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Chapter 1,2    Chapter 3,4,5  Chapter 6,7,8    Chapter 9,10

   

 

 

 

 

 

By

 

Prof. Abdel-Samad El-Hewala

 

Professor of Rheumatology & Rehabilitation

Faculty of Medicine

Zagazig University

 

 

 

 

 

 

 

 

 

 

 

        CONTENTS

 

Introduction

Chapter (1): Normal joint structure

Chapter (2): Diagnosis of rheumatic diseases

Chapter (3): Classification of rheumatic diseases

Chapter (4): Infectious arthritis

Chapter (5): Rheumatoid arthritis

Chapter (6): Sero-negative arthropathies

Chapter (7): Systemic connective-tissue diseases

Chapter (8): Crystal deposition diseases

Chapter (9): Osteoarthritis

Chapter (10): Low back pain

Introduction

heumatology is concerned with diseases of the joints and connective tissues. These structures can be damaged by a variety of pathological processes including infection, inflammation, degeneration, metabolic disturbances and systemic diseases such as leukaemia or haemochromatosis, which have their principal effect on other body systems.

Rheumatic disorders are frequent. Indeed about 30 % of a general practioner patients consult him for rheumatic pain (Figure 1). The most common rheumatic disorders are non-articular rheumatism and degenerative joint diseases. The classical rheumatic diseases such as rheumatoid arthritis or gout luckily affect a small percentage of patients (Figure 2).

 

In teaching rheumatology to medical students, books on the subject suitable for undergraduate reading are recommended. At present, the student has access only to general medical text books in which the rheumatic diseases are often dealt with inadequately, or he must turn to one of the few large textbooks of rheumatology that provide more detail than a student will require.

 

Hence this work, written primarily for the medical student, but providing also, it is hoped, an account of the subject that will suit both to the general practioner, and the postgraduate student.

 

 

 

 

 

 

Fig. (1): Incidence of rheumatic disorders among patients seen by general practioner.

 

 

 

 

Fig. (2): Pattern of rheumatic conditions diagnosed by rheumatologist

                       annually.

 

 

 

 

Chapter 1

NORMAL JOINT STRUCTURE

Joints are divided into three types:

uFibrous joints which allow almost no movement e.g. skull sutures.

vCartilaginous joints which allow limited movement e.g. articulations between vertebral bodies, symphysis pubis.

wSynovial joints which allow a wide range of free movement, e.g. all joints of limbs.

Synovial joints:

Synovial joints (Figure 3) have several characteristic features:

- Opposing bony surfaces covered with articular cartilage.

- A joint cavity which is only a potential space in life.

- A surrounding fibrous capsule.

- A synovial membrane which lines the whole interior of the joint space with the exception of the articular cartilage.

- Lubrication with synovial fluid.

Articular cartilage: usually hyaline, firmly attached to underlying bone by its deep calcified layer, smooth surface, contains neither nerves nor blood vessels. Derives its nourishment from the vascular network of adjacent synovium, synovial fluid and blood vessels in the underlying bone.

Fibrous capsule: consists of white fibrous tissue thickened in some areas to form named ligaments, usually attached to bone close to the edge of the articular surface. Has little elasticity and causes pain if subjected to sustained tension.

Synovial membrane: forms a relatively smooth lining surface covering all of the interior of the joint with the exception of articular cartilage and articular discs, or menisci. In some joints, finger-like processes (synovial villi) project into the joint cavity. The synovial membrane consists of a layer of surface cells (synoviocytes) 1-3 cells deep, overlying fibrous areolar connective tissue which contains the synovial vessels, capillary loops and lymphatics. Two different types of synoviocytes recognised on electron microscopy:

 

 

 

 

                 Fig. (3) Synovial joint

-Cell type A: has phagocytic function, it is responsible for removing particulate matter from the joint cavity.

- Cell type B: synthesize and secrete the hyaluronate-protein complex of synovial fluid, which is responsible for viscosity of synovial fluid.

Synovial Fluid: Viscous, pale yellow and clear. Present in small amounts (0.1-3 ml in knee joint) consists of a transudate (dialysate) of plasma and hyaluronate-protein complex.

Constituents:

1- Hyaluronate-protein complex:

- Secreted by type B synoviocytes

- Responsible for the fluid's high viscosity

- Concentration is decreased in presence of inflammation.

- Mucin clot test:

Addition of acetic acid to synovial fluid precipitates the hyaluronate-protein complex as mucin. In normal fluid with high concentration of hyaluronate, the clot is tight and well formed. In inflammatory types of arthritis, the fluid has a low concentration of hyaluronate, the clot is poor, fragmented or friable.

2- Proteins:

-normal concentration is about one-third of that in plasma (transudate) and is mainly albumin, there is no fibrinogen and the fluid does not clot.

