Rheumatoid Disorder

7/21/2019 Rheumatoid Disorder

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Rheumatoid DisordeAgus Widiyatmoko



The Algoritme



Musculoskeletal problems?



Articular or non articular?



Acute (< 6 weeks





!hronic non in#ammatory arthr



!hronic $n#ammatory Arthritis



!hronic $n#ammatory %oliarthritare Asymmetric





Acute Arthritis$' arthritis symptoms < 6 weeks



out Arthritis



out

•

!aused by deposition o' monosodium urate crysaround and in the tissues o' the )oint

• Three distinct stages*• aasymptomatic hyperuricemia+

• bacute intermittent gout+

•cchronic tophaceous gout



Risk ,actors 'or out

• Underexcretors (80%)• Male gender

• Postmenopausal females• Obesity, metabolic synd.• t!anol• "enal insufficiency• Plumbism• Medications (see separate)•

#e!ydration$lo flo• &ilipino ancestry• &ructose ingestion• Uromodulin 'idney dis.

•

Overproducers (20%)• Ethanol

• High cell turnover states(psoriasis, myeloprolif. disorde

• Excessive purine ingestion

• ! overactivity (x"lin#ed)

• H$! underactivity (x"lin#ed

• &eta aldolase deficiency• 'arcoidosis

• &2 deficiency

• o*n syndrome

• $lycogen storage dis. +, , -

• ever, post"op state



Risk ,actors 'or out

• Obesity, metabolic syndrom• t!anol

• #iuretics

•

&ructose ingestion• xcessie purine ingestion





./erproducers

• +-/0% of gouty patients areoerproducers.

• #istinguis!ed by / !our uric acid

excretion1 – 2 800 mg$d on regular diet.

– 2 300 mg$d on purinefree diet.

D A i t d ith



Drugs Associated with-yperuricemia

• #iuretics (loop and

t!ia4ide types)• 5odose aspirin• 6yclosporine,

tacrolimus• t!anol• t!ambutol

• Pyra4inamide• "itonair, darunair,

didanosine• 5eodopa

• /icotinic acid, niac

• ancreatic enymes

• !ituxima1

• &asilixima1

• eriparatide

• ilgrastim

• 'ildenafil

• iaoxide

• ytotoxicchemotherapy

D A i t d ith



Drugs Associated with-yperuricemia

• #iuretics (loop and

t!ia4ide types)• 5odose aspirin• 6yclosporine,

tacrolimus• t!anol• t!ambutol

• Pyra4inamide• "itonair, darunair,

didanosine• 5eodopa

• /icotinic acid, niac

• ancreatic enymes

• !ituxima1

• &asilixima1

• eriparatide

• ilgrastim

• 'ildenafil

• iaoxide

• ytotoxicchemotherapy



-yperuricemia 0 ou

7erum Uric cid(mg$dl) nnual ncidencof 9out (%)

: ;.0 0.+

;.0 < 8.= 0.-

2 =.0 .=



-yperuricemia and o

• >yperuricemia (2;.0 mg$dl) in -% 8% of mpopulation.• Most (about ?) are foreer asymptomatic• 80% of gouty patients !ae uric acid : = m• boe +0 mg$dl, ris' rises rapidly.

• 9out is t!e most common cause of monamiddleaged and elderly men (8% yearly p



Who Almost 1e/er ets

• Prepubertal c!ildren• Premenopausal omen

• 5oo' for en4yme defects in t!ese pa

• 5oo' for familial 'idney disease

%ro/ocati/e ,actors



%ro/ocati/e ,actors“ Adding Insult to Injury

• t!anol• 6essation of

et!anol

• Purineoerindulgence

• 7urgery

• *rauma

• Overexercise

• asting

• ever



The ,ructose !onnect

• &ructose raises uric acid leels in m• iggest source of fructose1 !ig! fruc

corn syrup.

