a comprehensive set on all Seropositive arthritides/ arthropathies mainly discussing the features of Rheumatoid arthritis.

1. SEROPOSITIVE
ARTHRITIS

2. INTRODUCTION
 SEROPOSITIVE ?
• RA FACTOR
• Anti-CCP antibodies
 RF assosciations
Rheumatology: Rheumatoid Arthritis; SLE; Sjogren’s; MCTD; Myositis;
Cryoglobulinemia;
Others: SABE; syphilis; Sarcoidosis; cirrhosis; Walden storm's macroglobulinemia;
etc ….
 RA factor is seen in 5-10% of normal population as well

4. Rheumatoid Arthritis
 Chronic systemic inflammatory disease
 Affects many organs
 Predominantly attacks the synovial tissues and joints.
 Peak 20-55yrs
 M:F = 1:3
 Clinincally Low-grade fever, fatigue, weight loss, muscle soreness, and
atrophy
Symmetric peripheral joint pain and swelling, particularly of the hands
 Typically involves small joints : metatarsophalangeal and
 metacarpo-phalangeal and carpal joints (very often SYMMETRICAL
involvement)
Axial skeleton involvement n advanced stages

5. CLINICAL DIAGNOSTIC CRITERIA
 American College of Rheumatology revised criteria require that 4 out of 7 of the
following are present 4:
1. morning stiffness lasting at least 1 hour before maximal improvement
2. soft tissue swelling of 3 or more joints observed by a physician
3. swelling of the proximal interphalangeal, metacarpophalangeal, or wrist
joints
4. symmetric swelling
5. rheumatoid nodules
6. the presence of rheumatoid factor; and
7. radiographic erosions and/or periarticular osteopenia in hand and/or
wrist joints.

6. RADIOLOGICAL FINDINGS
 X-RAYS
1. Soft-tissue changes
2. Osteoporosis
3. Joint space changes and alignment deformities
4. Periostitis
5. Erosions
6. Secondary osteoarthritis

7. SOFT TISSUE CHANGES
 More clinical exam than radiological finding
 Swelling due to
1. oedema of peri- articular tissues
2. synovial inflammation in bursae, joint spaces and along tendon
sheaths.
3. Joint distension increased synovial fluid.
 Hands: most commonly seen fusiform swelling
metacarpophalangeal joints
ulnar styloid (invl of ext carpi ulnaris tendon)
radial styloid (invl of radiocarpal synocial hypertrophy)
 Foot
 Similar fusiform swelling can be found in the 1st and
 5th metatarsal heads

9. At the Achilles tendon insertion
When synovitis thickens the bursa ,
oedema obliterates the local fat and
blurs out margins of the tendon
Note : the swelling is symmetric but if a
rheumatoid nodule Is present at the
swelling it may appear eccentric
(as in olecranon)

10. OSTEOPOROSIS
 Assessment of osteoporosis depends in part on film quality, and
comparison between normal and abnormal joints in the same
patient.
 Interpretation is subjective and changes arc seen only after loss of
25-50% of mineral density
 Types
1. Late/Generalised ( steroid and limitation of movement)
2. Early/ Localized (synovial inflammation and hyperaemia)
 In menopausal women , generalized osteoporosis masks the
osteoporotic changes due to RA
 Generalised or solitary sclerosis one or more distal phalanges is an
impoirtan finding

11.  Terminal phalangeal sclerosis
New bone with no ,medullary cavity .
IVORY PHALANX

12. JOINT SPACE CHANGES
 EARLY WIDENING due to synovial hypertrophy and Effusion
 LATER NARROWING of joint space due to cartilage destruction
by pannus
 Allignment abnormalities at joint due to weakening of capsule
and tendinitis
Leads to tendon rupture or improper muscle action
The boutonniere deformity results from proximal interphalangeal
joint flexion and distal intcrphalangeal joint extension
swan-neck deformity proximal interphalangeal joint extension
and distal interphalangeal joint flexion.
The boutonniere deformity is the more common.
Z-deformity radial deviation at the wrist;
ulnar deviation of the digits, and often palmar subluxation of the
proximal phalanges

13. JOINT SPACE CHANGES
 Swan neck deformity

14.  Synovitis of the metacarpophalangeal joint.
 Longitudinal high-resolution (10.5-MHz) sonogram shows thickened
synovial tissue (arrows).