- In inflammatory fluid the protein concentration rises to approach that of plasma (caudate); fibrinogen enters the fluid which can then clot.

3- Others:

- Electrolytes, uric acid, glucose: present in approximately the same concentration as plasma.

-Lysosomal enzymes: present in very low concentration and correlates roughly with the cell count

-Cells: total leucocytes count usually less than 200/mm3, predominately lymphocytes with some monocytes and poly-morphonuclear cells.

Functions:

Lubricates the joint and supplies nutriment to avascular articular cartilage.

                               Table (1) Normal synovial fluid

Synovial fluid	Average value
Volume (in knee) (ml)	2
Total protein (g/l)	20
Leucocytes /mm3	<200
Lymphocytes %	50
Mononuclear %	15
Polymorphs %	<25
Glucose	Approximately same as plasma
Uric acid
Electrolytes

 

Cartilaginous joints:

The intervertebral discs are interposed between the bodies of the vertebrae from the axis downwards. There is no disc between the atlas and the axis.

Each intervertebral disc is composed of three parts: (Figure 4)

u The cartilaginous plates

v The annulus fibrosus

w The nucleus pulposus

1- The cartilaginous plates: It incloses the disc from above and below. It covers the central part of the vertebral body and is firmly attached to the cancellous bone of the vertebral body.

2- The annulus fibrosus: Concentric connective tissue layers of firm and elastic consistency and firmly attached to both the cartilage plate and the marginal rim.

3- The nucleus pulposus: This is a gelatinous substance (fluid) contained within the annulus fibrosus and cartilaginous plate.

Functions of nucleus pulposus:

It acts as:

- A pivot for the movements of the vertebrae in relation to one another.

- Shock absorping mechanism. It distributes the load over the whole of the internal surface of the annulus fibrosus.

- Fluid exchange between vertebrae and discs. This is produced by the chemical force resulting from the water attracting capcity of the glycosaminoglycan macromolecules. These macromolecules "imbibe" water when the disc is not mechanically compressed (e.g. in recumbent posture when the disc tends to swell) and lose some of it during the course of each day by axial loading. Thus all individuals lose height due to axial weight bearing during day and regain height when recumbent at night.

N.B.: Spinal Joints:

The spine is an articulated column of vertebrae, each "couplet" of which is able to move through an intervertebral disc joint and two posterior facet joints. An abnormality of either type of joint will obviously have a deleterious effect on the other, a point of great importance in understanding the development of degenerative joint disease in the spine.

-The intervertebral disc joints: (discussed above)

- The posterior facet joints: (Figure 5)

The posterior facet joints are of the diarthrodial or synovial type. They serve to guide, steady and limit the movements of the vertebral bodies on one another. Being true synovial joints, they are comprised of a fibrous capsule, synovial membrane and articular surface.

 

 

 

 

 

 

 

 

 

 

Nucleus

 

 

 

Fig (4) Intervertebral disc

 

 

 

Fibrous Capsule          And Synovial membrane

Chapter 2

DIAGNOSIS OF RHEUMATIC DISEASES

In the diagnosis of rheumatic diseases, you should obtain a detailed history from a patient with joint disease since many systems besides the musculoskeletal may be involved. Examples of systemic manifestations are eye involvement in ankylosing spondylids and anaemia in rheumatoid arthritis.

The diagnosis should conducted in the following order:

1. History taking (symptoms)

2. Physical examination (signs)

3. Radiographic examination

4. Laboratory examination

Symptoms provides subjective data whereas physical signs, radiographic signs and the results of laboratory tests provide objective data.

1- History Taking

The important data in the patient's history are:

* Personal History:

Patient's name, sex, age, occupation, residence and his family responsibilities.

* Chief Complaint:

The chief complaint is the main symptom, or group of symptoms that have prompted your patient to seek your help and advice.

- Common Rheumatic Symptoms or Complaints:

The following are the main reasons why an arthritic patient will consult you:

Pain:

Pain is an important feature in most rheumatic diseases.

* Location:

What is the site of the pain? Is it well localized?

Is the pain at a single site or multiple sites?

Gout tends to produce monoarticular pain, while rheumatoid arthritis involves many joints.

What are the areas of radiation?

Pain from the hip often radiates to the knee.

* Timing:

Is this the first attack or a repeat attack?

If a repeat attack, does the pain involve the same joint or different joints?

What is the duration of the present attack?

Is the pain constant or intermittent?

The pain of malignancy is usually constant and unrelieved by rest.

What is the relation to activity?

The pain and stiffness in ankylosing spondylitis are often temporarily relieved by exercises, whereas pain of disc prolapse is often relieved by rest.

* Character

Obtain a description of the pain.

