关节炎(英文)（专业应用）.ppt

Things may come to those who wait, but only the things left by those who hustle.” – Abraham LincolnPathology of ArthritisDr. Venkatesh M. Shashidhar.Associate Professor of PathologyFiji School of MedicineArthritisArthritisJoints:ØMobility - Cranial sutures  Shoulder joint.ØArticular cartilage – hyaline – friction res.ØSynovial fluid – lubric/nutri, Type A & B synoviocytes. Hyaluronidase ØContinuous production and absorption. Affected by Inflammation, immobility.ØCapsule, ligaments, menisci.ØVascular, rich nerve supply Ø– Art. Cartilage*ArthritisArthritisJoints - AnatomyArthritisArthritisArthritis - IntroductionØInflammation of joints - CommonØCommon site for autoimmune injury§Heart valves & Joints - damage – Exposure of hidden antigens.ØInfections.ØDegeneration – Age/Stress/life styleØUse it or Loose it….!ArthritisArthritisArthritis – Clinical features:ØPain § Inflammation - capsule, synovium, periosteum.ØSwelling:§ inflammation, effusion, proliferation.ØRestricted movement § pain, fluid, synovial swelling, damage.ØDeformity § mal-alignment, erosion, ankylosisArthritisArthritisArthritis Clinical Classification:ØMonoarthritis: §Local, asymmetric, secondary.§Acute: Bacterial, Trauma, Crystal, Reactive§Chronic :Tuberculosis, Lyme, Fungal, Trauma, Tumors.ØPolyarthritis:§Chronic, symmetric, systemic.§Autoimmune, degenerative, Crystal.§Rarely infective.ArthritisArthritisPolyarthritis Classification:ØAutoimmune: §Rheumatic, Rheumatoid, Ankylosing spondylitis, Reiter syndrome etc. ØDegenerative: OsteroarthritisØ Crystal Deposition: §Gout – Monosodium urate§CPPD - Pseudo GoutØInfective - Septic, TB, Lyme etc. rare.Rheumatoid ArthritisArthritisArthritisEpidemiology of RAØPrevalence about 1% of US populationØFemale : Male ratio = 2:1ØStrong association with HLA DR4.ØConcordance in identical twins only 30%ArthritisArthritisRA - Definition:ØChronic Multisystem autoimmune inflammatory disorder primarily affecting joints producing a proliferative synovitis that often progresses to destruction of the articular cartilage and ankylosis.ArthritisArthritisEtiology:ØGenetic Susceptibility:§HLA DR4, or DR1 in 65% to 80% cases.ØMicrobial inciting agent:§Epstein-Barr virus, Borrelia & MycoplasmaØAutoimmunity:§IGM anti IgG – RA Factor.§Helper T cell (CD4) against type II collagen & cartilage glycoprotein-39ArthritisArthritisImmuno-dysregulation in RAØT lymphocytes  type II collagen & superantigen  releasing cytokines  inflammation.ØB cells  IgM Rheumatoid factor – anti IgG.ØMacrophages surround RF factor complex  type III injury (immune complex)  cytokine release  inflammation damage.ArthritisArthritisMorphology:ØProliferative synovitis with lymphocytes (CD4), plasma cell & macrophages Pannus.ØOrganizing fibrin (rice bodies).ØNeutrophils on the joint surface and fluid.ØJuxta-articular erosions, cysts & osteoporosisØFibrous ankylosis. ØSkin - Rheumatoid nodulesØVasculitis (commonly of digital arteries)ArthritisArthritisEarly Destruction in RA:Swan NeckDeformityArthritisArthritisRA - Clinical Features:1.Morning stiffness.2.Arthritis in 3 or more joint areas.3.Arthritis of small hand joints.4.Symmetric arthritis.5.Rheumatoid nodules.6.Serum rheumatoid factor.7.Typical radiographic changesAt least 4 features for diagnosis.ArthritisArthritisN.Synovium - - R.Arthritis:RA - Pannus:ArthritisArthritisRA - Pannus:Hyperplastic Hyperplastic inflammed inflammed synoviumsynoviumArthritisArthritisExtra-Articular RAØRheumatoid NodulesØVasculitisØPleuritisØPericarditisØTendonitisArthritisArthritisSkin RA Nodule:ArthritisArthritisSkin RA Nodule:ArthritisArthritisRheumatoid Nodule (skin):PalisadingPalisadingMacrophagesMacrophagesCentralCentralFibrinoidFibrinoidNecrosisNecrosisArthritisArthritisJoint involvement in RA:ArthritisArthritisSwan Neck Deformity in RA:ArthritisArthritisJoint Destruction in RA:Swan NeckDeformityArthritisArthritisRA Joint destruction, ankylosis:OsteoarthritisDegenerative arthrosis.(Osteoarthrosis)ArthritisArthritisOsteoarthritis:ØDegenerative end result - (ageing) >80% in >65y.ØProgressive erosion & fibrillation of articular cartilage  forms Loose bodies.ØLarge weight bearing joints.ØHardened articular bone – eburnation. & Subarticular cyst formation in bone.ØPeriarticular osteophyte formation. ØMild inflammation but painful, morning stiffness.