Introduction to Rheumatology Eldad Ben-Chetrit MD Head Reumatology Unit

Introduction to Rheumatology

Eldad Ben-Chetrit MD

Head Reumatology Unit

“Rheumatology is the internal medicine of the locomotor

system”

What is the source of the termRheumatology?

• Rheuma rheum-, rheuma-, rheumato-, rheumat-

(Greek: flux, that which flows; a stream; discharge)

Components of the locomotor system

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

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

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

Epidemiology

• Degenerative diseases• OA clinical 10-30%

X-ray (>55 yr) 80%

• Soft tissue rheumatism• Fibromyalgia 2-3%

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%

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

CDC: Census Bureau 2004

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

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 !!!

Classification –according to tissue involvement

1. Arthritides (inflammatory diseases)

2. Degenerative diseases

3. Soft tissue rheumatism

4. Muscular disorders

5. Bone disorders

6. Other

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

EtiologyHLA-DR4

HLA-B 27

HLA-B 51

ENVIRONMENTAL AND HOST FACTORS IN RHEUMATIC DISEASES

Environmental Factors Infectious Agents Host Factors

Geographical Race

Socio-economic Genetics

Occupation Sex

Diet Age

Toxins

SYMPTOMS AND SIGNS OF JOINT DISEASES

SYMPTOMS

Pain

Stiffness

Loss of Function

Systemic Features

SIGNS

Heat

Redness

Swelling

Tenderness

Loss of Movement

Deformity

Crepitus

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

Diagnostic Steps In Rheumatology

1.History taking

2.Physical examination

3.Radiology (imaging)

4.Laboratory methods

5.Histology (biopsy)

History taking

1.Onset (acute - chronic)2.Distribution (symmetry, migration, mono-polyart.)3.Severity (impairment, hospitalization)4.Functional capacity (at home, at work)

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

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

Physical examination Guidelines

Gait

Arms

Legs

Spine

Physical examination

* swelling * pain, tenderness * temperature, * colour * crepitation

* deformities

Rheumatoid Nodules

Radiological examination: aims

• Diagnostic value (RA, AS, OA)

• Differential diagnostic value (metast.)

• Progression, indicator of therapy (erosions)

Clinical Course of Progressive RA

Joint Inflammation

Joint Destruction

Functional Limitation

Physical Disability

Premature Mortality

Early RA

Late RA

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

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

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 ??

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

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

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

Histology(Diagnostic

value)

• Rheumatoid arthritis (?)• Tuberculosis• Sarcoidosis• Gout• Hemochromatosis• Multicentric

reticulohistiocytosis (RHS)• Pigmented villonodular

synovitis

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”

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

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

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.

The Sun is Rising for Patients with Rheumatic Diseases: The Future is Bright

History taking

1.Complaints (duration)

2.History of present symptoms

3.Previous illnesses

4.Social history

5.Family history

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

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

CDC: Census Bureau 2004