introduction to rheumatology eldad ben-chetrit md head reumatology unit
TRANSCRIPT
Introduction to Rheumatology
Eldad Ben-Chetrit MD
Head Reumatology Unit
“Rheumatology is the internal medicine of the locomotor
system”
What is the source of the termRheumatology?
• Rheuma rheum-, rheuma-, rheumato-, rheumat-
(Greek: flux, that which flows; a stream; discharge)
Components of the locomotor system
The Painter’s FamilyJacob Jordaens (1593-1678)
Evidence of: Rheumatoid Arthritis
The Virgin with Canon vanDer Paele, 1436Jan van Eyck (1385-1440)
Evidence of: Temporal (Giant Cell) Arteritis
Historical Perspective
Epidemiology - general
• At a given time 15-20% of the population
may have a rheumatic condition
• Every second person will have a
rheumatic disease during lifetime
Epidemiology - general
• In family prcatice, 15-20% of patients see the doctor due to rheumatic conditions
• 20% of patients with other complaints also have rheumatic conditions
Epidemiology
• Degenerative diseases• OA clinical 10-30%
X-ray (>55 yr) 80%
• Soft tissue rheumatism• Fibromyalgia 2-3%
Epidemiology
• Arthritides, autoimmune diseases• Rheumatoid arthritis 1-2%• AS (Bechterew’s disease) 0.1-1%• Psoriatic arthritis 0.1-0.2%• Gout (30-60 yr) 1.6%• SLE 0.1%• Scleroderma (SSc) 0.02%• Sjögren’s syndrome 1%
Importance and Impact of Rheumatologic Disease
Prevalence (per 100,000)
Male FemaleRheumatoid Arthritis 440 1,100Ankylosing Spondylitis 197 73Gout 980 230SLE 7 32Scleroderma 1 5Osteoarthritis 3,470 5,870
All Musculoskeletal conditions 15,510 20,720
CDC: Census Bureau 2004
Social and economical effects
Rheumatoid arthritis– Mortality
• life expectancy: 10 yrs less• ACR stage mortality equals to
(in the pre biologic era):
Diabetes –risk for heart disease
Social and economical effects
Non-steroidal antiinflammatory drugs (NSAID)• USA
• 13 million current user
• 70 million prescriptions / yr
• 30 billion OTC tablets / yr
• GI mortality: 0.22%
• NSAID assoc. Hospital admittance: 103.000 / yr
• cost of one admittance: 15-20.000 USD
• total cost: 2 billion USD / yr !!!
Classification –according to tissue involvement
1. Arthritides (inflammatory diseases)
2. Degenerative diseases
3. Soft tissue rheumatism
4. Muscular disorders
5. Bone disorders
6. Other
CLASSIFICATION Non-Articular Articular
MONOARTHRITIS
Infection
Crystal-induced
Trauma
Start of polyarthritis
POLYARTHRITIS
INFLAMMATORY NON INFLAMMATORY
METABOLIC DEG
RA Gout OA
SLE Amyloidosis
Spondyloarthropathy Pseudogout
Scleroderma
Polymyositis
EtiologyHLA-DR4
HLA-B 27
HLA-B 51
ENVIRONMENTAL AND HOST FACTORS IN RHEUMATIC DISEASES
Environmental Factors Infectious Agents Host Factors
Geographical Race
Socio-economic Genetics
Occupation Sex
Diet Age
Toxins
SYMPTOMS AND SIGNS OF JOINT DISEASES
SYMPTOMS
Pain
Stiffness
Loss of Function
Systemic Features
SIGNS
Heat
Redness
Swelling
Tenderness
Loss of Movement
Deformity
Crepitus
ARTHRITIS WARNING SIGNS
• Persistent pain and stiffness on arising
• Pain or tenderness in one or more joints
• Swelling in one or more joints
• Recurrence of these symptoms and signs in one or more joints
Diagnostic Steps In Rheumatology
1.History taking
2.Physical examination
3.Radiology (imaging)
4.Laboratory methods
5.Histology (biopsy)
History taking
1.Onset (acute - chronic)2.Distribution (symmetry, migration, mono-polyart.)3.Severity (impairment, hospitalization)4.Functional capacity (at home, at work)
History taking
1.Trauma
2.Operation
3.Special associated conditions• dermatological (psoriasis)• gastrointestinal (Crohn’s disease, colitis ulcerosa)• eye (uveitis, iritis)• metabolic (diabetes, hemochromatosis)• endocrine (thyroid, parathyroid, acromegaly)
4.Drug treatment (past and current)• drug-induced SLE
• Raynaud: beta blockers
History taking 1.Professional causes• toxins, chemicals (scleroderma)• "overuse" syndrome (carpal tunnel)
2.Sexual history • (STD, AIDS, Reiter’s)
3.Quality of life• overcrowded apartment (rheumatic fever)
4.Emotional and physical stress (fibromyalgia)
5.Diseases of family members• infectious diseases (rubella, hepatitis)
6.Travelling• AIDS, Reactive arthritis
Physical examination Guidelines
Gait
Arms
Legs
Spine
Physical examination
* swelling * pain, tenderness * temperature, * colour * crepitation
* deformities
Rheumatoid Nodules
Radiological examination: aims
• Diagnostic value (RA, AS, OA)
• Differential diagnostic value (metast.)