• 7ucrose does not seem to raise uric



2ink to !ardio/ascular D

• n experimental models, !yperuricemcauses1 – >ypertension – "educed perfusion – ndot!elial dysfunction

– "enal dysfunction

• "eersible it! !ypouricemics

,re4uent !linical Associa



,re4uent !linical Associawith out

• >ypertension• #iabetes

• >yperlipidemia

• Obesity

• t!anol < t!e fuel



out 0 5idney Diseas

• 7tones Uric acid and calcium• Urate nep!ropat!y c!ronic interstit

disease, not ell defined.

• Uric acid nep!ropat!y < acute tubula

deposition of uric acid, it! renal faseen in gout.

romodulin associated kid



romodulin7associated kiddisease

AKA:• &amilial medullary cystic 'idney dise

/.

• &amilial @uenile !yperuricemic nep!

• Uromodulin storage disease.



romodulin (cont8d

• Uromodulin (*amm>orsfall protein)accumulates in t!e t!ic' ascending 5oop of >enle.

• "educed excretion of uric acid.

• Ao renal deposition of urates.• utosomal dominant.



A Typical Attack o' o

• 5asts seeral days to seeral ee'

• May spread from @oint to @oint.

• Often accompanied by feer,leu'ocytosis.

• 9ets orse as t!e years go on.

• Pain appears last, disappears first

• Petite attac's occur (lasting !ours





!auses o' %odagra

• M7U• 6PP#

• >ydroxyapatite

• 7eptic

• Psoriatic, "eiterBs• "!eumatoid



















Radiographic -allmarks o



Radiographic -allmarks o

•Oer!anging edges

• Punc!ed out lesions it! sclerotic b

• Preseration of @oint space (till late)

• #egeneratie c!anges





The Three %hases o'



Treatment

• *reat acute attac'

• Preent ne attac's

• "educe uric acid leel(sometimes)

%hase 9 Terminatio



%hase 9 7 Terminatio

•

A7#• 6olc!cine

• ntraarticular steroids

• 7ystemic steroids

• 5+ in!ibitors

1&A$Ds



1&A$Ds

•

*reatment of c!oice inot!erise !ealt!y patient.

• oid in renal insufficiencyand in peptic ulcer disease.

•

oid salicylates (t!ese caussings in serum uric acid).

$ntra7Articular &teroid



$ntra7Articular &teroid

•

One or a fe @oints.• Aot useful for polyarticular o

softtissue gout.

• Ma'e sure infection not

present.

.ral !olchicine



.ral !olchicine

•

+./ mg folloed by 0.3 mg / !rs late• Loading dose same in renal insuffici

• Maintenance (preentie) dose 0.3 mbid.

•0.D mg /D times per ee' in dialysis(preentie).

&ystemic &teroids



&ystemic &teroids

•

Polyarticular attac's or feer.• 5ongstanding attac's (2D- days).

• Aeed diided doses.

• *aper oer ;+0 days.

• 7tart prop!ylactic agent (colc!icine)as possible.

Anakinra (.:72abel



Anakinra (.: 2abel

• ffectie for acute attac' in

studies.• est in pts !o cannot ta'esteroids or colc!cine.

• xpensie but + ee' oftreatment may be affordable.

• Aot for preentie use.• Ot!er interleu'in+ in!ibitors

currently in trials (rilonacept Ecana'inumab)



%hase ; 7 %re/enti/e The



%hase ; %re/enti/e The

•

6olc!icine or A7#.• lays use !en beginning a !ypou

drug.

• 6ontinue seeral ee's to years (deon top!i, serum uric acid).

• lays use before surgery in preiogouty patient.

%hase 7 -ypouricemic Th



%hase -ypouricemic Th

•

Aot eery patient needs it.• May not need it in1 – Fery elderly

– Aoncompliant

– nfreCuent attac's and no top!i

• May exacerbate attac's early on

oals o' -ypouricemT t t



Treatment

•

im for serum uric acid under 3, prenear - for some c!ronic gouty patien

• ut remember1 – allopurinol toxicity more li'ely it! !ig

– More li'ely it! renal insufficiency.

