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SEROPOSITIVEARTHRITIS

INTRODUCTION SEROPOSITIVE ?• RA FACTOR • Anti-CCP antibodies RF assosciationsRheumatology: Rheumatoid Arthritis; SLE; Sjogren’s; MCTD; Myositis;

Cryoglobulinemia;Others:; syphilis; Sarcoidosis; cirrhosis; Walden storm's

macroglobulinemia; etc …. RA factor is seen in 5-10% of normal population as well

Rheumatoid Arthritis  Chronic systemic inflammatory disease Affects many organs Predominantly attacks the synovial tissues and joints. Peak 20-55yrs approximately 1% of the population M:F = 1:3 Clinincally Low-grade fever, fatigue, weight loss, muscle

soreness, and atrophy Symmetric peripheral joint pain and swelling, particularly of the

hands

Typically involves small joints : metatarsophalangeal and metacarpo-phalangeal and carpal joints (very often

SYMMETRICAL involvement) Axial skeleton involvement in advanced stages

RADIOLOGICAL FINDINGS

X-RAYS1. Soft-tissue changes2. Osteoporosis3. Joint space changes and alignment deformities4. Periostitis5. Erosions6. Secondary osteoarthritis

SOFT TISSUE CHANGES More clinical exam than radiological finding Swelling due to 1. oedema of peri- articular tissues 2. synovial inflammation in bursae, joint spaces and along

tendon sheaths. 3. Joint distension increased synovial fluid. Hands: most commonly seen fusiform swelling metacarpophalangeal joints ulnar styloid (invl of ext carpi ulnaris tendon) radial styloid (invl of radiocarpal synovial hypertrophy)

Foot Similar fusiform swelling can be found in the 1st and 5th metatarsal heads

OSTEOPOROSIS Assessment of osteoporosis depends in part on film quality,

and comparison between normal and abnormal joints in the same patient.

Interpretation is subjective and changes are seen only after loss of 25-50% of mineral density

Types 1. Late/Generalised ( steroid and limitation of movement)2. Early/ Localized (synovial inflammation and hyperaemia) Generalised or solitary sclerosis one or more distal

phalanges is an important finding

Terminal phalangeal sclerosisNew bone with no ,medullary

cavity .IVORY PHALANX

JOINT SPACE CHANGES EARLY WIDENING due to synovial hypertrophy and Effusion LATER NARROWING of joint space due to cartilage

destruction by pannus Allignment abnormalities at joint due to weakening of

capsule and tendinitis Leads to tendon rupture or improper muscle action

The boutonniere deformity results from proximal interphalangeal joint flexion and distal intcrphalangeal joint extension

swan-neck deformity proximal interphalangeal joint extension and distal interphalangeal joint flexion.

The boutonniere deformity is the more common.Z-deformity radial deviation at the wrist;ulnar deviation of the digits, and often palmar subluxation of

the proximal phalanges

JOINT SPACE CHANGES

Swan neck deformity

Coronal contrast- enhanced fat-saturated T1-weighted MR image shows hyperenhancement of small joints in the hand (arrows), a finding that reflects hyperemic synovial tissue. Erosions (arrowheads) and thickened, intensely enhancing synovium are seen at the fifth metacarpophalangeal joint

EROSIONS Most important diagnostic feature Incidence rises with duration progresses (<40% at

3months to 90-95% at 10years ) Peri-articular erosion starts in the bare area In Hand 1. Carpal erosions occur extensively.2. Ulnar and radial styloid 3. Proximal compartment of distal radioulnar joint.4. Fusion is inevitable especially in CARPAL joints In Foot1. Earlier seen in feet most often 5th metacarpo-

phalangeal joint.2. Apart from posterior and inferior surfaces of 3. CALCANEUM tarsal erosion are uncommon4. (Tarsal erosion is seen commonly in sero-

negative)

Local Demeneralisation progressive resorption of Sub-cortical Bone Pannus spread Destruction of articular cartilage

Once destroyed the articular cartilage rarely reforms on healing

Erosive changes are less common in larger joints but bone destruction Is more

I

A. Diagram. Three sites for potential erosions to occur are shown.  B. Erosions. Note the erosion from the extensor carpi ulnaris (rat

bite lesion) (arrow) and prestyloid recess (arrowhead). Note the adjacent erosion on the triquetral bone (crossed arrow). 

C. Erosions. Note the three sites of ulnar erosion: extensor carpi ulnaris (arrow), prestyloid recess (arrowhead), and radioulnar articulation (crossed arrow). Observe the adjacent soft tissue swelling

RHEUMATOID ARTHRITIS: FEET A. Diagram, Marginal Erosions. Target sites for marginal

erosions lie on the medial surfaces of the metatarsal heads, except for the fifth metatarsal where early erosions can occur on the lateral side.

