1. Rasha Khamis Al-Dabbagh
5th year IUG medical student

2. • 3% of the population
• : ,3:1
• 4th-5th decade
• Smoking

3. • Unknown
• Multifactorial:
– HLA-DR4
– Some antigen -possibly a virus- sets off
a chain of events culminating in a chronic
inflammatory disorder with abnormal
immunological reactions.
– Autoantibodies “Rheumatoid Factor”

4. • All tissues are affected.
• Stages:
 Stage 1 synovitis :
– Synovial membrane inflammation &
thickening, cell-rich effusion, intact
joints & tendons, reversible.
– S&S: swelling, hotness, tenderness (PIP
& wrists >>> elbows, shoulders, knees,
ankles & feet)

5.  Stage 2 destruction :
– Articular cartilage erode & tendons may
rupture.
– S&S: stiffness & LOM esp. in the
morning, tendon ruptures. Subcutaneous
nodules in 25% (olecranon process).

6.  Stage 3 deformity :
– Articular destruction, capsular stretching,
tendon rupture. Progressive instability &
deformity.
– S&S: severe muscle wasting, painful callosities
under metatarsal heads.
– Deformities :
o Ulnar deviation, MCP subluxation or dislocation,
claw feet, atlantoaxial sublaxation
o Swan neck deformity
o Button hole deformity
o Z deformity of the thumb
o Carpal tunnel syndrome

8. • Rheumatoid nodules: in 25%, over
bony prominences, tendons, sclera,
viscera.
• Lymphadenopathy
• Vasculitis
• Muscle weakness
• Visceral disease (lungs, heart,
kidneys, brain & GIT)

10. Stage 1:
– Soft tissue swelling, periarticular
osoteoporosis.
Stage 2:
– Joint space narrowing, marginal bony
erosions (esp. wrists & PIP).
Stage 3:
– Articular destruction, joint deformity.

12. • ESR & CRP in active phase.
• RF in 80%, used in assessing
prognosis.
• ANA in 30-40%.

13. • Minimal criteria:
– Bilateral symmetrical polyarthritis.
– Involving proximal joints of hands or
feet.
– At least 6 weeks.
• Subcutaneous nodules, periarticular
erosins on x-ray confirm the
diagnosis.

14. • Seronegative polyarthritis
• Ankylosing spondylitis
• Reiter‟s disease
• Polyarticular gout
• Polyarticular osteoarthritis
• Polymyalgia rheumatica

15. • 80 % Classical „periodic‟ course:
relapsing & remitting.
• 5% Rapidly progressive: with visceral
involvement.
• 10% -in men over 55yrs- explosive onset
after which it tends to subside & follow
a mild course.
• In few patients only 1-2 attacks then
disappears.

16. • Infection (septic arthritis)
• Tendon rupture esp. wrist
• Joint line rupture
• Secondary osteoarthritis

17. • Rest
• Exercise
• Splintage & orthotic devices
• Rehabilitation
• Physiotherapy

18. • NSAIDS
• Low-dose corticosteroids
• DMARD e.g gold & pencillinamine
• Surgical:
– Operative Tx e.g. synovectomy, tendon
repair or joint stabilization
– Reconstructive surgery
– Arthrodesis, osteotomy, arthroplasty

20. • Chronic inflammatory disease
• 0.2% in Western Europe
• >
• 15-25 years

21. • Multifactorial:
– HLA-B27
– Trigger e.g. GU or GI infection

22. • Three characteristic lesions:
1. Synovitis of synovial joints.
2. Inflammation of fibro-osseous
junctions of fibrous joints, tendons &
ligaments (enthesopathy).
3. Ossification across the peripheries of
intervertebral discs.

23. • Fairly constant sequence:
Inflammation > granulation tissue >
cartilage or bone erosion >
replacement by fibrous tissue >
fibrous tissue ossification > ankylosis

24. • Mainly in spine & sacroiliac joints, sometimes
hips & shoulders, rarely peripheral joints.
• Persistent backache & stiffness worse in
morning or after inactivity.
• LOM of spine, extension being earliest &
most severe.
• In > 10% onset in a peripheral joint.
• Atypical onset is more common in .

25. Fingertips-to-floor Chest expansion
Wall test distance

26. • 6 A‟s:
– Anterior uveitis
– Atlanto-axial sublaxation
– Apical lung fibrosis
– Aortitis, aortic regurge & AV block
– Amyloidosis
– Achilles tendonitis

27. • Fuzziness or frank erosion of
sacroiliac joints, later sclerosis,
eventually ankylosis.
• Intervertebral discs ossification
causes bony bridges „syndesmophytes‟,
if several levels are involved bamboo
spine .

29. • ESR in active phase
• HLA-B27 in 90%

30. • Other sero-ve spondylarthropathies
• Ankylosing hyperostosis „Forestier‟s
disease‟:
– Mild or nonexistent S&S.
– Incidental x-rays show widespread ossification
of ligaments & tendon insertions.
• Mechanical back pain:
– in young adults
– Muscle strains, facet joint dysfunction,
discogenic disorders.