-ypouricemic Agent



-ypouricemic Agent

•

llopurinol• &ebuxostat

• Probenecid

• Pegloticase

• 5osartan (offlabel)• >ig!dose salicylates (offlabel)

• Fitamin 6 (offlabel)

-ypouricemic Therap



ypou ce c e ap

•

#onBt start !ypouricemic agent durinattac'.

• Use probenecid firstG itBs safer.

• #onBt use probenecid if1 – oerproducer

– creat clearance : D--0 ml$min.

– !istory of 'idney stones.

Reasons 'or -ypouricemTreatment ,ailure



Treatment ,ailure

• Aeed loer uric acid leels t!an Hno

• Aoncompliance.

• "enal insufficiency.

• "apid dissolution of top!i.•

"apid elimination of oxypurinol (mayit! combined allopurinol and probe

Asymptomatic -yperuric



y p yp

• #onBt treat it (t!is adice may c!angfuture)

• xception1 Patients getting c!emot!leu'emia, lymp!oma.

Ma)or To=icities o'



Allopurinol• ncreased gout attac's early on (use

prop!ylaxis)

• "as! (may be seere)

• 7teensJo!nson syndrome

• Fasculitis

•>epatitis

• "enal failure (interstitial nep!ritis)

• one marro suppression

Allopurinol -ypersensiti/it&yndrome



&yndrome

• &eer

• "as!

• "enal &ailure

• Hepatic in3ury• 4eu#ocytosis

• Eosinophilia (the

tipoff5)

• May be fatal. >ard to treat.• 7erious reactions to allopurinol reported

in + of /30 patients. 6rthritis !heum 27892, 79:

Treatment o' &tonesin outy %atients



in outy %atients

• llopurinol – calcium and uric acid

stones

• Potassium citrate – calcium and uric acid

stones – direct in!ibitor of

nucleation

• &luidsK

Treatment o' &tonesin outy %atients



in outy %atients

• llopurinol – calcium and uric acid stones

• Potassium citrate – calcium and uric acid stones

– direct in!ibitor of nucleation

• &luidsK

,ebu=ostat



• Aonxant!ine in!ibitor of LO and L

• etter tolerated t!an allopurinol.

• 5oer uric acid leels t!an allopur(-D% s. /+% met target of 3.0 mg$

• etter dissolution of top!i.

,ebu=ostat* >est se



• llopurinol failures

• "enal insufficiency

• *op!aceous gout

Allopurinol 0 ,ebu=ostat D$nteractions



$nteractions

• 5ife t!reatening interaction it!a4at!ioprine, 3mercaptopurine – "educe dose of purine analogue b

approximately /$D.

• *!eop!ylline

• Ot!er interactions also

%egloticase



• &or refractory c!ronicgout

• #issoles top!i in ee'sto mont!s

• Problems1

– nap!ylaxis – ntibody formation – Aot in 93P# defic. –



This is chronic

refractory

gout!



2osartan 0 it ! (.:72abel



2abel• 5oers uric acid 0.D < +.D mg$dl (dos

range /- < /00 mg$d).

• Uricosuric mec!anism.• Useful !en / !our uric acid is : 8

mg$d.• Maintain good !ydration.• ffect is not seen it! ot!er "s.• lso consider fenofibrate (Cuite goo

actually) and atorastatin (bot! offlabel).

• #onBt forget itamin 6 (-00 mg #)

&yno/ial ,luid in ou



• May be cloudy or clear.

• nspect for top!aceous deposits.

• N6 < /000 < -0,000 or more

• 9lucose normal.

•

eteen attac's, may !ae free crys• #onBt forget to culture it.

%&@D..T



• 6alcium pyrop!osp!ate 6rystal #ep#isease (6PP#) is t!e syndrome secto t!e calcium pyrop!osp!ate in artitissues.

• *!is includes1 6!ondrocalcinosis, 6

6PP# and Pseudogout.

%seudogout



• tiology1 t is un'non, but can be sto c!anges in t!e cartilage matrix orsecondary to eleated leels of calciinorganic pyrop!osp!ate.

• Pat!ology1 6PP# crystals are found

@oint capsule and fibrocartilaginousstructures. *!ere is neutrop!il infiltand erosions.