15.  Coronal contrast- enhanced fat-
saturated T1-weighted MR image shows
hyperenhancement of small joints in
the hand (arrows), a finding that
reflects hyperemic synovial tissue.
Erosions (arrowheads) and thickened,
intensely enhancing synovium are seen
at the fifth metacarpophalangeal joint

17. EROSIONS
 Most important diagnostic feature
 Incidence rises with duration progresses (<40% at
3months to 90-95% at 10years )
 Peri-articular erosion starts in the bare area
 In Hand
1. Carpal erosions occur extensively.
2. Ulnar and radial styloid
3. Proximal compartment of distal radioulnar joint.
4. Fusion is inevitable especially in CARPAL joints
 In Foot
1. Earlier seen in feet most often 5th metacarpo-
phalangeal joint.
2. Apart from posterior and inferior surfaces of
3. CALCANEUM tarsal erosion are uncommon
4. (Tarsal erosion is seen commonly in sero-negative)

18.  Local Demeneralisation  progressive resorption
of Sub-cortical Bone  Pannus sread 
Destruction of articular cartilage
 Once destroyed the articular cartilage rarely
reforns on helaing
 Erosive changes are less common in larger joints
but bone destruction Is more
 intraosseous defects-cysts (Geodes) are seen 3 –
4 cm or more in diameter.
 I

19.  A. Diagram. Three sites for potential erosions to occur are shown.
 B. Erosions. Note the erosion from the extensor carpi ulnaris (rat bite
lesion) (arrow) and prestyloid recess (arrowhead). Note the adjacent
erosion on the triquetral bone (crossed arrow).
 C. Erosions. Note the three sites of ulnar erosion: extensor carpi
ulnaris (arrow), prestyloid recess (arrowhead), and radioulnar
articulation (crossed arrow). Observe the adjacent soft tissue swelling

20.  RHEUMATOID ARTHRITIS: FEET
 A. Diagram, Marginal Erosions. Target sites for marginal erosions lie
on the medial surfaces of the metatarsal heads, except for the fifth
metatarsal where early erosions can occur on the lateral side.
 B. PA Foot. Typical radiographic depiction of the locational
predominance on the medial metatarsal surfaces, except at the fifth.
Note the phalangeal fibular deviation. (Lanois deformity)

22.  Coronal contrast-enhanced fat-
saturated T1-weighted MR image
shows synovitis of the second and
third metacarpophalangeal joints. A
subcortical cyst (arrowhead) is seen
near the bare area
 This type of lesion is called a pre-
erosion or subcortical erosion

23.  MR image shows a small effusion of
the third metacarpophalangeal
joint

24. PERIOSTEITIS
Local periosteal reactions occur either along the
midshaft of a phalanx or metacarpal as a reaction to
local tendinitis, at the metaphysis near a joint
affected by synovitis.
Such changes are less common in rheumatoid arthritis
than in the seronegative arthropathies

25. SECONDARY OA CHANGES
 Seen in Weight bearing joints
 Its seen at Hip joints commonly.
 Superimposes the undetected RA
 ASYMMETRY IS KEY IN DIAGNOSIS
 Reactive sclerosis and new bone formation in
osteoarthritis is not marked

26. INVOLVEMENT OF AXIAL SKELETON
 C1 /C2 JOINT
 Osteoporosis with disc narrowing
 Endplate irregularity.
 Little new bone formation
 Erosions of facet joints result in Subluxation
 Commonly seen in the synovial joint between the odontoid
peg and arch of atlas
potentiated by laxity of ligaments around the peg.
 Separation in flexion of more than 2.5 mm in adults or 5
mm in children is held to be abnormal.
 30% of patients with chronic rheumatoid arthritis and is
best seen in flexion.
 The eroded odontoid may also fracture
 Resorption of hone at non-articular surfaces occurs in the
cervical spine at the spinous processes, which become
short, sharp and tapered in patients with chronic disease

28.  the translocation of
odontoid into and beyond
the foramen magnum
(arrows) owing to erosion
and destruction of the upper
two cervical vertebrae

29. SACRO-ILIAC JOINT
 Sacro iliac Joint
 Changes are less common and less severe
than Spinal changes
 More common in seronegative disease but
may he seen in up to 30% of those with
longstanding disease.
 Seen more in women
 Usually unilateral and involving the lower
two thirds of the joint; erosions present
but no sclerosis; rarely, ankylosis.

