FIBROMYALGIA AND PATH PICCIES!Rick Allen

FIBROMYALGIA A.k.a Chronic Widespread Pain Related with Chronic fatigue syndrome Definition:

Chronic pain ->3mths Widespread -L. and R. sides, above and below waist Absence of inflammation (Pt. may perceive

swelling) Presence of pain at 11/18 common sites (though

may have pain at other sites).

Ache/burning, unremitting. Start in one spot before becoming widespread

Other CF: Fatigue (80-90%, often severe) Morning stiffness (80-90%) Poor concentration Low mood and sleep disturbance (70%) Difficult to live with/ family discord Brain scans suggest abnormal pain sensation

RF: Female (10:1) IBS Middle age (40-65) Chronic Headaches Low SES Anxiety Low education level Depression Stress Physical De-conditioning Sleep disturbances Pre-menstrual syndrome

Pathogenesis Unknown, many postulated, especially in relation to

abnormal pain perception (CNS) Chicken and the egg argument for psychological

abnormalities (pain cause issues?) Ix

All normal! Basically a diagnosis of exclusion Triggers

Emotional stress, infections, medical illness, surgery, hypothyroidism, trauma

Progression Can wax and wane, or be persistent through therapy

Prognosis Poor? 2 years: 24% remission, 47% no longer in

criteria

Treatment Education and Communication (include

family) CBT – avoid over-exertion etc. Stop drugs of dependance, or utilising

stimulating substances (caffeine = insomnia)

Long-term graded exercise programs Pharmacotherapy

NSAIDs SHOULD NOT WORK!!! Low dose TCA (amitriptyline) before bed helps

gain restorative sleep Treat symptoms (inc. mood disorders) as

appropriate

PATH PICTURE TIME!!!!

Cartilage erosion

Osteophyte formation (blue arrows)

Eburnation (polished and smooth surface of exposed underlying bone)

Cyst development (red arrows)

Severe Osteoarthritis

Acute Haemarthrosis

• 8 y.o.• Haemophili

ac

Bunion

• Woman• Aged 70• Chronic rubbing

against ill fitting shoes

Scoliosis

• Disc degeneration (blue arrows)

• Osteophytes (red arrows)

Severe Chronic Rheumatoid Arthritis

• Woman• Aged 66• Abundant fibrous

tissue surrounding joint (blue arrows)

Osteoarthritis

Severe Chronic Rheumatoid Arthritis

• Ankylosis of hip joint (blue arrows)

• Marked Osteoperosis• Hyperplasia of bone

marrow (hypersplenism/long-term glucocoticoid use?)

• thin cortex (red arrows

Palisaded epithelioid cells (black arrows) derived from macrophages

Central Pink amorphus zone (blue arrows) that stains for fibrin

Rheumatoid Nodule

• Hyperplastic synoviocytes (blue arrows)

• Chronic inflammation (red arrows)

• Vessel prominence• Many plasma cells• Rheumatoid synovium

Rheumatoid nodule from pt. w. long history of Rheumatoid Arthritis

• Male• 66 y.o.• Excised from

subcutaneous tissue over the elbow

Acute Suppurative Arthritis of elbow (arrows)

• Death from Septicaemia

• Group A β haemolytic streptococci involved

Severe Chronic Rheumatoid Arthritis

• Destruction and dislocation of knee joint

• Marked Osteoporosis

Ankylosis of hip due to Tuberculosis arthritis

• Age 57 at death• Hip joint space

(arrows) obliterated

• Dx w tuberculous arthritis at age 3

Gross degeneration

• Woman• Aged 70• Kyphosis• Schmorl’s nodes

(black arrows)• Anterior osteophytes

(red arrows)

• Female• 68 y.o.• Severe interstitial

pulmonary fibrosis (blue arrows) destruction of lung parenchyma

• Chronic Rheumatoid Arthritis, resp failure and cor pulmonale

• Adherent pleura (black arrows)

Severe osteoarthritis w fibrosis and haemosiderosis of the synovium

• Male• 50y.o.• Haemophiliac• Cartilage erosion

(black arrow)• Death from

retroperitoneal haemorrhage

• Hx. Of recurrent haemarthroses

Septic arthritis from Staph. aureus

• Male• 71 y.o.• Upper R. humerous• Diabetic• Destruction of articular

surface• Synovium microscopy

= active chronic inflam.• Purulent exudate in

joint space

Thickened and hyperplastic synovium (arrows)

Rheumatoid Arthritis

• Gross reduction of number and size of trabeculae

• Osteoporotic bone

Secondary osteoarthritis of the hip• Male

• Middle aged• Alkaptonuria and

ochronosis• Scant articular cartilage

remaining, pigmented

Chronic tophaceous gout

• Gross deformities caused by urate deposition

High power veiw Needle-shaped

urate crystals

• Foreign body Giant cells (arrows)

• Urate crystal aggregates surrounding them

Severe ankylosing spondylitis

• Male• 51 y.o.• Rigid spine• Longitudinal ligaments

undergone ossification• Many intervertebral discs

partially ossified (blue arrows)

• Fracture-dislocation (black arrows) w compression and necrosis of the cervical cord from fall 2.5 weeks before death

Tuberculosis of the spine

• Male• 51 y.o.• Gross destruction of

the spine• Spinal cord

compression• Histol and microbiol

assessments needed to Dx. …

Hypertrophic Pulmonary Osteoarthropathy

• Male• 54 y.o.• Tibia and fibula• Extensive new bone

formation (arrows) under the periosteum

• Clubbing• Dx. w malignant

pleural mesothelioma

Chronic gout

• Male• 64 y.o.• 1st metatarso-

phalangeal joint

• Blue arrows = urate deposits in joints

• Red arrows = urate deposits within extra-articular tissue