• Progression, indicator of therapy (erosions)
Clinical Course of Progressive RA
Joint Inflammation
Joint Destruction
Functional Limitation
Physical Disability
Premature Mortality
Early RA
Late RA
Imaging
1.X-ray (simple, comparative, tomography)2.Radioisotope scanning• Tc-99m scan (bone, joint) - SPECT• infection: Ga-67, labelled leukocyte scan
3.CT (hernia, tumor)4.MRI (hernia, soft tissue, early erosions)• indication: cartilage, tendon, meniscus, muscle5.Ultrasound (cysts, joints, fluid)6.Invasive techniques• arthrography
Laboratory examination
General, immunological
1.Acute phase reactants• ESR, CRP
2.Hematology• RBC, leukocytes, platelets, Hgb, Htc• blood smear
3.Immunology• rheumatoid factor (Latex, Rose-Waaler)• ANF (immunofluorescence: Hep-2 cells)• DNA, ENA, RNP, Sm, SS-A, SS-B autoantibodies• complement (CH50, C3, C4)• cryoglobulin• other
Laboratory examination Synovial fluid1.General assessment
*• color (yellow)*• clarity, opacity (clear-opalescens)*• viscosity (inflammation: decreased)2.*Cell count3.*Crystal analysis (polarized light)• urate: yellow• Ca-pyrophosphate: blue4.*Microbiology (smear, culture)5.Biochemistry• glucose (infection, tb: low)• protein, complement, RF ??
CLASSIFICATION OF SYNOVIAL EFFUSIONSA. NORMAL
Volume
Viscosity
Color
Clarity
Leukocytes
Culture
Crystals
Glucose
Less than 3.5 ml
High
Colorless to straw
Transparent
Less than 200
Negative
Negative
Nearly = to blood levels
CLASSIFICATION OF SYNOVIAL EFFUSIONS
B. NON - INFLAMATORYVolume
Viscosity
Color
Clarity
Leukocytes
Culture
Crystals
Glucose
Often more than 3.5 ml
High
Straw to yellow
Transparent
200 – 2000
Negative
Negative
Nearly = to blood levels
CLASSIFICATION OF SYNOVIAL EFFUSIONS
C. Inflammatory D-InfectionVolume
Viscosity
Color
Clarity
Leukocytes
Culture
Crystals
Glucose
Often more than 3.5 ml
Low
Yellow to yellow-green
Turbid
2,000-50,000 - >50000
Negative - Positive
Monosodium urate (Gout)Calcium pyrophosphate (pseudogout)
Lower than blood levels
Histology(Diagnostic
value)
• Rheumatoid arthritis (?)• Tuberculosis• Sarcoidosis• Gout• Hemochromatosis• Multicentric
reticulohistiocytosis (RHS)• Pigmented villonodular
synovitis
Arthritis - Misconceptions
• “You’re an Arthritis Doctor. What’s it like taking care of so many old patients”
• “Are all of your patients in wheelchairs?”
• “Arthritis is not a big deal because it’s not life-threatening”
All Arthritis Patients are Old
• Many forms of Arthritis
• Rheumatoid Arthritis commonly affects young women of childbearing age
• Osteoarthritis affects younger people who run, have traumatized their joints, are overweight, etc….
• Gout can affect people of all ages
Wheelchairs and Canes
• Thanks to recent advances and medical research, not as many face life in a wheelchair
• Treatments for many inflammatory arthritic conditions such as Spondylitis and Rheumatoid Arthritis have improved dramatically
• Joint replacement surgery has improved outcomes in Osteoarthritis
Arthritis is not Life-Threatening
• Systemic inflammatory diseases that cause arthritis can affect other organs and lead to life-threatening complications
• Chronic inflammation has now been linked to heart disease
• Advanced Osteoarthritis limits mobility and can lead to secondary health problems (obesity, heart problems, etc…)
• In cases that aren’t life-threatening, living in pain is life impairing.
The Sun is Rising for Patients with Rheumatic Diseases: The Future is Bright
History taking
1.Complaints (duration)
2.History of present symptoms
3.Previous illnesses
4.Social history
5.Family history
The Painter’s FamilyJacob Jordaens (1593-1678)
Evidence of: Rheumatoid Arthritis
The Virgin with Canon vanDer Paele, 1436Jan van Eyck (1385-1440)
Evidence of: Temporal (Giant Cell) Arteritis
Introduction to Rheumatology: Historical Perspective
Importance and Impact of Rheumatologic Disease
Prevalence (per 100,000)
Male FemaleRheumatoid Arthritis 440 1,100Ankylosing Spondylitis 197 73Gout 980 230SLE 7 32Scleroderma 1 5Osteoarthritis 3,470 5,870
All Musculoskeletal conditions 15,510 20,720
CDC: Census Bureau 2004