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Introduction to Rheumatology
Eldad Ben-Chetrit MD
Head Reumatology Unit
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“Rheumatology is the internal medicine of the locomotor
system”
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What is the source of the termRheumatology?
• Rheuma rheum-, rheuma-, rheumato-, rheumat-
(Greek: flux, that which flows; a stream; discharge)
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Components of the locomotor system
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The Painter’s FamilyJacob Jordaens (1593-1678)
Evidence of: Rheumatoid Arthritis
The Virgin with Canon vanDer Paele, 1436Jan van Eyck (1385-1440)
Evidence of: Temporal (Giant Cell) Arteritis
Historical Perspective
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Epidemiology - general
• At a given time 15-20% of the population
may have a rheumatic condition
• Every second person will have a
rheumatic disease during lifetime
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Epidemiology - general
• In family prcatice, 15-20% of patients see the doctor due to rheumatic conditions
• 20% of patients with other complaints also have rheumatic conditions
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Epidemiology
• Degenerative diseases• OA clinical 10-30%
X-ray (>55 yr) 80%
• Soft tissue rheumatism• Fibromyalgia 2-3%
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Epidemiology
• Arthritides, autoimmune diseases• Rheumatoid arthritis 1-2%• AS (Bechterew’s disease) 0.1-1%• Psoriatic arthritis 0.1-0.2%• Gout (30-60 yr) 1.6%• SLE 0.1%• Scleroderma (SSc) 0.02%• Sjögren’s syndrome 1%
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Importance and Impact of Rheumatologic Disease
Prevalence (per 100,000)
Male FemaleRheumatoid Arthritis 440 1,100Ankylosing Spondylitis 197 73Gout 980 230SLE 7 32Scleroderma 1 5Osteoarthritis 3,470 5,870
All Musculoskeletal conditions 15,510 20,720
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CDC: Census Bureau 2004
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Social and economical effects
Rheumatoid arthritis– Mortality
• life expectancy: 10 yrs less• ACR stage mortality equals to
(in the pre biologic era):
Diabetes –risk for heart disease
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Social and economical effects
Non-steroidal antiinflammatory drugs (NSAID)• USA
• 13 million current user
• 70 million prescriptions / yr
• 30 billion OTC tablets / yr
• GI mortality: 0.22%
• NSAID assoc. Hospital admittance: 103.000 / yr
• cost of one admittance: 15-20.000 USD
• total cost: 2 billion USD / yr !!!
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Classification –according to tissue involvement
1. Arthritides (inflammatory diseases)
2. Degenerative diseases
3. Soft tissue rheumatism
4. Muscular disorders
5. Bone disorders
6. Other
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CLASSIFICATION Non-Articular Articular
MONOARTHRITIS
Infection
Crystal-induced
Trauma
Start of polyarthritis
POLYARTHRITIS
INFLAMMATORY NON INFLAMMATORY
METABOLIC DEG
RA Gout OA
SLE Amyloidosis
Spondyloarthropathy Pseudogout
Scleroderma
Polymyositis
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EtiologyHLA-DR4
HLA-B 27
HLA-B 51
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ENVIRONMENTAL AND HOST FACTORS IN RHEUMATIC DISEASES
Environmental Factors Infectious Agents Host Factors
Geographical Race
Socio-economic Genetics
Occupation Sex
Diet Age
Toxins
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SYMPTOMS AND SIGNS OF JOINT DISEASES
SYMPTOMS
Pain
Stiffness
Loss of Function
Systemic Features
SIGNS
Heat
Redness
Swelling
Tenderness
Loss of Movement
Deformity
Crepitus
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ARTHRITIS WARNING SIGNS
• Persistent pain and stiffness on arising
• Pain or tenderness in one or more joints
• Swelling in one or more joints
• Recurrence of these symptoms and signs in one or more joints
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Diagnostic Steps In Rheumatology
1.History taking
2.Physical examination
3.Radiology (imaging)
4.Laboratory methods
5.Histology (biopsy)
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History taking
1.Onset (acute - chronic)2.Distribution (symmetry, migration, mono-polyart.)3.Severity (impairment, hospitalization)4.Functional capacity (at home, at work)
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History taking
1.Trauma
2.Operation
3.Special associated conditions• dermatological (psoriasis)• gastrointestinal (Crohn’s disease, colitis ulcerosa)• eye (uveitis, iritis)• metabolic (diabetes, hemochromatosis)• endocrine (thyroid, parathyroid, acromegaly)
4.Drug treatment (past and current)• drug-induced SLE
• Raynaud: beta blockers
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History taking 1.Professional causes• toxins, chemicals (scleroderma)• "overuse" syndrome (carpal tunnel)
2.Sexual history • (STD, AIDS, Reiter’s)
3.Quality of life• overcrowded apartment (rheumatic fever)
4.Emotional and physical stress (fibromyalgia)
5.Diseases of family members• infectious diseases (rubella, hepatitis)
6.Travelling• AIDS, Reactive arthritis
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Physical examination Guidelines
Gait
Arms
Legs
Spine
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Physical examination
* swelling * pain, tenderness * temperature, * colour * crepitation
* deformities
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Rheumatoid Nodules
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Radiological examination: aims
• Diagnostic value (RA, AS, OA)
• Differential diagnostic value (metast.)
