system against the body’s own tissue
Immunoproliferative Abnormal reproduction or multiplication of
cells of the lymphoid system
Immune system disorders
Immune system disorders
Generalized weakness in the absence of muscle disease is a common symptom
Nail bed changes are indicative of inflammatory disease
Source of joint swelling must be distinguished as articular (arthritis), periarticular (tenosynovitis), involving an entire limb (lymphedema) or occurring in another area (lipoma or tumor)
Neurologic disorders
Many neurologic disorders display features of immune dysfunction, including: Myasthenia gravis Guillain-Barre Multiple sclerosis ALS Acute disseminated encephalomyelitis
Myasthenia Gravis
Antibodies block receptors for Acetylcholine in muscles, leading to impaired muscle function
2 major peak onset times 20-30 years old (Women > Men) > 50 years old (Men > Women)
Myasthenia Gravis
Muscle weakness and fatigue Especially noted in the eyes, chewing,
swallowing and facial expression Worse with superimposed illness, menses and
warm air temperature Proximal > Distal – results in difficulty with
stairs, rising from a chair, combing hair and holding up the head
Muscle most affected are the cranial muscles, neck muscles, respiratory muscles and proximal limbs
No muscle atrophy or loss of sensation
Guillain-Barre Syndrome
A demyelinative disease of the peripheral nervous system, especially spinal nerves
Occurs after infectious illness, upper respiratory infection, vaccinations or viral infection such as measles, hepatitis or mono
Infection commonly precedes onset of symptoms by 1-3 weeks
Characterized by abrupt onset of paralysis Affects any age, sex or race
Guillain-Barre Syndrome
The immune system attacks its own myelin cells, because they look similar to the infection virus
Paralysis is usually symmetrical Affects LE UE respiratory muscles
(distal to proximal) Weakness and paralysis is sometimes
preceded by paresthesia and numbness Progression and severity of paralysis varies
Guillain-Barre Syndrome
Symptoms progress over 1-3 weeks, plateaus, then spontaneous improvement and recovery begin (May take 6-9 months)
Cranial nerves, especially the facial nerve, may be involved
Patients may have weak DTRs early in the course of the illness
Multiple Sclerosis
Most common demyelinating disease of the CNS – spares the peripheral nerves
Usually appears 20-40 years of age, with peak onset at 30
Women 2X > Men More prevalent in colder climates than
tropical areas
Multiple Sclerosis
Characterized by lesions throughout the CNS These lesions later form scars (plaques) Especially concentrated in the optic nerves,
cerebrum and cervical spinal cord When edema and inflammation subside,
some remyelination occurs, but often is incomplete
Axonal injury may cause permanent neurological dysfunction
Death is usually due to respiratory or urinary infections
Multiple Sclerosis
Symptoms vary depending on location of lesions
May experience extremity weakness Spasticity and hyperreflexia are common Fatigue and dysmetria (intention tremors) Urinary and/or bowel/bladder dysfunction are
common Optic neuritis (unilateral visual impairment) is
often the 1st symptom Warm temperatures worsen symptoms
Autoimmune disorders
Inability to distinguish self from nonself Immune system directs immune responses
against normal “self” tissue Antibodies are manufactured against the
body’s own cells and organs Implicated causes include genetics, sex
hormones, viruses, stress, cross-reactive antibodies, altered antigens and environment
May be organ specific or generalized (systemic)
Systemic Autoimmune disorders
Fibromyalgia Rheumatoid Arthritis Systemic Lupus Erythematosus Scleroderma Spondyloarthropathy
Ankylosing spondylitis Reiter’s syndrome Psoriatic arthritis Lyme disease
Fibromyalgia
Noninflammatory condition Characterized by generalized
musculoskeletal pain and tenderness to palpation of specific points
