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1、“Things may come to those who wait, but only the things left by those who hustle.” Abraham Lincoln,Pathology of Arthritis,Dr. Venkatesh M. Shashidhar. Associate Professor of Pathology Fiji School of Medicine,Joints:,Mobility - Cranial sutures Shoulder joint. Articular cartilage hyaline friction res.
2、 Synovial fluid lubric/nutri, Type A & B synoviocytes. Hyaluronidase Continuous production and absorption. Affected by Inflammation, immobility. Capsule, ligaments, menisci. Vascular, rich nerve supply Art. Cartilage*,Joints - Anatomy,Arthritis - Introduction,Inflammation of joints - Common Common s
3、ite for autoimmune injury Heart valves & Joints - damage Exposure of hidden antigens. Infections. Degeneration Age/Stress/life style Use it or Loose it.!,Arthritis Clinical features:,Pain Inflammation - capsule, synovium, periosteum. Swelling: inflammation, effusion, proliferation. Restricted moveme
4、nt pain, fluid, synovial swelling, damage. Deformity mal-alignment, erosion, ankylosis,Arthritis Clinical Classification:,Monoarthritis: Local, asymmetric, secondary. Acute: Bacterial, Trauma, Crystal, Reactive Chronic :Tuberculosis, Lyme, Fungal, Trauma, Tumors. Polyarthritis: Chronic, symmetric, s
5、ystemic. Autoimmune, degenerative, Crystal. Rarely infective.,Polyarthritis Classification:,Autoimmune: Rheumatic, Rheumatoid, Ankylosing spondylitis, Reiter syndrome etc. Degenerative: Osteroarthritis Crystal Deposition: Gout Monosodium urate CPPD - Pseudo Gout Infective - Septic, TB, Lyme etc. rar
6、e.,Rheumatoid Arthritis,Epidemiology of RA,Prevalence about 1% of US population Female : Male ratio = 2:1 Strong association with HLA DR4. Concordance in identical twins only 30%,RA - Definition:,Chronic Multisystem autoimmune inflammatory disorder primarily affecting joints producing a proliferativ
7、e synovitis that often progresses to destruction 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 & Mycoplasma Autoimmunity: IGM anti IgG RA Factor. Helper T cell (CD4) against type
8、 II collagen & cartilage glycoprotein-39,Immuno-dysregulation in RA,T 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.,Mo
9、rphology:,Proliferative synovitis with lymphocytes (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 arterie
10、s),Early Destruction in RA:,Swan Neck Deformity,RA - 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 changes,At least 4 features for diagnosis.,N.Synovium
11、- - R.Arthritis:,RA - Pannus:,RA - Pannus:,Hyperplastic inflammed synovium,Extra-Articular RA,Rheumatoid Nodules Vasculitis Pleuritis Pericarditis Tendonitis,Skin RA Nodule:,Skin RA Nodule:,Rheumatoid Nodule (skin):,Palisading Macrophages,Central Fibrinoid Necrosis,Joint involvement in RA:,Swan Neck
12、 Deformity in RA:,Joint Destruction in RA:,Swan Neck Deformity,RA Joint destruction, ankylosis:,Osteoarthritis,Degenerative arthrosis. (Osteoarthrosis),Osteoarthritis:,Degenerative end result - (ageing) 80% in 65y. Progressive erosion & fibrillation of articular cartilage forms Loose bodies. Large w
13、eight bearing joints. Hardened articular bone eburnation. & Subarticular cyst formation in bone. Periarticular osteophyte formation. Mild inflammation but painful, morning stiffness. Limited range of movements Heberden nodes (F),Normal - Femur Head - OA,Normal,Osteoarthritis,Femur Osteroarthritis:,J
14、oint Mice or Loose Bodies:,Spine Osteophytes (OA):,Radiologic Features:,nonuniform joint space loss, osteophyte formation, cyst formation subchondral sclerosis Sclerosis, ankylosis & deformity.,Osteoarthritis:,Narrow joint space Lipping osteophyte Dislocation Osteoporosis.,Osteophyte formation:,Bone
15、 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 cortex (open arrowheads).,Osteoarthritis:,Lateral view of the left knee shows sclerosis with marked osteophyte formation (arrows). The oste
16、ophytes are best seen in this view.,Osteoarthritis:,Subchondral cysts (solid arrowhead),OA Fingers:,OA Hip:,OA Hip: 1997, bilateral, joint space narrowing (arrows) at the hips that is worse on the left side,OA Hip: Subchondral sclerosis (solid arrowhead) and cyst (arrow) formation are also noted on
17、the left side,OA Hip:left hip arthroplasty,OA - Clinical Features:,pain worsens with activity & improves on rest. Instability of joints Knee. Crepitus, limitation of motion. Muscle spasm, and tendon and capsular contractures. Early morning stiffness lasts 1 hour or more. bony overgrowth interphalang
18、eal joints distal(Heberdens) proximal (Bouchards).,Differentiating Features:,Rheumatoid Arthritis: Young, small joints Autoimmune. Synovial Inflammation synovium Cartilage Osteoarthritis: Old, Large joints Degenerative. Cartilage degeneration. Cartilage Synovium,Arthritis Other,Infective, traumatic,
19、 secondary to systemic diseases.,Seronegative arthropathies,Ankylosing Spondylitis: Adolescent boys, HLA B27, axial joints (sacroiliac) Reiter Syndrome: Triad of arthritis, urethritis/cervicits & conjuctivitis Autoimmune but initiated by bacterial infection. Enteropathic Arthritis: Secondary to bowe
20、l infections (salmonella, shigella) HLA B27 positive Psoriatic Arthritis: 5% of patients, starts in DIP joints, similar to RA.,Septic Arthritis:,Gonococcal Arthritis:,Juvenile Rheumatoid Arthritis:,Before age 16 Multisystem involement - Spleenomegaly, Starts with systemic involvement unlike RA. No s
21、erum RA Factor Seronegative Antinuclear Antibody (ANA) +ve autoimmune.,Big Toe in Gout:,Joint Destruction in Gout:,Gout Tophi:,Urate Crystals (Gout):,Pseudo Gout,Calcium PyroPhosphate Deposition disease CPPD Chondrocalcinosis.,CPPD (Chondrocalcinosis),Type A Pseudo gout Knee, men Type B Pseudo rheum
22、atoid - polyarthritis Type C Pseudo OA + acute attacks, women Type D Pseudo OA - acute attacks, hands Type E Asymptomatic Type F Pseudoneuropathic,CPPD-Arthritis (pseudo gout):,Pseudo Gout Calcium pyrophoshate,Ankylosing Spondylitis,Marie-Strumpell Arthritis Young males, 90% HLA B27 + 25% have iriti
23、s 10% Aortic insufficiency Strongly familial, 100% concordance in monozygotic twins.,AS - fusion of vertebral bodies due to bridging syndesmophytes.,Scoliosis in Ankylosing Spondylitis,Organisms in Reiters,Shigella Flexneri Salmonella S.typimurium others Yersinia enterocolitica Campylobacter Jejuni
24、Chlamydia trachomatis Ureaplasma urealyticum,Arthritis Comparison:,The gem cannot be polished without friction, nor man perfected without trials or problems (or exams)!. -Chinese proverb,Pathology of Reiters Syndrome,Acute Synovitis Chronic changes (in some) Unilateral Sacroilitis Ascending arthropathy Ossification & enthesopathy Ileal, colonic or urethral - non specific mucosal inflammation,Reiters Syndrome:,Iritis:,