Is it burning, stabbing, aching.................... etc.?

What aggravate pain? The effect of movement. What relieve pain?

* The effect of medication;

Musculoskeletal features other than pain:

Determine the relative importance and relation of the other features to the pain.

What is the location, timing and character of stiffness or limitation of movement?

Is there stiffness in the morning, or after rest?

Is the limitation of movement constant or intermittent?

What is the location, timing and character of:

Swelling?

Deformity?

* Fever:

Has the patient had a low grade fever?

with tuberculosis arthritis there may be a persistent low grade fever.

What is the relationship of the fever to the onset of joint pain?

Acute attacks of subacromial bursitis can be accompanied by pyrexia.

The arthritis of Reiter's syndrome may follow an acute febrile episode.

Is the fever sustained or remittent?

In rheumatic fever the fever is relatively constant.

In still's disease it fends to subside over night.

Is the fever accompanied by other physical findings such as night sweats, chills or rigor?

The febrile reaction to an acute septic arthritis is often associated with chills and rigor.

* Decrease in function:

The patient complaint may be due to decreased ability due to muscle weakness or fatigue, giving way (instability) of a joint, or stiffhess of a joint.         

* Medications:

Has there been previous drug therapy?

Are there known drug allergies?

The .symptoms may be due to drug allergy.

What type and amount of medication is currently required?

* Occupational and Social History:

What is the patient's occupation?

Does he do heavy or sedentary work?

Assess the disability and the functional impairment.

What are the specific limitations of activities?

What did you do that can't do now?

* Family History:

Ask for the presence of joint disease in other members of the family. Diseases which may exhibit rheumatic features and which demonstrate familial patterns include:

Psoriasis   Ankylosing spondylitis    Ulcerative colitis   Gout   Haemophilia

* Past history:

It is important to obtain a history of previous illnesses, previous injuries,previous related treatment, peptic ulcer and other G.I. distu­rbances ,asthma and other allergies .

2- Physical Examination:

Since rheumatic disease involves predominantly the musculo-skeletal system, the physical examination is particularly concerned with the muscles, bones and joints. Because other systems can be involved, a complete physical examination is required. * The joints:

Inspection :-

Swelling

Skin changes

Tenderness

Movements

Deformity

Muscles

Swelling:

In osteoarthrosis this is typically bony, with osteophytes and new bone formation,

In inflammatory joint disease swelling may be due either to soft tissue swelling or to fluid, or both .

Proof of the fluid nature of a joint swelling may be obtained by "patellar tap test" or "cross fluctuation".

The overlying skin:

Redness of the skin indicates an acute inflammatory reaction within the joint.

It is common in septic arthritis, crystal synovitis and rheumatic fever.

The skin overlying an acute gouty joint tends to be dry, while that overlying a rheumatic fever or septic joint is moist.

Increased warmth of the skin overlying an inflamed joint is a definite and useful sign and a sensitive indication of inflammation within the joint, it is usually positive when an effusion of any size is present.

Tenderness:

Tenderness is a particularly valuable indicator of inflammation in small joint. Apply gentle pressure and watch the patients face to see if you are producing pain.

Movement:

Joint movements may be active or passive, in general, testing of passive movements is more informative about the state of an actual articulation, for active movements may be impaired by muscle weakness or lesions of tendons in many situations it is wise to test-both. The observer notes whether the movements are painful and whether palpable crepitus is produced in the joint. In an acutely inflamed joint, passive movement typically produces pain throughout the whole range, and tenderness can be elicited over all exposed aspects of the articulation. When these criteria are not fulfilled it is necessary to consider whether the inflammation may lie outside the joint well-known diagnostic pitfolls in this regard are the erronious diagnosis of arthritis in children with juxta-articular inflammation due to acute osteomyelitis mistakenly be diagnosed as suffering from arthritis of the wrist or knee joint.

 

Crepitus is an indication of joint pathology. It is elicited by placing a palpating hand over the joint while the other hand moves the articulation passively. Crepitus is also audible with a stethoscope. Soft fine crepitus may be felt in rheumatoid arthritis.

Crepitus presumably indicates that the moving surfaces are no longer smooth cartilage, osteoarthrosis is associated with more coarse crepitus while rheumatoid arthritis is associated with fine crepitus.

The muscles:

Muscle wasting should be noted, palpation for muscle tenderness. Examine the muscle groups not individual muscles. Polyarthritis may be associated with muscle tenderness. The distribution of muscle involvement is important. Determine whether it is central or peripheral and whether flexor or extensor groups are involved, neuropathies usually involve peripheral muscles. Myopathies usually involve proximal muscles.

So the first point when you see a patient who complains of pain and swelling in a joint is to distinguish between the various types of arthritis, for simplicity you have to distinguish between the degenerative type of arthritis and the inflammatory arthritis.