Women > Men Preadolescents to early postmenopausal,
rare in older adults Possible genetic predisposition Dysregulation of the neurohormonal and
autonomic nervous systems
Fibromyalgia vs. Myofascial Pain
Myofascial Pain Fibromyalgia Syndrome Syndrome
Fibromyalgia Tender Points
Pain in 11 of the 18 Tender Points with palpation by definition
Fibromyalgia
Widespread pain ( > 3 months) Widespread local tenderness Fatigue Morning stiffness Sleep disturbances Muscle spasms or nodules Aggravated by cold, stress, excessive or no
exercise and physical activity
Rheumatoid Arthritis
Chronic, systemic, inflammatory disorder of unknown cause
Affects various organs – predominantly the synovial tissues of the diarthroidal joints
Women >> Men Can occur at any age, but most common
between 20 and 40 years old
Rheumatoid Arthritis
Malaise, fatigue and diffuse musculoskeletal pain are common initial symptoms
Pain, tenderness, swelling and redness localize to specific joints
Gel phenomenon – Prolonged stiffness (>1hr) which is relieved with activity, but recurs with prolonged posture throughout the day
Bilateral and Symmetrical joint structural damage – hands, wrists, elbows, and shoulders
Rheumatoid Arthritis
DIP involvement is rare Limited ROM is common Wrist deformities include flexion, pronation,
radial or ulnar deviation, palmar subluxation of the carpals and dorsal subluxation of the ulnar head
MCP deformities are increased ulnar drift and palmar subluxation
Rheumatoid Arthritis
Rheumatoid Arthritis
Arthritic changes
Swan neck deformity – Flexion of the MCP and DIP with hyperextension of the PIP Due to contracture of the intrinisic muscles or
tearing of the volar plate Commonly seen with RA
Boutonniere deformity – Extension of the MCP and DIP with flexion of the PIP Due to rupture of the central tendinous slip of
the extensor hood Commonly seen with RA
Swan neck deformity
Boutonniere deformity
Rheumatoid Arthritis
Foot deformities include subluxation of the MTP heads and foreshortening of the extensor tendons Hammer toe Cock up deformities
Cervical spine involvement Stiffness Atlantoaxial subluxation
Systemic Lupus Erythematosus
Chronic systemic inflammatory disease characterized by injury to the skin, joints, kidneys, heart and blood forming organs, nervous system and mucous membranes
Red, butterfly rash Discoid – Skin only affected Systemic – More severe and can affect
almost any organ or system of the body
Systemic Lupus Erythematosus
Systemic Lupus Erythematosus
Common age of presentation is 15-40 years, rarely occurs in older people
Women 10-15X > Men Arthralgias and arthritis are the most common
manifestations Hands, wrists and knees are symmetrically involved Rarely directly affects the spine Peripheral neuropathies are common Frequently c/o numbness of the tip of the tongue and
inside the mouth Decrease in distal limb reflexes
Scleroderma
Characterized by inflammation and fibrosis of many body parts
Affects skin, blood vessels, synovium, skeletal muscle, kidneys, lungs, heart and GI tract
Can occur in individuals of any age, race or sex
Most common in young or middle-age women (age 25-55)
Scleroderma
Hallmark signs Raynaud’s phenomenon Tight skin
Arthralgia, stiffness and arthritis Mild muscle weakness, tenderness and pain Progresses to atrophy, deconditioning and
flexion contractures Esophageal hypomotility – very common Intestinal hypomotility intermittent diarrhea,
bloating, cramping, malabsorption and wt loss
Scleroderma
Spondyloarthropathy
A group of noninfectious, inflammatory, erosive diseases
Not seropositive for rheumatoid factor Men > Women Includes:
Ankylosing spondylitis Reiter’s syndrome Psoriatic arthritis Lyme disease
Ankylosing Spondylitis
Inflammation of fibrous tissue which affects the insertions of ligaments and capsules into bone
Primarily affects the SI joints, spine and large peripheral joints
Accompanied by fever, fatigue, loss of appetite, and redness and pain of the eyes
