hatem h eleishi, md professor of rheumatology, cairo university
DESCRIPTION
Rheumatoid Arthritis Wednesday , April 29 th , 2009. Lecture 1 Rheumatoid Arthritis From the General Practitioner’s Perspective to the Basic Rheumatologist’s Perspective. Hatem H Eleishi, MD Professor of Rheumatology, Cairo University - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/1.jpg)
![Page 2: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/2.jpg)
![Page 3: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/3.jpg)
Hatem H Eleishi, MDProfessor of Rheumatology, Cairo UniversityConsultant Rheumatologist, Dr. Soliman Fakeeh Hospital
Rheumatoid ArthritisWednesday, April 29th, 2009
Lecture 1Rheumatoid Arthritis
From the General Practitioner’s Perspectiveto the Basic Rheumatologist’s Perspective
![Page 4: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/4.jpg)
WHAT MANY DOCTORS KNOW ABOUT RHEUMATOID ARTHRITIS
WHAT MANY DOCTORS MIGHT NOT KNOW ABOUT RHEUMATOID ARTHRITIS
IN THIS LECTURE
![Page 5: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/5.jpg)
RHEUMATOID ARTHRITIS AS MANY DOCTORS KNOW IT
![Page 6: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/6.jpg)
CLINICALLY:POLYARTHRITISIN TIME, CRIPPLING JOINT DEFORMITIES
LABORATORY: POSITIVE RF, HIGH ESR
PLAIN RADIOLOGY: ARTICULAR EROSIONS
MANAGEMENT: NO REAL TREATMENT; ONLY NSAIDs, MAY BE STEROIDSMTX WHICH IS VERY TOXIC
AN AUTOIMMUNE DISEASE THAT IS CHARACTERIZED BY:
![Page 7: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/7.jpg)
IN SHORT
A CRIPPLING DISASTER THAT MORE OR LESS HAS NO TREATMENT
![Page 8: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/8.jpg)
RHEUMATOID ARTHRITIS AS MANY DOCTORS MIGHT NOT KNOW IT
PRESENTATION LABS IMAGING MANAGEMENT
![Page 9: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/9.jpg)
ABOUT THE PRESENTATION OFRHEUMATOID ARTHRITIS
IN ADDITION TO A SYMMETRICAL POLYARTHRITIS WHICH IS SOMETIMES RATHER SUBTLE, WE HAVE OTHER PRESENTATIONS TOO;
TRUE: THE MOST COMMON PRESENTATION ISA SYMMETRICAL POLYARTHRITIS
![Page 10: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/10.jpg)
WE HAVE
THE RELUCTANT RA
THE STUTTERING RA
THE DISGUISED RA
THE ACHES ALL OVER RA
THE PUFFY RA
![Page 11: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/11.jpg)
A 42-YEAR OLD MALE WITH RECCURRENT ATTACKS OF PAIN AND SWELLING OF A WRIST OR A SHOULDER OR AN ANKLE FOR 2 YEARS.
DURATION OF EACH ATTACK: 3-7 DAYS
ATTACK FREE PERIOD: 2-3 MONHTS
THE RELUCTANT RA
OR PALINDROMIC RHEUMATISM
PRESENTATION 1 OF 5
![Page 12: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/12.jpg)
2003: A 33-YEAR OLD FEMALE PRESENTED WITH INFLAMMATORY MONOARTHRITIS OF THE RIGHT WRISTPLAIN FILM OF HER HANDS: NORMALMRI: EFFUSION, SYNOVIAL THICKENING, BONE MARROW EDEMA
EARLY 2003: SHE STARTED TO COMPLAIN OF PAIN AND MS OF HER RIGHT WRIST
S T U T T E R I N G RA
LATE 2003: PAIN AND SWELLING OF THE ELBOWS, KNEES, ANKLES
ANY POLYARTHRITIS CAN INITIALLY START AS A MONOARTHRITIS
PRESENTATION 2 OF 5
![Page 13: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/13.jpg)
RA RA
FEMALE; 48Y-OLDOA KNEES / HANDS
LATELY PAINNOCTURNAL PAINSREC EFFUSIONS
PLAINS: OAESR 50RF +VESYNOVIONALYSIS: INFLAMMATORY SF
RA ON TOP OF OA OR DISGUISED RA
PRESENTATION 3 OF 5
![Page 14: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/14.jpg)
Mona, a 32-year old female, presented with diffuse aches all over of 3 months’ duration. She had a MS of 10-60 minutes and nocturnal pain sometimes.