• Progression, indicator of therapy (erosions)
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Clinical Course of Progressive RA
Joint Inflammation
Joint Destruction
Functional Limitation
Physical Disability
Premature Mortality
Early RA
Late RA
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Imaging
1.X-ray (simple, comparative, tomography)2.Radioisotope scanning• Tc-99m scan (bone, joint) - SPECT• infection: Ga-67, labelled leukocyte scan
3.CT (hernia, tumor)4.MRI (hernia, soft tissue, early erosions)• indication: cartilage, tendon, meniscus, muscle5.Ultrasound (cysts, joints, fluid)6.Invasive techniques• arthrography
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Laboratory examination
General, immunological
1.Acute phase reactants• ESR, CRP
2.Hematology• RBC, leukocytes, platelets, Hgb, Htc• blood smear
3.Immunology• rheumatoid factor (Latex, Rose-Waaler)• ANF (immunofluorescence: Hep-2 cells)• DNA, ENA, RNP, Sm, SS-A, SS-B autoantibodies• complement (CH50, C3, C4)• cryoglobulin• other
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Laboratory examination Synovial fluid1.General assessment
*• color (yellow)*• clarity, opacity (clear-opalescens)*• viscosity (inflammation: decreased)2.*Cell count3.*Crystal analysis (polarized light)• urate: yellow• Ca-pyrophosphate: blue4.*Microbiology (smear, culture)5.Biochemistry• glucose (infection, tb: low)• protein, complement, RF ??
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CLASSIFICATION OF SYNOVIAL EFFUSIONSA. NORMAL
Volume
Viscosity
Color
Clarity
Leukocytes
Culture
Crystals
Glucose
Less than 3.5 ml
High
Colorless to straw
Transparent
Less than 200
Negative
Negative
Nearly = to blood levels
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CLASSIFICATION OF SYNOVIAL EFFUSIONS
B. NON - INFLAMATORYVolume
Viscosity
Color
Clarity
Leukocytes
Culture
Crystals
Glucose
Often more than 3.5 ml
High
Straw to yellow
Transparent
200 – 2000
Negative
Negative
Nearly = to blood levels
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CLASSIFICATION OF SYNOVIAL EFFUSIONS
C. Inflammatory D-InfectionVolume
Viscosity
Color
Clarity
Leukocytes
Culture
Crystals
Glucose
Often more than 3.5 ml
Low
Yellow to yellow-green
Turbid
2,000-50,000 - >50000
Negative - Positive
Monosodium urate (Gout)Calcium pyrophosphate (pseudogout)
Lower than blood levels
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Histology(Diagnostic
value)
• Rheumatoid arthritis (?)• Tuberculosis• Sarcoidosis• Gout• Hemochromatosis• Multicentric
reticulohistiocytosis (RHS)• Pigmented villonodular
synovitis
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Arthritis - Misconceptions
• “You’re an Arthritis Doctor. What’s it like taking care of so many old patients”
• “Are all of your patients in wheelchairs?”
• “Arthritis is not a big deal because it’s not life-threatening”
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All Arthritis Patients are Old
• Many forms of Arthritis
• Rheumatoid Arthritis commonly affects young women of childbearing age
• Osteoarthritis affects younger people who run, have traumatized their joints, are overweight, etc….
• Gout can affect people of all ages
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Wheelchairs and Canes
• Thanks to recent advances and medical research, not as many face life in a wheelchair
• Treatments for many inflammatory arthritic conditions such as Spondylitis and Rheumatoid Arthritis have improved dramatically
• Joint replacement surgery has improved outcomes in Osteoarthritis
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Arthritis is not Life-Threatening
• Systemic inflammatory diseases that cause arthritis can affect other organs and lead to life-threatening complications
• Chronic inflammation has now been linked to heart disease
• Advanced Osteoarthritis limits mobility and can lead to secondary health problems (obesity, heart problems, etc…)
• In cases that aren’t life-threatening, living in pain is life impairing.
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The Sun is Rising for Patients with Rheumatic Diseases: The Future is Bright
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History taking
1.Complaints (duration)
2.History of present symptoms
3.Previous illnesses
4.Social history
5.Family history
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The Painter’s FamilyJacob Jordaens (1593-1678)
Evidence of: Rheumatoid Arthritis
The Virgin with Canon vanDer Paele, 1436Jan van Eyck (1385-1440)
Evidence of: Temporal (Giant Cell) Arteritis
Introduction to Rheumatology: Historical Perspective
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Importance and Impact of Rheumatologic Disease
Prevalence (per 100,000)
Male FemaleRheumatoid Arthritis 440 1,100Ankylosing Spondylitis 197 73Gout 980 230SLE 7 32Scleroderma 1 5Osteoarthritis 3,470 5,870
All Musculoskeletal conditions 15,510 20,720
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CDC: Census Bureau 2004