31. • Medical:
– Exercise
– Postural training to prevent deformity
– Analgesics & NSAIDs
• Surgical:
– Joint replacement for hip stiffness
– Vertebral osteotomy for severe flexion
deformity

33. • Common features:
1. Characteristic spondylitis & sacroiliitis.
2. HLA-B27 association.
3. Familial aggregation.
4. Familial overlap with members having one
disorder & relatives having another.
• Includes:
– Ankylosing spondylitis
– Psoriatic arthritis
– Reiter‟s disease
– IBD associated arthritis

34. • Psoriatic arthritis ≠ RA + Psoriasis
• : equal
• HLA-B27 in 60%
• S&S:
– Mainly in IP joints of fingers & toes.
– Not as symmetrical as in RA.
– Arthritis mutilans in severe cases.
– ¼ develop AS-like sacroiliac & vertebral
changes.

35. • Treatment:
– Judicious splintage to prevent deformity.
– Topical skin preparations.
– NSAIDs.
– Surgery for unstable joints.

36. • Triad: polyarthritis, conjunctivitis &
non-specific urethritis.
•Synoivitis is due to abnormal
immune response to infection
or its products elsewhere
urogenital or bowel
infection
 Lymphogranuloma venereum
& Chlamydia trachomatis in
GUT.
 Shigella, Salmonella &
Yersinia enterocolitica in GIT.

37. • Hx of GU infection or diarrhea.
• Mainly large joints, knee & ankle.
• Tenosynovitis & plantar fasciitis are common
• Sacroiliitis & spondylitis causing backache &
stiffness occur at some stage.
• „Self-limiting‟ but 80% have symptoms for many
years.
• Ocular lesions: conjunctivitis,
episcleritis & uveitis.

38. • Normal at first
• Erosive arthritis after many months.
• AS-like sacroiliac & vertebral
changes.

39. • HLA-B27 in 75% .
• ESR in active phase.
• Urethral fluids, faeces or Ab test
may indicate the organism.

40. • Directed at the GU or GI infection
“Antibiotics”.
• Chlamydia: daily tetracycline for 6
months.
• Local:
– Rest & splintage in severe arthritis.
– Anti-inflammatory agents.

42. • Noninfective inflammatory joint
disease > 3 months in children < 16
years.
• : equal.
• 1 per 1000 children.
• Multifactorial: Genetic
predisposition + abnormal
immune response to some antigen.
• RF is -ve

43. 1. Systemic JCA:
– Age < 3 years.
– Onset: intermittent fever, rashes &
malaise.
– May be lymphadenopathy,
hepatosplenomegaly.
– Joint swelling after weeks-months.

44. 2. Pauciarticular JCA:
– Commonest form.
– Age < 6 years, girls.
– Few joints, no systemic illness.
– Pain & swelling in medium-sized joints.
– Chronic iridocyclitis in 50%.

45. 3. Polyarticular sero+ve JCA:
– Older girls.
– Resembles RA juvenile RA .
– RF is +ve.
4. Sero-ve spondarthritis:
– Older boys.
– Sacroiliitis & spondyliitis.
– May be hips & knees.
– HLA-B27 often +ve juvenile AS .

47. • Stiffness , sometimes permanent.
• Growth defects & retardation.
• Iridocyclitis , may lead to blindness.
• Amyloidosis, can be fatal.

48. • General: similar to RA
• Local: prevent stiffness & deformity
– Night splints.
– Prone lying for some period daily to prevent
flexion contracture of hips.
– Active exercises.
• Surgical: for painful eroded joints
– Custom-designed arthroplasty of hip & knee.
– Arthrodesis of wrist & ankle.

49. • Most recover with moderate LOM.
• 5-10% severely crippled esp. JRA.
• 3% mortality :
– Overwhelming infection,
– Renal failure due to amyloidosis.

51. • Auto-immune disorders.
• Like RA triggered by viral infection in
genetically predisposed individuals.
• SLE:
– Progressive joint deformity is unusual.
– A curious complication is avascular
necrosis usually in femoral head.

52. • A descriptive term for a condition in
which patients complain of pain &
tenderness in muscles & other soft
tissues around the back of the neck &
shoulders, lower back & upper buttocks.
• No pathology in affected tissues.
• Depression & anxiety.

53. • Criteria:
– Widespread pain in all four body
quadrants.
– At least 9 pairs of tender points in
physical examination.

54. • Cause:
– unknown
– Suggested theories:
• Abnormality of ”sensory processing” i.e. ”low pain
threshold”.
• Activation of stress responses by sudden
accidents or traumatic life events.
• Tx:
– Physiotherapy & daily exercise.
– Injections into painful areas.
– Psychotherapy.