Classic presentation is insidious onset of mid to LBP > 3 months
Ankylosing Spondylitis
Usually worse in the morning and lasts > 1 hr Pain described as achy or “jolting” Localized to the pelvis, buttocks, and hips Often confused with sciatica, but neurological
exam will be negative with AS Progressively decreasing ROM Vertebral bridging is evident on X-ray Spinal column appearance is referred to as
“bamboo spine” in late stages
Ankylosing Spondylitis
Uveitis, conjunctivitis or iritis Pulmonary changes may be confused with TB Cardiovascular complications include cardiomegaly,
conduction defects and pericarditis Spinal fractures with minor trauma are common –
Most common lower C-Spine Atlantoaxial subluxation – Present with severe neck
or occipital pain with referral to the retroorbital or frontal area
Cauda equina syndrome is a late manifestation Spinal stenosis pain and numbness of LEs, worse
with walking, relieved by rest
Ankylosing Spondylitis
Reiter’s Syndrome
AKA Reactive arthritis Characterized by a triad of arthritis,
conjunctivitis, and nonspecific urethritis Primarily men aged 20-40 Symptoms begin acutely 2-4 weeks after
venereal infections or gastroenteritis Distal joints are prominently affected Radiologic changes of the SI joints and spine
are asymmetric
Reiter’s Syndrome
Arthritic changes are most common to the weight bearing joints of the LEs
Affected joints are warm, tender, edematous and painful with active or passive ROM
Septic joints – identified by dusky-blue discoloration or frank erythema accompanied by severe tenderness
Heel pain – frequent distinctive and disabling manifestation. Due to enthesitis of the plantar aponeurosis and Achilles tendon on the calcaneus
Psoriatic Arthritis
Distinct disease that combines features of RA and spondyloarthropathies
Affects both sexes equally Women – Symmetric polyarthritis Men – Spinal involvement
Usually occurs at age 20-30 years Onset is usually preceded by psoriasis Skin lesions and nail lesions are common
Psoriatic Arthritis
Psoriatic Arthritis
Severe arthritic changes occur early in the disease Distal Proximal (DIP joints included) Arthritis mutilans
Pain and stiffness with morning stiffness > 30 minutes. Aggravated by immobility, reduced with physical activity
Pain with stress on the joints Joint line is tender Joint effusion is present Dactylitis – “Sausage fingers”
Dactylitis
References “Ankylosing Spondylitis”. Retrieved 6/22/08 from the World Wide Web. http://
www.spondylitis.org/about/as.aspx Braunstien BL, Provost TT. 1988.Cutaneous Medicine. In: The Principles and Practice of
Medicine. 22nd edition. Harvey, et al editors. Norwalk, CT. Appleton & Lange. p1211-1212. Goodman CC, Snyder TE. 2007. Screening for Immunologic Disease. In: Differential
Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p517-557.
Goodman CC, Snyder TE. 2000. Overview of Immunologic Signs and Symptoms. In: Differential Diagnosis in Physical Therapy. 3rd edition. St. Louis, MO: Saunders Elsevier. p405-406.
Psoriatic Arthritis. Retrieved 6/4/07 from the World Wide Web. http://www.hopkins-arthritis.org/arthrtitis-info/psoriatic-arthritis/clinical-manifestation.html.
Rubin E, Farber JL. 1999. Pathology. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins p693. In: Porth editor: Pathophysiology Concepts of Altered Health States, 6th edition. Philadelphia, PA: Lippincott Williams & Wilkins, p839.
Scleroderma. Retrieved 06/22/08 from the World Wide Web. http://www.scleroderma.org/.../scleroderma-hand_jpg.htm
Swanson AB. 1995. Pathogenesis of Arthritic Lesions. In: Rehabilitation of the Hand: Surgery and Therapy, Volume 2. 4th edition. Philadelphia, PA: Mosby. P1307-1313.
Swanson AB. 1995. Pathomechanics of Deformities in Hand and Wrist. In: Rehabilitation of the Hand: Surgery and Therapy, Volume 2. 4th edition. Philadelphia, PA: Mosby. P1315-1327.
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