30. Shoulder joint changes
 Uniform loss of glenohumeral
joint space, marginal
erosions (particularly at the
superior lateral portion of
the humerus), humerus often
subluxated superiorly,
tapered distal clavicle,
seemingly widened
acromioclavicular joint
space.

33. Hip joint changes
 RHEUMATOID ARTHRITIS: PROTRUSIO
ACETABULI.
 A. AP Hip Unilateral. Observe the
symmetric loss of joint space and
axial migration of the femoral head,
creating a protrusio acetabuli
(arrow).
 B. AP Pelvis Bilateral. Note the
uniform loss of joint space, small
femoral heads, and protrusio
acetabuli, characteristic of long-
standing rheumatoid arthritis.
 Note: The most common cause for
bilateral protrusio acetabuli in the
adult is rheumatoid arthritis

34. Knee joint changes
A. Uniform Loss of Joint Space. Despite the loss of joint space, the distinct
absence of subchondral sclerosis and diffuse osteopenia.
B. Suprapatellar Effusion. Observe the bulging soft tissue density owing to
effusion (arrows). A patellar erosion can also be appreciated.
C. Baker’s Cyst. Note that on arthrography the extent of the cyst is defined
extending into the popliteal space (arrows). Observe the rupture and dissection of
the rheumatoid cyst into the posterior calf.

36. BONE SCAN
Whole-body radioisotope scan showing areas of
increase in uptake in the neck, both shoulder
joints, the elbow joints, the left hip, both
knees and ankles
The distribution of disease is shown, but the
changes on this scan are not specific.

37. NON-RHEUMATOLOGIC FEATURES
 cardiovascular disease
1. accelerated coronary artery and cerebrovascular atherosclerosis which
contribute significantly to the excess mortality of RA
2. pericarditis
3. vasculitis : occurs more commonly with severe erosive disease, rheumatoid
nodules, high RF titres.
 cutaneous involvement
• rheumatoid nodules are usually seen in pressure areas : elbows, occiput,
lumbosacral3. They generally occur in RF positive patients 9.
 ocular involvement
1. keratoconjunctivitis sicca
2. uveitis
3. Episcleritis
 Respiratory system: parenchymal or pleural diseases ;
manifests as pleural thickening or Effusion, ground glass opacities
Bronchiolitis , bronchienctasis (advanced stages), nodules – cavitation is seen
commonly.

39. CAPLAN’S SYNDROME
 Caplan syndrome (also known as rheumatoid
pneumoconiosis) is the combination of seropositive
rheumatoid arthritis and a characteristic pattern
of fibrosis.
 5 - 50 mm well-defined nodules in the upper lung
lobes / lung periphery.
 nodules may remain unchanged, multiply, calcify,
or become thick walled cavities.
 background changes of pneumoconiosis
 may have an accompanying pleural effusion

41. SLE
 chronic, inflammatory, connective tissue
disorder of unknown cause
 Common in young females
 Classical Butterfly Rash over face.
 SLE, like many autoimmune diseases, affects
females more frequently than males, at a rate
of almost 9 to 1.
 RA factor , ANA
 Unlike rheumatoid arthritis, lupus arthritis is
less disabling <10% lupus arthritis will develop
deformities of the hands and feet
 present with a symmetrical peripheral
arthropathy
 Soft tissues swelling with calcification around
joints and in blood vessels
 Erosion is minimal and usually does not cause
severe destruction of the joints.

42. SLE
 Most deformities as in swan neck , ulnar
deviation are reversible and arise due to tendon
or ligament laxity
 Avascular necrosis is common
 In lateral radiograph
1. Mal-alignments, most commonly at the
metacarpo-phalangeal and proximal
inter-phalangeal joints of the fingers and the
carpometacarpal,
1. metacarpophalangeal and the interphalangeal
joints of the thumb
Note : in an AP view most of the time these will be
less apparent ….?