%seudogout



• #emograp!ics1 t is predominantly aof t!e elderly, pea' age 3- to ;- year!as female predominance (&1M, /;1+

• Prealence of c!ondrocalcinosis is -t!e general population.

%seudogout



• #isease ssociations1 !ypert!yroid!ypocalciuria, !ypercalcemia,!emoc!romatosis, !emosiderosis,!ypop!osp!atasia, !ypomagnesemi!ypot!yroidsm, gout, neuropat!ic @o

amyloidosis, trauma and O.

%seudogout



• 6linical Manifestations

• Pseudogout1 Usually presents it! selflimited attac's resembling acute*!e 'nee is inoled in -0% of t!e cafolloed by t!e rist, s!oulder, an'l

elbo.

%seudogout



• n -% of patients gout can coexist

pseudogout.

• *!e diagnosis is confirmed it! t!e fluid analysis and$or t!e presence ofc!ondrocalcinosis in t!e radiograp!

• cute Pseudogout primarily affects

%seudogout



• 6!ronic 6PP#1 predominately affect

it is a progressie, often symmetric,polyart!ritis.

• Usually affects t!e 'nees, rists, /nM6PBs, !ips, spine, s!oulders, elbo

an'les.• 6!ronic 6PP# differs from pseudog

c!ronicity, inolement of t!e spine M6PBs.

%seudogout



• 6!ondrocalcinosis1 9enerally is an i

finding in L"ays.

• #iagnostic *ests1 nflammatory cell t!e synoial fluid. "!omboidal or rointracellular crystals. maging studi

c!ondrocalcinosis usually in t!e 'necan be seen in t!e radial @oint, symppubis and interertebral discs.

%seudogout



• #ifferential #iagnosis1 ncludes sept

art!ritis, gout, inflammatory O, "!ert!ritis, neuropat!ic art!ritis and >Osteoart!ropat!y.

%seudogout



• *!erapy1 t is similar to gout and inc

intrarticular corticosteroids. 6olc!icbe used in acute attac's and also inprop!ylaxis. *!ere is no specific trefor c!ronic 6PP#. t is important to t

secondary causes and colc!icine co!elpful.

Treatment o' Acute %sued



• spiration (more important

t!an in goutK)• "est

• ntraarticular steroids

• A7#s

• 7ystemic steroids

• 6olc!icine

• 5+ n!ibitors





!hronic Arthritis" 6 weeks



!hronic 1on $n#ammatArthritis



OSTEOARTHRITIS

OSTEOARTHROSIS

DEGENERATIVE JOINT DISEASE

D@,$1$T$.1



Osteoarthritis OA is a degenerative

disease o' diarthrodial (synovial joints characteriBed by Breakdon o' articular cartilage

and !roli"erative changes o'surrounding bones

@%$D@M$.2.C



.steoarthritis(.A is the #ost $o##o )oint disease

.A o' the knee )oint is 'ound in %&' o'the population o/er 6 years o' age

Radiological e/idence o' .A can be'ound in o/er E F o' the population

2$M$T@D ,1!T$.1



.A may cause 'unctional loss

Acti/ites o' daily li/ing Most important cause o' disa(ility in

old age

Ma)or indication 'or )oint replacementsurgery

!-ARA!T@R$&T$!& ., .A



.A is a $hroni$ disease o' themusculoskeletal system itho)tsyste#i$ in/ol/ement

.A is mainly a nonin*a##atorydisease o' syno/ial )oints

1o )oint ankylosis is obser/ed in the

course o' the disease



AGE



%rimary .A , -& years

Direct correlation

Aging process

R$&5 ,A!T.R& ,.R %R$MARC .A



Age

&e=

.besity

enetics

Trauma (daily

&@!.1DARC .&T.ART-R$T$&



Tra)#a %re/ious )oint disorders+ !ongenital hip dislocation $n'ection* &eptic arthritis >rucella Tb $n#ammatory* RA A& Metabolic* out