In case of inflammatory arthritis the synovial membrane is diseased and becomes inflammed and thickened, the ligaments and tendons are lined by synovial membrane. When you examine such a joint you will find all signs of inflammation:

Redness

Hotness           Because of increased blood supply

Swelling

Tenderness

Limitation of movements

3- Radiographic Examination:

A- Plain X-rays in arthritis may show:

- Soft-tissue swelling.

- Osteoporosis (loss of density, fine trabeculate, thin cortex).

- Diminshes joint space (cartilage destruction).

- Soft-tissue calcification.

- Bone destruction (erosions, cysts, osteolysis).

- Periosteal reaction.

- New bone formation (sclerosis/osteophytes).

- Sublaxation of joints.

- Bony ankylosis.

B- Imaging in Rehumatic Disorders:

- Arthrography:contrast medium injected into joint, double contrast effect provided by mixture of air and contrast medium e.g. to detect meniscial injuries, to diagnose rupture popliteal cyst.

- Radio-isotope (technetium- 99m) scanning: To show bone lesions (e.g. secondary deposits or paget's disease).

- Radiculography and myelography: To assess intervertebral disc disease and spinal canal dimensions.

- Ultrasound scanning: Differentiates between cystic and solid structures, in muscles and subcutaneous tissues.

- CT scanning: Useful to demonstrate vertebral fractures, spinal stenosis, intervertebral disc lesions, secondary deposists in spine, thoracic outlet lesions.

- Thermography: Measurement of heat radiation from skin can be useful for assessment of Raynaud's syndrome, confirmation of absence of arthritis in psychogenic rheumatism, assessment of soft-tissue lesions such as tennis elbow.

4- Laboratory Investigations

1- Blood Investigations

A) Blood Picture:

- Normocytic, hypochromic anaemia is common in inflammatory joint diseases e.g. rheumatoid arthritis, spondylitis and rheumatic fever. In systemic lupus erythematosus (SLE), autoimmune haemolytic anaemia may occur.

- Leucocytosis occurs in rheumatic fever, poly-arteritis and septic arthritis.

- Leucopenia occurs in Felly's syndrome, drug sensitivities and SLE

- Eosinophilia occurs in some rheumatoid patients treated with gold.

- Thrombocytopenia (.platelet count below 150,000 /mm3) causes bleeding when platelets fall below 40,000/mm3. This occurs in thrombocytopenic purpura, aplastic anaemia, acute leukaemia, occasionally SLE and autoimmune diseases with platelet antibodies in drug treatment (e.g. penicillamine).

- The association of Polycythaemia with polyarthritis suggests secondary gout.

B) Erythrocyte sedimentation rate:

In rheumatology, the following approximate upper limits of ESR are allowed (ESR increases with age), males 20 mm/hour , females 25 mm/h.

Anaemia gives apparent increase in ESR.

ESR increased by rise in fibrinogen, alpha-2 or gamma globulin cholesterol, Raised ESR occurs in the following connective tissue disorders: rheumatic fever, rheumatoid arthritis, infective arthritis, ankylosing spondylitis, acute gout and systemic collagen disorders, very high ESR should raise suspicion of malignancy, multiple myeloma or systemic collagen disorder.

C) Acute phase reactants:

C- reactive protein, plasma viscosity.

They may be used as alternative to ESR, unlike ESR, they are not influenced by age, sex or anaemia.

D) Serum muscle enzymes:

Raised in myopathies and muscular dystrophies and polymyositis especially creatine phosphokinase.

E) Uric acid level:

Normal level (males 4-6 mg/100 ml, females 4-5 mg/100 ml).

Increased in gout and familial hyperuricaemia.

F) Blood Urea, creatinine:

Estimated to detect renal disease in SLE, polyarteritis.

2- Urine Analysis:

A) Proteinuria: Proteinuria in RA, may indicate amyloid disease, gold nephropathy, analgesic nephropathy, or, most common, intercurrent pyelonephritis. Bence Jones protein in some cases of multiple myeloma.

B) Black urine: Black urine in alkaptonuria (associated with ochronotic arthritis). Urine darkness on standing or alkalinization.

C) Urine chemistry: Calcium (normal 2.5- 7.5 n mol/ 24h) raised in hyperparathyroidism, decreased in osteomalacia.

Creatinuria (over 24 n mol/ 24 h) in muscle wasting disease.

3- Synovial Fluid Anaylsis

Analysis of synovial fluid is mandatory in acute monoarthritis, and useful in patients with polyarthritis. Although there are many aspects to synovial fluid analysis, the main reasons for aspiration are:

- Microsocpic examination and culture.

- Examination for crystals under polarized light microscope.

- Total and differential cell count.