Lady With Joint Stiffness

Thursday, January 28, 2010
This is X-ray of  hands of a 53 years old woman who has been having joint stiffness which was lasting for about 1 hour particularly in the morning since she was 25 years.What are the Abnormalities that you can see in this Xray and What is the Diagnosis?
How would you treat this patient?



ANSWER -  Rheumatoid arthritis
Rheumatoid arthritis is a chronic systemic disease that primarily affects the joints.It affects appoxiate 1% of the adult population worldwide.Rheumatoid arthritis is more common in women than men.The onset of the disease is usually between the ages of 40 and 70.Rheumatoid arthritis is the 2nd most common form of chronic arthritis.It is characterised by inflammatory changes in the synovial membranes and articular structures leading to deformity and ankylosis.

The aetiology of rheumatoid arthritis is multifactorial.
Genetic factors - 12-15% in monozygotic twins,4% in dizygotic twins,presence of HLA DR4 alleles is a poor prognostic factor



Pathogenesis
Rheumatoid arthritis (RA) is an autoimmune disease
Plasma cells in the subsynovial layer of joints secrete immunoglobulins (mainly IgG and IgM)
They activate the complement cascade
Complements stimulate leucocyte proliferation and activation
Infiltration of the synovium with T cells and secrete tumour necrosis factor alpha,interleukin 1
Cytokines may stimulate pannus formation  with destruction of periarticular soft tissues, articular cartilage and bone and new blood vessel formation.
(pannus - prolferation of granulation tissue containing containing numerous lymphocytes and plasma cells)

Clinical Features
Insidious onset
Constitutional symptoms - malaise, fatigue, non-localised musculoskeletal pain,low grade fever

Articular manifestations

  • Joint involvement - monarticular,oligoarticular or  polyarticular and usually symmetrical
  • Joints involved are Metacarpophalangeal joints,proximal interphalangeal joints ,wrists, elbows, shoulders, knees, ankles and feet
  • RA is almost always spares the Distal Interphalangeal Joints
  • Local swelling, redness and pain
  • Stiffness following inactivity
  • Characteristic deformities In the hands, ulnar deviation of the fingers due to subluxation at the metacarpophalangeal joints, 'swan neck deformity', 'boutonniere' or Z deformity of the thumb
  • Cervical spine is affected in 30% of the patients with RA.
  • ligamentous erosion leads to joint laxity and subluxation of atlanto-axial joint
  • Synovial cysts -eg; Baker cyst

Extra-articular manifestations

  • Systemic manifestations
Rheumatoid nodules
Pyoderma gangrenosum
Osteoporosis
Peripheral entrapment neuropathies
   Carpal tunnel syndrome
   Cubital tunnel syndrome
Myositis
Amyloidosis, particularly of the kidneys
 

  • Respiratory manifestations
 Pleurisy 
 Pleural effusion 
 Pulmonary fibrosis 
 Caplan's syndrome
 Obliterative bronchiolitis
 Haematological manifestations
 Anaemia of chronic disease

  • Lymphoreticular manifestations
Lymphadenopathy - soft, non-tender
Splenomegaly
Felty's syndrome

  • Ocular manifestations
Keratoconjunctivitis sicca
Episcleritis
Scleritis and scleromalacia perforans
Iritis
Sjogren's Syndrome

  • Cardiac manifestations
 Pericarditis
 Pericardial effusion
 Myocarditis
 Valvular heart disease
 Conduction defects

Investigations

  • Raised ESR and CRP
  • (+ve)rheumatoid factor in 80% Other blood tests: FBC (anaemia), low albumin level, hypergammaglobulinaemia, increased fibrinogen level, circulating complement level is usually normal
  • joint aspiration
  • X-ray findings
        Soft tissue swelling and osteoporosis
        Narrowing of the 'joint space' and marginal bony erosions
        Deformity

Management

Pharmacological
Disease-modifying anti-rheumatic drug (DMARD) -include sulfasalazine, methotrexate, intramuscular gold (sodium aurothiomalate), oral gold (auranofin), penicillamine, and hydroxychloroquine
Analgesics, NSAIDS and steroids

Physiotherapy

Surgical management
Tendon repair or tendon transfer
Arthrodesis
Osteotomy,
Joint replacement
Excision arthroplasty

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9 comments

  1. Anonymous Says:
  2. Reumatoid Arthritis

     
  3. Anonymous Says:
  4. I guess rhematoid arthritis and treatment would be
    any DMARD( NSAIDS should be used as a bridge to DMARD as it takes longer to start action)

     
  5. Anonymous Says:
  6. Rheumatoid arthritis,it's the wright diagnosis.
    Treatment: in the early stages DMARDS improves symptoms,then steroids ar good for reducing the inflammation,and are good for treating acute exacerbations of disease.NSAID are good to control symptoms.

     
  7. Anonymous Says:
  8. probably rheumatoid arthritis and disease would probably call for DMARD...

     
  9. Anonymous Says:
  10. -ulnar phalangeal deviation
    -periarticular osteoporosis
    -ankylosis of the proximo-medial interphalangeal articulation (manus dx., dg. II)
    -subluxation of the proximo-medial interphalangeal articulation (manus dx., dg. III)
    -diffuse inflammatory changes of the metacarpo-phalangeal articulations (both hands)

    diagnosis- arthritis rheumtica

     
  11. Anonymous Says:
  12. *-ankylosis of the proximo-medial interphalangeal articulation (manus dx., dg. IV)

     
  13. Anonymous Says:
  14. Rheumatoid Arthritis
    The X-ray, shows ulnar deviation with frank deformities and subluxation of both hands.

    Rx: Analgesics, Drug modifying Anti Rheumatoid Drugs, and a cast.

     
  15. Anonymous Says:
  16. artrita reumatoida

     
  17. Anonymous Says:
  18. i think late onset RA and dmard therapy should be enough if not anti TNF agnents can be used
    and a splint for hands

     

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