-ematologic* -emophilia @ndocrine* DM

ETIO.OG/ O0 OA



!artilage properties

>iomechanical problem

%rimary eneraliBed .A





&TR!TR@ ., G.$1T!ART$2A@



1ollagen (Type ; +roteogly$an

7 -yaluronic acid

7 lycoseaminoglycan

Water 1ondro$yte

Regeneration and Degeneration



%AT-.2.C ., .A



,ibrillation

@burnation

.steophytes

&ubcondral cysts

@T$.%AT-.@1@&$& ., .A



Agegender

2ocal

enetic .A biochemicae:ects

.ther 'actors

@T$.%AT-.@1@&$& ., .A



Dys'unction o' )oint cartilage

!ondrocyte 'unction* 97 Degredati/eenBymes

(metalloproteases

;7 $nhibitors Degeneration and regeneration 'unction

are balanced

$279 ↑ degredati/e enBymes↑ H syno/iain#ammation results* >reakdown o'

%AT-.@1@&$& ., .A



!ytokines $279 $276 T1,7α

!ell destruction

Membrane phospholipids

Arachidonic acid

!o=79 !o=7;



$279 and #etallo!roteases ha/ebeen 'ound to play an important role in$artilage destr)$tion3

2ocal growth 'actors especiallytrans'orming growth 'actor (T, are

in/ol/ed in the 'ormation o'osteo!hytes

2A>.RAT.RC ,$1D$1& ., .A



There are no pathognomoniclaboratory Indings 'or .A

2aboratory analysis is per'ormed 'or

di2erential diagnosis

RAD$.2.$! ,$1D$1& ., .A

1arro ing o' )oint space (due to loss o'



1arrowing o' )oint space (due to loss o'cartilage

Osteo!hytes

&ubchondral (paraarticular sclerosis

>one cysts

RAD$.2.$! RAD@ ., .A



9 1ormal ; Mild

Moderate

J &e/ere

5ellgren 2awrence !lassiIcation

DIAGNOSIS O0 OA



1.INI1A. 0INDINGS

Goint pain H

RADIO.OGI1 0INDINGS

.steophytes

1.INI1 O0 OA SIGNS ANDS/3+TO3S



Goint pain 7 degenerati/e

&ti:ness 'ollowing inacti/ity K min

2imitation o' R.M K later stages

De'ormity K restricition o' AD2

OA O0 4NEE JOINT 5GONARTHROS



More common in obese 'emales

o/er L years o' age Goint sti:ness (< minutes Mechanical pain %hysical e=amination Indings* !repitus %ain on pressure %ain'ul R.M and 'unctional limitation 2imitation o' R.M in later stages o' .A (Irst

e=tension 2aboratory analysis within normal limits

@1 A2& 7 .RT-.&$&





RADIO.OGI1 0INDINGS7 GRADE8 9 -7









.A ., -$% G.$1T

More common in #ales over -& years



More common in #ales over -& yearso' age

Goint sti:ness %ain o' hip gluteal and groin areas

radiating to the knee (1 obturatorius

Mechanical pain

2imited walking 'unction

!.ART-R.&$&

+hysi$al e:a#ination*



y

Antalgic limping

2imitation o' R.M (Irst internal rotation

%ain'ul R.M

Trendelenburg test positi/ity

2eg length discrepancy

2aboratory analysis within normal limits

>$.M@!-A1$!&









7RAC ., -$% .A



%eripheral Goints -ands



,eet

TR@ATM@1T ., .A



&ymptomatic treatment

&tructure modi'ying treatment

&urgical treatment

&TR!TR@ M.D$,C$1 TR@ATM@1T



-yaluronic acid in)ection (-A

lycose amino glycans (A

%R$MARC %R@@1T$.1 ., .A ??