She was afraid she might have cancer or rheumatoid arthritis but had been reassured by her family doctor that she didn’t have cancer and that her RF test was negative.
PRESENTATION 4 OF 5
![Page 15: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/15.jpg)
Examination revealed a very anxious patient with inconsistent tenderness over several small joints of the hands but also over the trunk as well as the flesh of the forearms and legs.
Investigations: ESR 21CBC, liver, kidney, electrolytes: normalRF; ANA: negativeHepatitis serology: negativeA plain film of the hands and feet were normal
![Page 16: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/16.jpg)
DIFFUSE ACHES ALL OVER RA
OR FIBROMYALGIC RA
A Tc99 bone scan was done
![Page 17: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/17.jpg)
Early rheumatoid arthritis can sometimes be
a vague diagnosis
Bone scan helps to settle the diagnosis
in such situations
![Page 18: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/18.jpg)
Abu-Ismail, a 59-year old male, presented with gradual onset of pain and swelling of his hands with NP and MS of 4 hoursExamination: diffuse swelling (puffinness) of the dorsum of both hands; tenderness of the MCPs, and wristsLABS: ESR 70; Hb 11gm%; RF: Negative
RS3PE REMITTING SYMMETRICAL SERONEGATIVE SYNOVITIS
WITH PITTING EDEMA OR PUFFY RA
PRESENTATION 5 OF 5
![Page 19: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/19.jpg)
THE RELUCTANT RA
THE STUTTERING RA
THE SNEEKY RA
THE ACHES ALL OVER RA
THE PUFFY RA
![Page 20: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/20.jpg)
RHEUMATOID ARTHRITIS
AS MANY DOCTORS MIGHT NOT KNOW IT
PRESENTATION LABS IMAGING MANAGEMENT
![Page 21: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/21.jpg)
ABOUT THE LABORATORY INVESTIGATIONS
IN RHEMATOID ARTHRITIS
![Page 22: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/22.jpg)
THERE ARE CAUSES FOR A POSITIVE RF OTHER THAN RA
SO YOU CANNOT RELY SOLELY ON A POSITIVE RF TO DIAGNOSE RA
POSITIVE RHEUMATOID FACTOR“THE RHEUMATOID CETRTIFICATE”
![Page 23: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/23.jpg)
RHEUMATOID FACTOR IS POSITIVE IN ONLY 70% OF PATIENTS AND NEGATIVE IN 30%
SO A NEGATIVE RF DOESN’T RELIABLY EXCLUDE RA
NEGATIVE RHEUMATOID FACTOR
![Page 24: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/24.jpg)
ESR IS NOT INVARIABLY ELEVATEDIN RA
ESR
![Page 25: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/25.jpg)
ABOUT THE IMAGING OFRHEUMATOID ARTHRITIS
![Page 26: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/26.jpg)
NOT EVERY RHEUMATOID DISEASE IS NECESSARILY EROSIVE
![Page 27: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/27.jpg)
BEFORE LOOKING FOR EROSIONS, LOOK FIRST FOR: JAOJSN
![Page 28: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/28.jpg)
IN EARLY RA, PLAIN FILMS MAY BE NORMAL ANYWAY
OTHER IMAGING MODALITIES MAY THEN BE NEEDED TO CONFIRM THE DIAGNOSIS
![Page 29: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/29.jpg)
What is the most important thing that is needed to make the diagnosis of RA?