ØLimited range of movements Heberden nodes (F)ArthritisArthritisNormal -- Femur Head -- OANormalOsteoarthritisArthritisArthritisFemur Osteroarthritis:ArthritisArthritisJoint Mice or Loose Bodies:ArthritisArthritisSpine Osteophytes (OA):ArthritisArthritisRadiologic Features:Ønonuniform joint space loss, Øosteophyte formation, Øcyst formation Øsubchondral sclerosisØSclerosis, ankylosis & deformity.Osteoarthritis:•Narrow joint space•Lipping – osteophyte•Dislocation•Osteoporosis.Osteophyte formation:Bone cysts in OA:ArthritisArthritisOsteoarthritis: AnkylosisØvarus deformity of the knee and collapse of the joint space with destruction of the medial cartilage and the subchondral cortex (open arrowheads). ArthritisArthritisOsteoarthritis:ØLateral view of the left knee shows sclerosis with marked osteophyte formation (arrows). The osteophytes are best seen in this view. ArthritisArthritisOsteoarthritis:ØSubchondral cysts (solid arrowhead) ArthritisArthritisOA Fingers:ArthritisArthritisOA 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 the left side OA Hip:left hip arthroplasty ArthritisArthritisOA - Clinical Features:Øpain worsens with activity & improves on rest.ØInstability of joints – Knee.ØCrepitus, limitation of motion. Muscle spasm, and tendon and capsular contractures.ØEarly morning stiffness lasts 1 hour or more.Øbony overgrowth – interphalangeal joints distal(Heberden's) proximal (Bouchard's).ArthritisArthritisDifferentiating Features:Rheumatoid Arthritis:Rheumatoid Arthritis:ØYoung, small jointsØAutoimmune.ØSynovial InflammationØsynovium  CartilageOsteoarthritis:Osteoarthritis:ØOld, Large jointsØDegenerative.ØCartilage degeneration.ØCartilage  SynoviumArthritis Other Infective, traumatic, secondary to systemic diseases. ArthritisArthritisSeronegative arthropathiesØAnkylosing Spondylitis:§Adolescent boys, HLA B27, axial joints (sacroiliac)ØReiter Syndrome:§Triad of arthritis, urethritis/cervicits & conjuctivitis§Autoimmune but initiated by bacterial infection.ØEnteropathic Arthritis:§Secondary to bowel infections (salmonella, shigella)§HLA B27 positiveØPsoriatic Arthritis:§5% of patients, starts in DIP joints, similar to RA.Septic Arthritis:ORGANISM PEAK AGE INCIDENCE GRAM STAIN Hemophilus influenzae Children Gram negative coccobacilli Neisseria gonorrheae Young adults Gram negative diplococci Salmonella young with Sickle Cell An. Gram negative rods Staph. aureus Adults Gram positive cocci in clusters Escherichia coli Adults Gram negative rods Pseudomonas Adults Gram negative rods ArthritisArthritisGonococcal Arthritis:ArthritisArthritisJuvenile Rheumatoid Arthritis:ØBefore age 16ØMultisystem involement - Spleenomegaly,ØStarts with systemic involvement unlike RA.ØNo serum RA Factor – SeronegativeØAntinuclear Antibody (ANA) +ve  autoimmune.ArthritisArthritisBig Toe in Gout:ArthritisArthritisJoint Destruction in Gout:ArthritisArthritisGout Tophi:ArthritisArthritisUrate Crystals (Gout):Pseudo Gout•Calcium PyroPhosphate Deposition disease•CPPD•Chondrocalcinosis.ArthritisArthritisCPPD – (Chondrocalcinosis)ØType A – Pseudo gout – Knee, menØType B – Pseudo rheumatoid - polyarthritisØType C – Pseudo OA + acute attacks, womenØType D – Pseudo OA - acute attacks, handsØType E – AsymptomaticØType F – PseudoneuropathicArthritisArthritisCPPD-Arthritis (pseudo gout):ArthritisArthritisPseudo Gout – Calcium pyrophoshateArthritisArthritisAnkylosing SpondylitisØMarie-Strumpell ArthritisØYoung males, 90% HLA B27 +Ø<1% Rheumatoid factor – seronegative.Ø>25% have iritisØ10% Aortic insufficiencyØStrongly familial, 100% concordance in monozygotic twins.AS - fusion of vertebral bodies due to bridging syndesmophytes.ArthritisArthritisScoliosis in Ankylosing SpondylitisArthritisArthritisOrganisms in Reiter’s ØShigella FlexneriØSalmonellaØS.typimurium – othersØYersinia enterocoliticaØCampylobacter JejuniØChlamydia trachomatisØUreaplasma urealyticumArthritisArthritisArthritis Comparison:"The gem cannot be polished without friction, nor man perfected without trials or problems (or exams)…!."--Chinese proverbArthritisArthritisPathology of Reiter’s SyndromeØAcute SynovitisØChronic changes (in some)ØUnilateral SacroilitisØAscending arthropathyØOssification & enthesopathyØIleal, colonic or urethral - non specific mucosal inflammationArthritisArthritisReiter’s Syndrome:ArthritisArthritisIritis:ArthritisArthritis。