Regular e=ercises

Weight control

%re/ention o' trauma

A$M& ., .A TR@ATM@1T



%ain relie'

%reser/ation and restoration o' )oint'unction

@ducation

1on7%harmacologic Treatment o'.A

%atient education



%atient education Weight loss (i' o/erweight

Aerobic e=ercise programs %hysical therapy Range7o'7motion e=ercises

Muscle7strengthening e=ercises Assisti/e de/ices 'or ambulation

%atellar tapingAppropriate 'ootwear

2ateral7wedged insoles ('or genu /arum >racing .ccupational therapy Goint protection and energy conser/ation

%-ARMA!.2.$! TR@ATM@1T ., .A



.ral &ystemic Medical Agents

7 Analgesics (acetaminophen

7 1&A$Ds

7 .pioid analgesics

$ntraarticular agents*

-yaluronan

lucocorticoids (e:usion

Topical agents



HAND OA 9 RESTING S+.INT



S/3+TO3ATI1 TREAT3ENT O0 OA

De$rease o" joint loading



j g

7 ;eight $ontrol

7 &plinting

7 Walking sticks

E:er$ises

7 &wimming

7 Walking

7 &trengthening

+atient ed)$ation







$1A&$@ [email protected]&



Goint la/age

Arthroscopy

!artilage gre'ting7 genetic engineering

&urgery

.steotomy

Goint replacement



!hronic $n#ammatoryArthritis



Rheumatoid Artritis

Rheumatoid Arthritis

DeInition



Multisystem Autoimmune$n#ammatory !ondition

&ymmetrical%olyarthropathy&mall )oints

@pidemiology

$t can de/elop at any age but typicallystarts between J7 6 years



starts between J 6 years

,emale*Male (*9

!ommon Arthritis* 9 in 9 de/elop RA

at some stage in their li'e

%athophysiology

1ot completelyelucidatedN



Autoimmune Trigger &yno/ial cell

hyperplasia andendothelial cell acti/ation

uncontrolledin#ammation bonedestruction

enetics

&ymptoms and &igns

Morning sti:ness lasting O9 hourP

&welling in O )ointsP



&welling in O )oints

&welling in hand )ointsP &ymmetric )oint swellingP

@rosions or declaciIcations on =ray o'hand

Rhematoid nodules Abnormal serum R,PMust be present O6 weeks

Rheumatoid Arthritis A person shall be said

to have rheumatoidarthritis if he or she has



satisfied 4 of 7 criteria,

with criteria 1-4present for at least 6weeks

@=tra7articularmani'estations



Functional Presentation andDisability of RA In the initial stages of each joint involvement, th

warmth, pain, and redness, with corresponding d



p p g

of range of motion of the affected joint

rogression of the disease results in reducible anfi!ed deformities

"uscle weakness and atroph# develop earl# in thof the disease in man# people

$n/estigations

>loods ,>! 0@s 2,Ts @&R !R% R, anti !!%



$maging



Complications of Rheumatoid Arthritis

$omplications include% $arpal tunnel s#ndrome, &aker's c#st, vasculitis, subcu



p # , # , ,nodules, (j)gren's s#ndrome, peripheral neuropath#, cpulmonar# involvement, *elt#'s s#ndrome, and anemia



DMARD&

[email protected]@AT@ (Irst line7 oral ulcersalopecia $ upset hepatoto=ic



&2,A&A2AQ$1@7 $ upset lesshepatoto=ic

2@,21.M$D@7 2i/er cirrhosis $ upsetalopecia

N.2D7 Rash lomerulonephropathy

N%@1$!$22$AM$1@7 Rash lupus7like illnes

Treatment (urger#%

+emoval ofi fl d i



inflamed s#noviumArthroplast#

h#sical therap#



Vocational Implications ofRheumatoid Arthritis "ost jobs reuiring medium to heav# lifting are not desir

Acti ities s ch as climbing balancing stooping kneeling



Activities such as climbing, balancing, stooping, kneeling

or walking are hampered

/!tremes of weather or abrupt changes in temperature savoided 0 indoor controlled climate better

Lupus Systemic lupus

erythematosus also calledSLE , or lupus2 is anautoimmune disease of the



bod#3s connective tissues

Autoimmune means that theimmune s#stem attacks thetissues of the bod# In (5/,the immune s#stem primaril#attacks parts of the cellnucleus

