to Rheumatological Diseases Introduction to Rheumatological Diseases Dr. Fakhir Yousif

Major Symptoms In Joint Disorders Pain Stiffness Joint swelling Functional impairments Systemic manifestations Extr-articular features Peri-articular symptoms

pain There may be : There may be: The pain may occur : Pain (arthralgia). Inflammation (arthritis) - redness, warmth, and swelling There may be: Only a single joint involved (mono-articular). Multiple joints involved. The pain may occur : Only with use, suggesting a mechanical problem (eg, osteoarthritis, tendinitis). At rest, suggesting inflammation (eg,rheumatoid arthritis crystal disease, septic arthritis).

Joint pain may arise from: Structures within the joint (intra-articular): Sources of pain within the joint include the joint capsule, periosteum, ligaments, subchondral bone, and synovium, but not the articular cartilage, which lacks nerve endings

The quantity or severity of rheumatic pain varies widely from patient to patient and from time to time in any one patient. Except under extremely aggravating circumstances, it is general chronology of a rheumatic pain syndrome often helps to suggest a precise diagnosis; however, rheumatic pain in general may begin insidiously or abruptly and persist for only a few days or indefinitely. With definitive diagnosis in mind, the time and nature of onset and subsequent overall disease behavior should be determined.It is less severe than ischemic, neuropathic, or visceral pain .

Stiffness Stiffness is a perceived sensation of tightness when attempting to move joints after a period of inactivity. It typically subsides over time. Its duration may serve to distinguish inflammatory from non-inflammatory forms of joint disease. With inflammatory arthritis, the stiffness is present upon waking and typically lasts 30-60 minutes or longer. With noninflammatory arthritis, stiffness is experienced briefly (eg, 15 min) upon waking in the morning or following periods of inactivity.

Swelling With inflammatory arthritis, joint swelling is related to synovial hypertrophy, synovial effusion, and/or inflammation of periarticular structures. The degree of swelling often varies over time. With noninflammatory arthritis, the formation of osteophytes leads to bony swelling. Patients may report gnarled fingers or knobby knees. Mild degrees of soft tissue swelling do occur and are related to synovial cysts, thickening, or effusions.

Limitation of motion Weakness Loss of joint motion may be due to structural damage, inflammation, or contracture of surrounding soft tissues. Patients may report restrictions on their activities of daily living, such as fastening a bra, cutting toenails, climbing stairs, or combing hair. Weakness Muscle strength is often diminished around an arthritic joint as a result of disuse atrophy. Weakness with pain suggests a musculoskeletal cause (eg, arthritis, tendonitis) rather than a pure myopathic or neurogenic cause. Manifestations include decreased grip strength, difficulty rising from a chair or climbing stairs, and the sensation that a leg is "giving way."

Examination of the joint Redness Hotness Tenderness Limitation of movement Loss of function

Classification of Joint Disorders R.A. / sero-ve spondarthritis / SLE / … etc Inflammatory / autoimmune disorders “Degenerative joint disease” (osteoarthritis) Disc prolapse / meniscus tear …etc Mechanical disorders Septic / T.B. / Brucella / gonococcal … etc Infective Gout & pseudogout Crystal induced Traumatic joint disorders Tendinitis / bursitis / capsulitis / epicondylitis / carpal tunnel … etc Periarthritis Sickle cell disease / acromegaly / Systemic diseases related joint problem others

classification Polyarthritis : more than 4 joints . Oligoarthritis : 2-4 joints . Monoarthritis : one joint . Chronic polyarthritis : more than 2 months . Acute , recent … within 2 or “few” months . “Early” R.A : ? Few months to 2 years . Migratory arthritis : Typical non additive. Additive. 15

monoarthritis Causes : Acute bacterial arthritis (septic , brucella ….). Acute gout. Pseudogout. Monoarticular onset of chronic inflammtory joint disease such as reactive arthritis , rheumatoid arthritis and chronic juvenile arthritis. Traumatic arthritis. Hemophilic joint.

polyarthritis Rheumatoid arthritis and other immune related disorders such as juvenile rheumatoid arthritis , spondylarthropathies , systemic lupus and other connective tissue diseases . Generalized osteoarthritis . Pseudogout . Sarcoidosis .

Migratory Arthritis Rheumatic fever Typical (classical)  pattern ; arthritis does not remain in a single joint more than 7 days . Gonococcal arthritis Viral arthritis SLE Idiopathic juvenile arthritis Poly articular gout Acute reactive arthritis others Migratory element 

CLINICAL FEATURES COMMON TO SEROPOSITIVE ARTHRITIS (RA) Morning stiffness (> 1 hour Arthritis of three or more joint areas Arthritis of hand joints Symmetrical arthritis Rheumatoid nodules Rheumatoid factor seropositive (rheumatoid factor positive ) Radiological changes Duration of 6 weeks or more

CLINICAL FEATURES COMMON TO SERONEGATIVE SPONDARTHRITIS 1-Asymmetrical inflammatory oligoarthritis (lower > upper limb) 2-Sacroiliitis 3- inflammatory spondylitis 4-Inflammatory enthesitis 5-Absence of nodules and other extra-articular features of RA 6-Male predominance in A.S. & in Re A 7-Association with HLA-B27

8-Mucosal surface inflammation-conjunctivitis, buccal ulceration, urethritis, prostatitis, bowel ulceration Pustular skin lesions, nail dystrophy 9-Anterior uveitis 10-Aortic root fibrosis (aortic incompetence, conduction defects) 11-Erythema nodosum

Special Joints Features Red overlying skin : - Acute gout . - Septic arthritis . - Skin infection . - Flare of Heberden’s nodules . 22

Systemic Manifestation Such as fever , weight loss , reduced appetite and general weakness . Mild to moderate severity systemic features can occur in most causes of polyarthritis but not polyarticular O.A. Severe systemic features : Arthritis of infective disorders e.g infective endocarditis . Still’s disease . SLE . Acute reactive arthritis . Bacterial arthritis (about 10-19% polyarthritis) . 23

Extraarticular Manifestation SLE, Still’s disease , others vasculitides , Henoch-schonlein purpura . Skin rash Rheumatoid arthritis , acute rheumatic fever . Subcutaneous nodules SLE, Behcet’s disease , sarcoidosis , streptococcal infection , drugs … Erythema nodosum SLE , discoid lupus . Patchy / cicatricial alopacia SLE , Behcet’s disease , drugs (MTX , Gold …) . Oral / Pharyngeal ulcers . Behcet’s disease Oral + Scrotal &/or penile ulcers Behcet’s , sero –ve spondarthritis Anterior uveitis (Iritis) R.A. Scleritis / Episcleritis R.A. Others Secondary Sjogrens syndrome 24

Internal Organ Manifestation SLE , Drugs and others . Glomerulonephritis SLE , antiphospholipid syndrome , others . CNS involvment R.A. , SLE , systemic sclerosis Inflammatory lung disease Systemic sclerosis Dysphagia SLE , antiphospholipid syndrome , Behcet’s disease . Vascular occlusions SLE , R.A. and others . Pleural and/or pericardial effusions SLE , R.A. Still’s disease ankylosing spondylitis , acute rheumatic fever . Cardiac involvment Seronegative spondarthritis , R.A. and others . Various enthesopathies and periarthropathies SLE , antiphospholipid syndrome Excessive fetal loss 25