dr. m jokardoctorjokar.com/attachment/doc/rheumatoidarthritis.pdf · ra -definition chronic...
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Dr. M Jokar
By: Dr. Mohammad Hasan Jokar
RA - Definition
chronic systemic inflammatory disorderunknown etiologydiarthroidal jointssynovium affectedbone, cartilage, ligamentsdeformityextra-articular manifestations
By: Dr. Mohammad Hasan Jokar
RA - Epidemiology
worldwide distributionall races female > male 3:11% adults in U.SThe most common Inflammatory
disorder of jointAll ages(peak 35-55)
By: Dr. Mohammad Hasan Jokar
Causes
The cause of rheumatoid arthritis is unknown
Several factors have been identified that may lead to its causeGenetic factorsEnvironmental factorsHormonal factors
By: Dr. Mohammad Hasan Jokar
Pathophysiology
Ag Genetic Background APC
Ab B cell T Cell
IC Complement PMN
Inflammation
By: Dr. Mohammad Hasan Jokar
AgBacterialViralFoodsHSP 65 KDCollagen type IIProteoglycans
By: Dr. Mohammad Hasan Jokar
GENETIC BACKGROUND
First-degree relatives 3%Monozygotic twins 30%HLA-DR4 80%shared epitope (amino acids 70 to 74 of
DR beta chains)
By: Dr. Mohammad Hasan Jokar
Ag presentation
By: Dr. Mohammad Hasan Jokar
B Cell RF
By: Dr. Mohammad Hasan Jokar
Rheumatoid factor series of antibodies that recognize the Fc
portion of an IgG molecule any serotypemost IgMmany conditions associated with RF positivity -
chronic inflammation 70% RA positive at onset, overall 85% in first
two years associated with more severe disease, extra-
articular manifestations, mortalityBy: Dr. Mohammad Hasan Jokar
Anti-Cyclic Citrullinated Peptide Antibodies (AntiCCP)
Sensitivity 80%Specificity 95%
By: Dr. Mohammad Hasan Jokar
Ag + Ab
Synovium
InflammationBy: Dr. Mohammad Hasan Jokar
Inflammation
Cellular PMN Lysosome Arachidonic acid
HumoralHageman factorKinin system complement
By: Dr. Mohammad Hasan Jokar
Neuroendocr ine Axis
HypothalamusIL1
Hypophysis
Estrogen Androgen Cortisol
Immune response InflammationBy: Dr. Mohammad Hasan Jokar
Cytokines
I L1
I L6
TNF
By: Dr. Mohammad Hasan Jokar
IL1T Cell ActivationCartilage destructionBone destructionNeuroendocrne system activationFeverConstitutional symptomsAcute phase reactants
By: Dr. Mohammad Hasan Jokar
Clinical manifestations
By: Dr. Mohammad Hasan Jokar
OnsetIn two thirds the onset will begin with aprodromal illness lasting for weeks tomonths. The features of this illness arefatigue, anorexia, generalized weaknessand vague musculo-skeletal symptoms.
By: Dr. Mohammad Hasan Jokar
Onset
In 10% of people, the onset will be moreacute, with rapid development ofpolyarthritis, often accompanied byconstitutional symptoms including fever,lymphadenopathy and splenomegaly.
By: Dr. Mohammad Hasan Jokar
Clinical manifestations
Articular
Nonarticular
By: Dr. Mohammad Hasan Jokar
Articular Features
Pain Swelling TendernessWarmth (large joints) Stiffness (“gel phenomenon”) Deformity Redness is rare Symmetrical polyarthritis
By: Dr. Mohammad Hasan Jokar
Normal versus Ivoveded joint
By: Dr. Mohammad Hasan Jokar
Rheumatoid Arthritis
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
Joints most commonly affected are:
PIPMetacarpophalangeal (MCP)CarpalElbowsMetatarsophalangealFeetKneesUpper cervical spine
By: Dr. Mohammad Hasan Jokar
Joints spared are:
DIPLumbar spineSacro-iliac
By: Dr. Mohammad Hasan Jokar
HandsZ deformitySwan neckBoutonniereCarpal tunnel syndrome
By: Dr. Mohammad Hasan Jokar
“Z deformity”; radial deviation at the wrist, ulnar deviation at MCP joints
By: Dr. Mohammad Hasan Jokar
Swan neck”; PIP extension, with DIP flexion.