(5/ affects tissues throughout

the bod# *ive times as man#women as men get (5/ "ostpeople develop the diseasebetween the ages of 1 and4, although it can show upat an# age

Lupus - Anatomy (5/ causes tissue

inflammation and blood vesselproblems prett# muchan#where in the bod# (5/particularl# affects the



particularl# affects the

kidne#s 8he tissues of thekidne#s, including the bloodvessels and the surroundingmembrane, become inflamed swollen2, and deposits ofchemicals produced b# thebod# form in the kidne#s8hese changes make itimpossible for the kidne#s tofunction normall#

ote the granular appearanceof the corte! of these lupusaffected kidne#s 0 it's acrossthe entire surface of bothkidne#s suggesting a chroniccondition

Lupus Anatomy (cont! 8he inflammation of (5/ can be seen in the

lining, covering, and muscles of the heart8he heart can be affected even if #ou arenot feeling an# heart s#mptoms 8he mostcommon problem is bumps and swelling ofth d di hi h i th li i



the endocardium, which is the lining

membrane of the heart chambers andvalves (5/ also causes inflammation and

breakdown in the skin +ashes can appearan#where, but the most common spot isacross the cheeks and nose

eople with (5/ are ver# sensitive tosunlight &eing in the sun for even a shorttime can cause a painful rash (ome peoplewith (5/ can even get a rash fromfluorescent lights

+ashes caused b# (5/ are red, itch#, andpainful 8he most t#pical (5/ rash is calledthe butterfly rash, which appears on theface 0 particularl# the cheeks and across thenose (5/ can also causes hair loss 8he hairusuall# grows back once the disease isunder control

Lupus Anatomy ("oints Almost ever#one with (5/ has joint pain

or inflammation An# joint can beaffected, but the most common spots arethe hands, wrists, and knees 9suall# the

j i t b th id f th b d



same joints on both sides of the bod# are

affected 8he pain can come and go, or itcan be long lasting 8he soft tissuesaround the joints are often swollen, butthere is usuall# no e!cess fluid in the

joint "an# (5/ patients describe musclepain and weakness, and the muscletissue can swell

Lupus Anatomy 5upus can also affect the nervous s#stem causing

headaches, sei:ures, and organic brain s#ndrome



It can cause anemia due to blood loss or from thdisease it does not directl# effect the red blood

regnanc#% the chances of miscarriage, prematuand death of the bab# in the uterus are high

#erone$ati%e #pondyloarthropa $onsist of a group of related

disorders that include +eiter3ss#ndrome, ank#losing spond#litis,psoriatic arthritis, and arthritis in



p

association with inflammator# boweldisease ;ccurs more age at diagnosis in the

third decade and a peak commonl#among #oung men, with a meanincidence between ages < and =4

8he prevalence appears to be about1>

8he male-to-female ratio approaches4 to 1 among adult $aucasians

?enetic factors pla# an importantrole in the susceptibilit# to eachdisease



#erone$ati%e #pondyloarthropa 8he spond#loarthropathies share certain common features, including

of serum rheumatoid factor, an oligoarthritis commonl# involving larthe lower e!tremities, freuent involvement of the a!ial skeleton, faclustering and linkage to @5A-&<7



clustering, and linkage to @5A &<7

8hese disorders are characteri:ed b# inflammation at sites of attachligament, tendon, fascia, or joint capsule to bone enthesopath#2

#acroiliitis (acroiliitis is an

inflammation of thesacroiliac joint ( t ll i l d



(#mptoms usuall# include afever and reduced range ofmotion

icture on the bottomright shows an individualwith 0 sacroiliitis andAnk#losing (pond#litis

8he arrows point to theinflamed and narrowed (I joints 8he# are whitedue to bon# sclerosisaround the joints

An&ylosin$ #pondylitis $hronic disease that primaril#

affects the spine and ma# leadto stiffness of the back 8he

joints and ligaments thatnormall# permit the back to



normall# permit the back to

move become inflamed 8he joints and bones ma# growfuse2 together

8he effects are inflammationand chronic pain and stiffnessin the lower back that usuall#starts where the lower spine is

joined to the pelvis or hip

iagnosis is made through%a2 medical histor# includings#mptoms, b2 B-ra#s, andpossibl# c2 blood tests for@5A-&<7 gene

