關(guān)節(jié)炎(英文)

1、“Things may come to those who wait, but only the things left by those who hustle.” Abraham LincolnDr. Venkatesh M. Shashidhar.Associate Professor of PathologyFiji School of MedicineJoints: Mobility - Cranial sutures Shoulder joint. Articular cartilage hyaline friction res. Synovial fluid lubric/nutr

2、i, Type A & B synoviocytes. Hyaluronidase Continuous production and absorption. Affected by Inflammation, immobility. Capsule, ligaments, menisci. Vascular, rich nerve supply Art. Cartilage*Joints - AnatomyArthritis - IntroductionInflammation of joints - CommonCommon site for autoimmune injury H

3、eart valves & Joints - damage Exposure of hidden antigens.Infections.Degeneration Age/Stress/life styleUse it or Loose it.!Arthritis Clinical features:Pain Inflammation - capsule, synovium, periosteum.Swelling: inflammation, effusion, proliferation.Restricted movement pain, fluid, synovial swell

4、ing, damage.Deformity mal-alignment, erosion, ankylosisArthritis Clinical Classification:Monoarthritis: Local, asymmetric, secondary. Acute: Bacterial, Trauma, Crystal, Reactive Chronic :Tuberculosis, Lyme, Fungal, Trauma, Tumors.Polyarthritis: Chronic, symmetric, systemic. Autoimmune, degenerative,

5、 Crystal. Rarely infective.Polyarthritis Classification:Autoimmune: Rheumatic, Rheumatoid, Ankylosing spondylitis, Reiter syndrome etc. Degenerative: Osteroarthritis Crystal Deposition: Gout Monosodium urate CPPD - Pseudo GoutInfective - Septic, TB, Lyme etc. rare.Rheumatoid ArthritisEpidemiology of

6、 RAPrevalence about 1% of US populationFemale : Male ratio = 2:1Strong association with HLA DR4.Concordance in identical twins only 30%RA - Definition:Chronic Multisystem autoimmune inflammatory disorder primarily affecting joints producing a proliferative synovitis that often progresses to destruct

7、ion of the articular cartilage and ankylosis.Etiology:Genetic Susceptibility: HLA DR4, or DR1 in 65% to 80% cases.Microbial inciting agent: Epstein-Barr virus, Borrelia & MycoplasmaAutoimmunity: IGM anti IgG RA Factor. Helper T cell (CD4) against type II collagen & cartilage glycoprotein-39I

8、mmuno-dysregulation in RAT lymphocytes type II collagen & superantigen releasing cytokines inflammation.B cells IgM Rheumatoid factor anti IgG.Macrophages surround RF factor complex type III injury (immune complex) cytokine release inflammation damage.Morphology: Proliferative synovitis with lym

9、phocytes (CD4), plasma cell & macrophages Pannus. Organizing fibrin (rice bodies). Neutrophils on the joint surface and fluid. Juxta-articular erosions, cysts & osteoporosis Fibrous ankylosis. Skin - Rheumatoid nodules Vasculitis (commonly of digital arteries)Early Destruction in RA:Swan Nec

10、kDeformityRA - Clinical Features:Morning stiffness.Arthritis in 3 or more joint areas.Arthritis of small hand joints.Symmetric arthritis.Rheumatoid nodules.Serum rheumatoid factor.Typical radiographic changesAt least 4 features for diagnosis.N.Synovium - - R.Arthritis:RA - Pannus:Extra-Articular RAR

11、heumatoid NodulesVasculitisPleuritisPericarditisTendonitisSkin RA Nodule:Skin RA Nodule:Rheumatoid Nodule (skin):Joint involvement in RA:Swan Neck Deformity in RA:Joint Destruction in RA:Swan NeckDeformityRA Joint destruction, ankylosis:OsteoarthritisDegenerative arthrosis.(Osteoarthrosis)Osteoarthr

12、itis: Degenerative end result - (ageing) 80% in 65y. Progressive erosion & fibrillation of articular cartilage forms Loose bodies. Large weight bearing joints. Hardened articular bone eburnation. & Subarticular cyst formation in bone. Periarticular osteophyte formation. Mild inflammation but

13、 painful, morning stiffness. Limited range of movements Heberden nodes (F)Normal - Femur Head - OANormalOsteoarthritisFemur Osteroarthritis:Joint Mice or Loose Bodies:Spine Osteophytes (OA):Radiologic Features:nonuniform joint space loss, osteophyte formation, cyst formation subchondral sclerosisScl

14、erosis, ankylosis & deformity.Osteoarthritis: Narrow joint space Lipping osteophyte Dislocation Osteoporosis.Osteophyte formation:Bone cysts in OA:Osteoarthritis: Ankylosis varus deformity of the knee and collapse of the joint space with destruction of the medial cartilage and the subchondral co

15、rtex (open arrowheads). Osteoarthritis: Lateral view of the left knee shows sclerosis with marked osteophyte formation (arrows). The osteophytes are best seen in this view. Osteoarthritis: Subchondral cysts (solid arrowhead) OA Fingers:OA Hip:OA Hip: 1997, bilateral, joint space narrowing (arrows) a

16、t the hips that is worse on the left side OA Hip: Subchondral sclerosis (solid arrowhead) and cyst (arrow) formation are also noted on the left side OA Hip:left hip arthroplasty OA - Clinical Features:pain worsens with activity & improves on rest.Instability of joints Knee.Crepitus, limitation o

17、f motion. Muscle spasm, and tendon and capsular contractures.Early morning stiffness lasts 1 hour or more.bony overgrowth interphalangeal joints distal(Heberdens) proximal (Bouchards).Differentiating Features: Young, small joints Autoimmune. Synovial Inflammation synovium Cartilage Old, Large joints

18、 Degenerative. Cartilage degeneration. Cartilage SynoviumArthritis Other Infective, traumatic, secondary to systemic diseases. Seronegative arthropathies Ankylosing Spondylitis: Adolescent boys, HLA B27, axial joints (sacroiliac) Reiter Syndrome: Triad of arthritis, urethritis/cervicits & conjuc

19、tivitis Autoimmune but initiated by bacterial infection. Enteropathic Arthritis: Secondary to bowel infections (salmonella, shigella) HLA B27 positive Psoriatic Arthritis: 5% of patients, starts in DIP joints, similar to RA.Septic Arthritis:ORGANISM PEAK AGE INCIDENCE GRAM STAIN Hemophilus influenza

20、e Children Gram negative coccobacilli Neisseria gonorrheae Young adults Gram negative diplococci Salmonella young with Sickle Cell An. Gram negative rods Staph. aureus Adults Gram positive cocci in clusters Escherichia coli Adults Gram negative rods Pseudomonas Adults Gram negative rods Gonococcal A

21、rthritis:Juvenile Rheumatoid Arthritis:Before age 16Multisystem involement - Spleenomegaly,Starts with systemic involvement unlike RA.No serum RA Factor SeronegativeAntinuclear Antibody (ANA) +ve autoimmune.Big Toe in Gout:Joint Destruction in Gout:Gout Tophi:Urate Crystals (Gout):eCPPD (Chondrocalc

22、inosis) Type A Pseudo gout Knee, men Type B Pseudo rheumatoid - polyarthritis Type C Pseudo OA + acute attacks, women Type D Pseudo OA - acute attacks, hands Type E Asymptomatic Type F PseudoneuropathicCPPD-Arthritis (pseudo gout):Pseudo Gout Calcium pyrophoshateAnkylosing SpondylitisMarie-Strumpell ArthritisYoung males, 90% HLA B27 +25% have i