By: Dr. Mohammad Hasan Jokar
“Boutonniere”; PIP flexion, with DIP extension.
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
Extra-articular manifestations
Generalfever, lymphadenopathy, weight loss, fatigue
Dermatologicpalmar erythema, nodules, vasculitis
Ocularepiscleritis/scleritis, scleromalacia perforans,
choroid and retinal nodules
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
Rheumatoid nodule
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
Rheumatoid nodule
FrequencySize ConsistencyLocationsSymptomsPathologyRF+
By: Dr. Mohammad Hasan Jokar
Extra-articular manifestations
Pulmonarypleuritis, nodules, interstitial lung disease
OthersSjogren’s syndrome, amyloidosis
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
Caplan's syndrome
By: Dr. Mohammad Hasan Jokar
Extra-articular manifestations
Cardiacpericarditis, myocarditis, coronary vasculitis,
nodules on valvesNeuromuscularentrapment neuropathy, peripheral neuropathy,
mononeuritis multiplexHematologicAnemia, Felty’s syndrome, lymphomas
By: Dr. Mohammad Hasan Jokar
Backer’s cyst
By: Dr. Mohammad Hasan Jokar
Rheumatoid vasculitis
By: Dr. Mohammad Hasan Jokar
Laboratory abnormalities
anemia of chronic diseaseLeukocytosis thrombocytosis in active disease low white cell count in Felty’sESRCRPRf
By: Dr. Mohammad Hasan Jokar
Unusual patterns of RA
Adult-onset Still’s diseasePalindromic rheumatismMonoarticular
By: Dr. Mohammad Hasan Jokar
DDX of a positive RF
normal - 1-4%, 10-25% over age 70systemic autoimmune diseases infectionsmalignancychronic liver diseasepulmonary diseases
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
RA - differential diagnosis
spondyloarthropathiesCTDspolyarticular goutCPPDviral infectionsfibromyalgia
By: Dr. Mohammad Hasan Jokar
RA - differential diagnosis
UncommonhypothyroidismSBEhemochromatosishypertrophic pulmonary osteoarthropathyhyperlipoproteinemiashemoglobinopathiesrelapsing polychondritis
By: Dr. Mohammad Hasan Jokar
X - Ray
Soft tissue swellingJuxtaarticular osteoporosisErosionsAnkylosis
By: Dr. Mohammad Hasan Jokar
RA: Erosion Progression
By: Dr. Mohammad Hasan Jokar
By: Dr. Mohammad Hasan Jokar
Pathology
Synovial lining cell proliferationSubsynovial infiltrationsPannus formation
By: Dr. Mohammad Hasan Jokar
Synovial thickening
By: Dr. Mohammad Hasan Jokar
Pannus
By: Dr. Mohammad Hasan Jokar
Felty’s syndrome classic triad
RA, splenomegaly, leukopenia generally a neutropenia (<2000/mm3) thrombocytopenia may occur complications
infections, non-healing leg ulcersmost require no additional treatment for
cytopenias splenectomy?
By: Dr. Mohammad Hasan Jokar
RA - ManagementNonpharmacologicPatient educationrest splinting
physical therapyheat, cold, ultrasound, paraffin,
massageoccupational therapy
By: Dr. Mohammad Hasan Jokar
RA - Management
PharmacologicanalgesicsNSAIDs - full dosecorticosteroids
prednisone at low dose intra-articular steroids
By: Dr. Mohammad Hasan Jokar
Disease modifying agents
every patient should be considered for at least one modifying agent
MethotrexateAntimalariaSulfasalasineCytotoxic agents
By: Dr. Mohammad Hasan Jokar
RA - long term prognosis
RA shortens survival and produces disability
1/3 leave work force in five yearsaggressive DMARD TX can reduce
disability by 30% in 10-20 years
By: Dr. Mohammad Hasan Jokar