 B. PA Foot. Typical radiographic depiction of the locational predominance on the medial metatarsal surfaces, except at the fifth. Note the phalangeal fibular deviation. (Lanois deformity)

Coronal contrast-enhanced fat-saturated T1-weighted MR image shows synovitis of the second and third metacarpophalangeal joints. A subcortical cyst (arrowhead) is seen near the bare area

This type of lesion is called a pre-erosion or subcortical erosion

MR image shows a small effusion of the third metacarpophalangeal joint

PERIOSTEITIS

Local periosteal reactions occur either along the midshaft of a phalanx or metacarpal as a reaction to local tendinitis, at the metaphysis near a joint affected by synovitis. Such changes are less common in rheumatoid arthritis than in the seronegative arthropathies

SECONDARY OA CHANGES Seen in Weight bearing joints Its seen at Hip joints commonly. Superimposes the undetected RA ASYMMETRY IS KEY IN DIAGNOSIS Reactive sclerosis and new bone formation

in osteoarthritis is not marked

INVOLVEMENT OF AXIAL SKELETON C1 /C2 JOINT Osteoporosis with disc narrowing Endplate irregularity. Little new bone formation Erosions of facet joints result in Subluxation Commonly seen in the synovial joint between the

odontoid peg and arch of atlaspotentiated by laxity of ligaments around the peg. Separation in flexion of more than 2.5 mm in adults

or 5 mm in children is held to be abnormal. 30% of patients with chronic rheumatoid arthritis

and is best seen in flexion. The eroded odontoid may also fracture

the translocation of odontoid into and beyond the foramen magnum (arrows) owing to erosion and destruction of the upper two cervical vertebrae

SACRO-ILIAC JOINT Sacro iliac Joint Changes are less common and less

severe than Spinal changes More common in seronegative

disease but may be seen in up to 30% of those with longstanding disease.

Seen more in women Usually unilateral and involving the

lower two thirds of the joint; erosions present but no sclerosis; rarely, ankylosis.

Shoulder joint changes Uniform loss of

glenohumeral joint space, marginal erosions (particularly at the superior lateral portion of the humerus), humerus often subluxated superiorly, tapered distal clavicle, seemingly widened acromioclavicular joint space.

Hip joint changes RHEUMATOID ARTHRITIS:

PROTRUSIO ACETABULI. A. AP Hip Unilateral. Observe the

symmetric loss of joint space and axial migration of the femoral head, creating a protrusio acetabuli (arrow).

 B. AP Pelvis Bilateral. Note the uniform loss of joint space, small femoral heads, and protrusio acetabuli, characteristic of long-standing rheumatoid arthritis. 

Note: The most common cause for bilateral protrusio acetabuli in the adult is rheumatoid arthritis

Knee joint changes

A. Uniform Loss of Joint Space. Despite the loss of joint space, the distinct absence of subchondral sclerosis and diffuse osteopenia. B. Suprapatellar Effusion. Observe the bulging soft tissue density owing to effusion (arrows). A patellar erosion can also be appreciated. C. Baker’s Cyst. Note that on arthrography the extent of the cyst is defined extending into the popliteal space (arrows). Observe the rupture and dissection of the rheumatoid cyst into the posterior calf.

BONE SCAN

Whole-body radioisotope scan showing areas of increase in uptake in the neck, both shoulder joints, the elbow joints, the left hip, both knees and ankles The distribution of disease is shown, but the changes on this scan are not specific.

RA is a systemic disease with RA is a systemic disease with extraarticular manifestationsextraarticular manifestations

Eyes KeratoconjunctivitisSicca syndromeScleritisEpiscleritisKeratitis corneal ulcerationChoroiditisRetinal vacuitiesEpiscleral nodulesLungsPleuritis ± pleural effusionsPulmonary nodulesInterstitial pulmonary fibrosis

HeartPericarditisMyocarditisEndocarditisValvular fibrosis

LiverEnzyme abnormalities due to drug reactions or Sjögren’s syndrome

Blood / blood vesselsMild anemiaVasculitisFelty’s syndrome

SkinRheumatoid nodules VasculitisInterstitial granulomatous dermatitis

Firestein. ACP Medicine, Rheumatology II

Secondary Sjögren’s syndrome

RA: Current Pharmacologic OptionsRA: Current Pharmacologic Options Agents that are effective in controlling the signs and symptoms of RA, but

have no effect on disease progression

NSAIDs reduce inflammation and pain COX-2 inhibitors are similar to NSAIDs, but with improved GI safety and

tolerability and higher cardiac side effects Analgesics- these medicines do not affect inflammation, but work on pain

pathways to decrease subjective feeling of pain.

DMARDs impact the signs, symptoms, and disease progression of RA, as well as improve the quality of life and functionality of the patient

Corticosteroids have anti-inflammatory and immunoregulatory activity, but nominal disease-modifying capability

Irvine S, et al. Ann Rheum Dis. 1999;58:510–513; Madhok R, Capell HA. Lancet 1999;353:257–258; ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46:328–346; Goldbach-Mansky R, Lipsky PE.Annu Rev Med. 2003;54:197–216.