A good lab
An imaging center
A chair
A screening questionnaire for the population
Knowing the family history of your patient
Two doctors rather than one
![Page 30: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/30.jpg)
HISTORY-TAKING IS THE MOST IMPORTANT STEP TO COME TO THE CORRECT DIAGNOSIS
![Page 31: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/31.jpg)
THERE ARE 3 TYPES OF HISTORY THAT COULD BE TAKEN FROM A PATIENT:
THE POLICE OFFICER’S HISTORY
THE JOURNALIST’S HISTORY
THE GOOD DOCTOR’S HISTORY
![Page 32: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/32.jpg)
GOOD DOCTORS DO NOT
DIAGNOSE DISEASES
THEY JUST LEAVE DISEASES DIAGNOSE THEMSELVES
![Page 33: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/33.jpg)
لكل ، البشر مثل األمراضو المميزة مالمحه مرضالتي الخاصة طبائعهو تزداد ثم الطبيب يدرسهابها معرفته تصقلو البحث و بالممارسة
المستمر .اإلطالع
أثناء في المميزة المالمح هذه على الطبيب يتعرفالمريض مع الحوار
هي المرض لتشخيص خطوة أهم فإن هذا :وعلى
على إجاباته إلى و المريض إلى الجيد اإلستماعالطبيب أسئلة
![Page 34: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/34.jpg)
إجاباته إلى و المريض إلى الجيد باإلستماع يحدث ماذاالطبيب؟ أسئلة على
في المريض يقع ........حفرة
يسيبه يقع
لوحده، ما يزقوش
يفعل ماذاالطبيب هذه في الحالة؟
![Page 35: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/35.jpg)
ABOUT THE MANAGEMENT OFRHEUMATOID ARTHRITIS
![Page 36: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/36.jpg)
MANAGEMENT OF RA COMPRISES:
PATIENT EDUCATION AND INSTRUCTIONS
MEDICAL TREATMENT
REHABILITATION
SURGICAL TREATMENT SOMETIMES
![Page 37: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/37.jpg)
DON’T UNDERESTIMATE THE POWER OF TALKING TO YOUR PATIENT
PATIENT EDUCATION
![Page 38: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/38.jpg)
MEDICAL TREATMENT
REHABILITATION
NSAIDs AND PHYSIOTHERAPY
Hydroxychloroquine, sulfasalazine, gold
Methotrexate, lefulonamide
Biological Agents
Aim of medical treatment: Induction and maintenance of remission
![Page 39: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/39.jpg)
Severe systemic
illness
Bridge therapy
Intra-articular steroids
Corticosteroids are not part of the medical treatment of RA except in very selected situations as:
![Page 40: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/40.jpg)
Conclusions
![Page 41: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/41.jpg)
THERE IS MUCH MORE ABOUT RHEUMATOID ARTHRITIS THAN JUST:
A CRIPPLING JOINT DISEASE WITH A POSITIVE RF
AND NO TREATMENT
![Page 42: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/42.jpg)
A SYMMETRIC POLYARTHRITIS IS THE COMMONEST PRESENTATION,
BUT
THERE ARE OTHER NOT UNCOMMON PRESENTATIONS FOR RHEUMATOID ARTHRITIS AS WELL
PRESENTATION
![Page 43: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/43.jpg)
THE MOST IMPORTANT STEP TOWARDS A DIAGNOSIS OF RA IS
A GOOD HISTORY TAKEN BY A GOOD DOCTOR
PRESENTATION
![Page 44: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/44.jpg)
A POSITIVE RF DOESN’T NECESSARILY MEAN RA
AND
A NEGATIVE RF DOESN’T NECESSARILY MEAN NO RA
INVESTIGATIONS
![Page 45: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/45.jpg)
PLAIN FILMS IN EARLY RA
MAY BE NORMAL
INVESTIGATIONS
![Page 46: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/46.jpg)
DOCTORS ARE MORE THAN JUST
TABLETS
MANAGEMENT
![Page 47: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/47.jpg)
A MOST INDISPENSIBLE STEP IN THE MANGEMENT OF PATIENTS WITH RA IS
PATIENT EDUCATION
MANAGEMENT
![Page 48: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/48.jpg)
CORTICOSTEROIDS HAVE NO PLACE IN THE TREATMENT OF
RA EXCEPT IN
VERY SPECIAL SITUATIONS
MANAGEMENT
![Page 49: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/49.jpg)
VARIOUS IMMUNOMODULATORS AND IMMUNOSUPPRESSIVES AND BIOLOGICAL AGENTS ARE AVAILIABLE FOR THE INDUCTION AND MAINTENANCE OF REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS
MANAGEMENT
![Page 50: Hatem H Eleishi, MD Professor of Rheumatology, Cairo University](https://reader035.vdocuments.us/reader035/viewer/2022062410/56815a81550346895dc7eb59/html5/thumbnails/50.jpg)
Thank you