An&ylosin$ #pondylitis 8reatment options%

Cith earl# diagnosis and treatment,pain and stiffness can be controlledand ma# reduce fusing In women, A(



and ma# reduce fusing In women, A(

is usuall# mild and hard to diagnose /!ercise

"edications% (AIs, (ulfasala:ine osture management

(elf-help aids

(urger#

Reiter's #yndrome Arthritis that produces pain, swelling, redness and heat i

joints It can affect the spine and commonl# involves thethe spine and sacroiliac joints It can also affect man# otof the bod# such as arms and legs "ain characteristic fe



of the bod# such as arms and legs "ain characteristic feinflammation of the joints, urinar# tract, e#es, and ulceraskin and mouth

8he s#mptoms are fever, weight loss, skin rash, inflammsores, and pain

Reiter's #yndrome +eiter3s often begins following

inflammation of the intestinal or urinar#tract It sets off a disease processinvolving the joints, e#es, urinar# tract,and skin "an# people have periodic



and skin "an# people have periodicattacks that last from three to si!months (ome people have repeatedattacks, which are usuall# followed b#s#mptom-free periods

iagnosis is made through a ph#sicale!am, skin lesions, and a test for the

@5A-&<7 gene





Psoriatic Arthritis iagnosis ma# involve B-ra#s, blood

tests, and joint fluid tests 8reatment options%



(kin care 5ight treatment 9.& or 9.A2 $orrective cosmetics "edications% glucocorticoids, (AIs, "A+s

disease-modif#ing anti-rheumatic drugs2 /!ercise +est

@eat and cold (plints (urger# rarel#2

Scleroderma (Systemic sclerosis)

Definition: progressive sclerosis of skin andconnective tissue; fibrous and vascular chanskin, blood vessels, muscles, synovium, inte

http://www.drgreene.org/body.cfm?id=49&action=display&articlenum=429

http://www.drgreene.org/body.cfm?id=49&action=display&articlenum=429



organs. become “hide bound” Immune-mediated disorder; genetic compo

Scleroderma (Systemic sclerosis)

bnormal amounts of fibrous connective tisdeposited in skin, blood vissels, lungs, kidneother organs



!an be systemic or locali"ed #!$%&'( syndr

CREST Syndrome

!alcinosis

$aynaud)sphenomena



phenomena

%sophagealhypomotility

&clerodactyl#skin changes offingers(

'elangiectasia#macula-likeangioma of skin(

More on CRES

T

2rest 'yndrome

CREST Syndrome & scleroderma

http://members.aol.com/_ht_a/REDAPRIL4/index.html






&clerodactyl#locali"edscleroderma offingers(

+a#naud's diseasewith ischemia

Manifestations &

Complications (systemic)

*emale +: ain, stiffness,

polyartheritis



ausea,vomiting

!ough /ypertension $aynauld)s

syndrome Skin atrophy,hyperpigmented

Scleroderma cont.

%sophagealhypomotility leadsto fre0uent reflu1



0

2I complaintscommon

3ung-pleuralthickening andpulmonary fibrosis

$enal disease...leadingcause of death4

Diagnosis/Treatment

Scleroderma $56 autoimmune

disease

$adiological:pulmonary fibrosis,



bone resorption,subcutaneouscalcification, distalesophagealhypomotility

%&$ elevated

CBC anemia Gammaglobulin lelels

elevaed; RA present

Skin biopsy to confirm

Scleroderma: Patient Care

Do)s void cold



rovide small, fre0uentfeedings

rotect fingers

&it upright post meals

o fingersticks

Daily oral hygiene

Scleroderma: Patient Care

7edications: based upon

symptoms:



Immunosuppressive agents steroids remitting agents

Ca channels blockers alpha!adrenergic blockers

"# receptor blockers

AC$ inhibitors Broad spectrum antibiotics



Thank Cou

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Rheumatoid Disorder

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