RA: Disease Modifying therapiesRA: Disease Modifying therapies

Traditional DMARDs Biological DMARDSFor example For example

Methotrexate Leflunomide (Arava®) Sulfasalazine (SSZ,

Azulfidine®) Hydroxychloroquine

(HCQ, Plaquenil®)

TNF antagonists Etanercept (Enbrel®) Adalimumab (Humira®) Infliximab (Remicade®) Certolisumab pegol (Cimzia®) Golimumab (Simponi®)

Abatacept (Orencia®) Rituximab (Rituxan®) Azathioprine,

cyclosporine Tocilizumab (Actemra®) Tofacitinib (Xeljanz®)

British Journal of Nursing (2013) volume: 22 issue: 6 – 308, 310, 318

British Journal of Nursing (2013) volume: 22 issue: 6 – 308, 310, 318

SLE chronic, inflammatory, connective tissue

disorder of unknown cause Common in young females Classical Butterfly Rash over face. SLE, like many autoimmune diseases,

affects females more frequently than males, at a rate of almost 9 to 1.

RA factor , ANA Unlike rheumatoid arthritis, lupus arthritis

is less disabling <10% lupus arthritis will develop deformities of the hands and feet

present with a symmetrical peripheral arthropathy

Soft tissues swelling with calcification around joints and in blood vessels

Erosion is minimal and usually does not cause severe destruction of the joints.

SLE Most deformities as in swan neck , ulnar

deviation are reversible and arise due to tendon or ligament laxity

Avascular necrosis is common

Dermatomyositis Calcinosis Interstitialis Universalis Degeneration of collagen tissue diffuse subcutaneous plaques or nodules of

calcium or reticular calcification often with overlying ulceration.

In addition with progression, calcified masses or sheets of calcium and phosphate metabolism.

Seen in quadriceps, deltoid , calf muscles , elbows, kness, hands, abdominal wall, chest wall

Pointing and resorption of terminal tufts Bone erosions are not a feature of these

diseases. Progressive disease is invariably fatal High incidence of malignancy is seen

POLYMYOSITIS

Polymyositis (PM) refers a rare autoimmune (at times considered paraneoplastic) inflammatory myositis. It is considered a form of idiopathic inflammatory myopathy.

The condition is closely related to dermatomyositis and the term “polymyositis” is applied when the condition spares the skin.

Progressive systemic sclerosis (SCLERODERMA) CREST SYNDROME (CalcinosisRaynauds phenomenon : episodes of intermittent pallor of the fingers and

toes on exposure to cold, secondary to vasoconstriction of the small blood vessels)

Esophageal abnormalities: dilatation and hypoperistalsisSclerodactyly Telengiectasia

30% to 40% of patients have a positive serologic test for rheumatoid factor and a positive antinuclear antibody (ANA) test.

Progressive systemic sclerosis Bone changes1. acro-osteolysis (resorption of the distal phalanges)2. periarticular osteoporosis3. joint space narrowing4. erosions Soft tissue changes1. subcutaneous and periarticular calcification2. atrophy especially at tips of fingers3. With retraction of skin4. flexion contractures Other less common documented

musculoskeletal findings

1. rib resorption, mandibular angle resorption, radius and ulna resorption

2. terminal phalangeal sclerosis

Corroborative findings are seen in the gastrointestinal tract, where dilatation of the esophagus and small bowel

Pseudo diverticula of colon is also seen

In lungs Most predominant feature will be fibrosis early stages may show ground glass

changes later stages may

show honeycombing and evidence of lung volume loss

lung bases and sub-pleural regions typically involved 

cysts may be present measuring 1-5cm in diameter 

pleural effusions are usually not a feature

ESOPHAGEAL DILATATION IS PATHOGNONOMIC

MCTD MIXED CONNECTIVE TISSUE DISEASE Overlap syndrome ( mix of Rheumatoid arthritis,

dermatomyositis, SLE, Progressive systemic sclerosis) The distribution may mimic rheumatoid arthritis, but

distal interphalangeal joints may be affected and the peripheral arthropathy may be asymmetrical.

Osteoporosis (JUXTA ARTICULAR) Soft tissue swelling and Joint space narrowing. Erosive changes are not frequent as in RA Distal phalanges show soft tissue loss, distal tuft

bone resorption and calcification is feature of Progressive systemic sclerosis

Sjogren’s syndrome

Chronic Autoimmune disease Primarily affect Salivary and lacrimal glands resulting in XEROSTOMIA

and keratoconjuctivtis sicca

Secondary Sjogren’s seen most commonly in people with diagnosed with RA

And SLEAs a single entity sjogren’s doesn’t involve the joints.But definitely aggravates the primary Rheumatologic Arthropathy

thereby increasing the Morbidity and Mortality