44. Dermatomyositis
 Calcinosis Interstitialis Universalis
 Degeneration of collagen tissue
 diffuse subcutaneous plaques or nodules of calcium or
reticular calcification often with overlying ulceration.
 In addition with progression, calcified masses or sheets
of calcium and phosphate metabolism.
Seen in quadriceps, deltoid , calf muscles , elbows, kness,
hands, abdominal wall, chest wall
 Pointing and resorption of terminal tufts
 Bone erosions are not a feature of these diseases.
 Progressive disease is invariably fatal
 High incidence of malignancy is seen

46. POLYMYOSITIS
 Polymyositis (PM) refers a rare autoimmune (at
times considered paraneoplastic) inflammatory
myositis. It is considered a form of idiopathic
inflammatory myopathy.
 The condition is closely related to
dermatomyositis and the term “polymyositis” is
applied when the condition spares the skin.

47. Progressive systemic sclerosis
(SCLERODERMA)
 CREST SYNDROME (
Calcinosis
Raynauds phenomenon : episodes of intermittent pallor of the fingers and toes
on exposure to cold, secondary to vasoconstriction of the small blood vessels)
Esophageal abnormalities: dilatation and hypoperistalsis
Sclerodactyly
Telengiectasia
 30% to 40% of patients have a positive serologic test for rheumatoid factor
and a positive antinuclear antibody (ANA) test.

48. Progressive systemic sclerosis
 Bone changes
1. acro-osteolysis (resorption of the distal phalanges)
2. periarticular osteoporosis
3. joint space narrowing
4. erosions
 Soft tissue changes
1. subcutaneous and periarticular calcification
2. atrophy especially at tips of fingers
3. With retraction of skin
4. flexion contractures
 Other less common documented musculoskeletal
findings
1. rib resorption, mandibular angle resorption, radius and
ulna resorption
2. terminal phalangeal sclerosis

49.  Corroborative findings are seen in the
gastrointestinal tract, where dilatation of
the esophagus and small bowel
 Pseudo diverticula of colon is also seen
 In lungs
Either UIP or NSIP pattern
Most predominant feature will be fibrosis
 early stages may show ground glass
changes
 later stages may show honeycombing and
evidence of lung volume loss
 lung bases and sub-pleural regions
typically involved 4
 cysts may be present measuring 1-5cm in
diameter 4
 pleural effusions are usually not a
feature
 ESOPHAGEAL DILATATION IS
PATHOGNONOMIC

50. MCTD
 MIXED CONNECTIVE TISSUE DISEASE
 Overlap syndrome ( mix of Rheumatoid arthritis,
dermatomyositis, SLE, Progressive systemic sclerosis)
 The distribution may mimic rheumatoid arthritis, but
distal interphalangeal joints may be affected and the
peripheral arthropathy may be asymmetrical.
 Osteoporosis (JUXTA ARTICULAR)
 Soft tissue swelling and Joint space narrowing.
 Erosive changes are not frequent as in RA
 Distal phalanges show soft tissue loss, distal tuft bone
resorption and calcification is feature of Progressive
systgemic sclerosis

51. Sjogren’s syndrome
 Chronic Autoimmune disease
 Primarily affect Salivary and lacrimal glands resulting in XEROSTOMIA and
keratoconjuctivtis sicca
 Secondary Sjogren’s seen most commonly in people with diagnosed with RA
 And SLE
As a single entity sjogren’s doesn’t involve the joints.
But definitely aggravates the primary Rheumatologic Arthropathy therby
increasing the Morbidity and Mortality

52. SPOTTERS

53. THANK YOU

56. Jaccoud’s arthropathy
 This condition is characterized by subluxation of
metacarpophalangeal joints, “swan-neck” and Boutonniere
deformities, besides “Z” deformity of thumb
 CAN also occur in shoulder, knee and joints of feet.

58. Hidebound bowel sign
 The hidebound bowel sign refers to an appearance on a barium study of the
small bowel in patients with scleroderma. The sign describes the narrow
separation between the valvulae conniventes which are of normal thickness
despite dilatation of the bowel lumen.
 Although the term hidebound is used specifically to describe scleroderma, the
same appearance can be present in sprue. Stack of coins is an alternate
descriptive term that can be used for both conditions.

62. case of persistent monoarticular
arthritis
 Because of the chronic use of corticoids in such patients, the signs and
symptoms of infection are frequently masked and the process generally
presents a chronic and indolent course.
 In, the absence of a clinical response to the therapy with corticoids or other
immunosuppressive drugs should raise the suspicion of an underlying
infectious process.