关节炎(英文).ppt

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1、“Things may come to those who wait,but only the things left by those who hustle.”Abraham LincolnPathology of ArthritisDr.Venkatesh M.Shashidhar.Associate Professor of PathologyFiji School of MedicineArthritis ArthritisJoints:Mobility-Cranial sutures Shoulder joint.Articular cartilage hyaline frictio

2、n res.Synovial fluid lubric/nutri,Type A&B synoviocytes.Hyaluronidase Continuous production and absorption.Affected by Inflammation,immobility.Capsule,ligaments,menisci.Vascular,rich nerve supply Art.Cartilage*Arthritis ArthritisJoints-AnatomyArthritis ArthritisArthritis-IntroductionInflammation of

3、joints-CommonCommon site for autoimmune injury Heart valves&Joints-damage Exposure of hidden antigens.Infections.Degeneration Age/Stress/life styleUse it or Loose it.!Arthritis ArthritisArthritis Clinical features:Pain Inflammation-capsule,synovium,periosteum.Swelling:inflammation,effusion,prolifera

4、tion.Restricted movement pain,fluid,synovial swelling,damage.Deformity mal-alignment,erosion,ankylosisArthritis ArthritisArthritis Clinical Classification:Monoarthritis:Local,asymmetric,secondary.Acute:Bacterial,Trauma,Crystal,Reactive Chronic:Tuberculosis,Lyme,Fungal,Trauma,Tumors.Polyarthritis:Chr

5、onic,symmetric,systemic.Autoimmune,degenerative,Crystal.Rarely infective.Arthritis ArthritisPolyarthritis Classification:Autoimmune:Rheumatic,Rheumatoid,Ankylosing spondylitis,Reiter syndrome etc.Degenerative:Osteroarthritis Crystal Deposition:Gout Monosodium urate CPPD-Pseudo Gout Infective-Septic,

6、TB,Lyme etc.rare.Rheumatoid ArthritisArthritis ArthritisEpidemiology of RAPrevalence about 1%of US populationFemale:Male ratio=2:1Strong association with HLA DR4.Concordance in identical twins only 30%Arthritis ArthritisRA-Definition:Chronic Multisystem autoimmune inflammatory disorder primarily aff

7、ecting joints producing a proliferative synovitis that often progresses to destruction of the articular cartilage and ankylosis.Arthritis ArthritisEtiology:Genetic Susceptibility:HLA DR4,or DR1 in 65%to 80%cases.Microbial inciting agent:Epstein-Barr virus,Borrelia&MycoplasmaAutoimmunity:IGM anti IgG

8、 RA Factor.Helper T cell(CD4)against type II collagen&cartilage glycoprotein-39Arthritis ArthritisImmuno-dysregulation in RAT lymphocytes type II collagen&superantigen releasing cytokines inflammation.B cells IgM Rheumatoid factor anti IgG.Macrophages surround RF factor complex type III injury(immun

9、e complex)cytokine release inflammation damage.Arthritis ArthritisMorphology:Proliferative synovitis with lymphocytes(CD4),plasma cell¯ophages Pannus.Organizing fibrin(rice bodies).Neutrophils on the joint surface and fluid.Juxta-articular erosions,cysts&osteoporosis Fibrous ankylosis.Skin-Rheum

10、atoid nodules Vasculitis(commonly of digital arteries)Arthritis ArthritisEarly Destruction in RA:Swan NeckDeformityArthritis ArthritisRA-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 rheu

11、matoid factor.7.Typical radiographic changesAt least 4 features for diagnosis.Arthritis ArthritisN.Synovium-R.Arthritis:RA-Pannus:Arthritis ArthritisRA-Pannus:Hyperplastic Hyperplastic inflammed inflammed synovium synoviumArthritis ArthritisExtra-Articular RARheumatoid NodulesVasculitisPleuritisPeri

12、carditisTendonitisArthritis ArthritisSkin RA Nodule:Arthritis ArthritisSkin RA Nodule:Arthritis ArthritisRheumatoid Nodule(skin):Palisading PalisadingMacrophages MacrophagesCentral CentralFibrinoid FibrinoidNecrosis NecrosisArthritis ArthritisJoint involvement in RA:Arthritis ArthritisSwan Neck Defo

13、rmity in RA:Arthritis ArthritisJoint Destruction in RA:Swan NeckDeformityArthritis ArthritisRA Joint destruction,ankylosis:OsteoarthritisDegenerative arthrosis.(Osteoarthrosis)Arthritis ArthritisOsteoarthritis:Degenerative end result-(ageing)80%in 65y.Progressive erosion&fibrillation of articular ca

14、rtilage forms Loose bodies.Large weight bearing joints.Hardened articular bone eburnation.&Subarticular cyst formation in bone.Periarticular osteophyte formation.Mild inflammation but painful,morning stiffness.Limited range of movements Heberden nodes(F)Arthritis ArthritisNormal-Femur Head-OANormalO

15、steoarthritisArthritis ArthritisFemur Osteroarthritis:Arthritis ArthritisJoint Mice or Loose Bodies:Arthritis ArthritisSpine Osteophytes(OA):Arthritis ArthritisRadiologic Features:nonuniform joint space loss,osteophyte formation,cyst formation subchondral sclerosisSclerosis,ankylosis&deformity.Osteo

16、arthritis:Narrow joint space Lipping osteophyte Dislocation Osteoporosis.Osteophyte formation:Bone cysts in OA:Arthritis ArthritisOsteoarthritis:Ankylosis varus deformity of the knee and collapse of the joint space with destruction of the medial cartilage and the subchondral cortex(open arrowheads).

17、Arthritis ArthritisOsteoarthritis:Lateral view of the left knee shows sclerosis with marked osteophyte formation(arrows).The osteophytes are best seen in this view.Arthritis ArthritisOsteoarthritis:Subchondral cysts(solid arrowhead)Arthritis ArthritisOA Fingers:Arthritis ArthritisOA Hip:OA Hip:1997,

18、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 Arthritis ArthritisOA-Clinical Features:pain worsens with activity&improves on rest.Ins

19、tability of joints Knee.Crepitus,limitation of motion.Muscle spasm,and tendon and capsular contractures.Early morning stiffness lasts 1 hour or more.bony overgrowth interphalangeal joints distal(Heberdens)proximal(Bouchards).Arthritis ArthritisDifferentiating Features:Rheumatoid Arthritis:Rheumatoid

20、 Arthritis:Young,small joints Autoimmune.Synovial Inflammation synovium CartilageOsteoarthritis:Osteoarthritis:Old,Large joints Degenerative.Cartilage degeneration.Cartilage SynoviumArthritis Other Infective,traumatic,secondary to systemic diseases.Arthritis ArthritisSeronegative arthropathies Ankyl

21、osing Spondylitis:Adolescent boys,HLA B27,axial joints(sacroiliac)Reiter Syndrome:Triad of arthritis,urethritis/cervicits&conjuctivitis Autoimmune but initiated by bacterial infection.Enteropathic Arthritis:Secondary to bowel infections(salmonella,shigella)HLA B27 positive Psoriatic Arthritis:5%of p

22、atients,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 pos

23、itive cocci in clusters Escherichia coli Adults Gram negative rods Pseudomonas Adults Gram negative rods Arthritis ArthritisGonococcal Arthritis:Arthritis ArthritisJuvenile Rheumatoid Arthritis:Before age 16Multisystem involement-Spleenomegaly,Starts with systemic involvement unlike RA.No serum RA F

24、actor SeronegativeAntinuclear Antibody(ANA)+ve autoimmune.Arthritis ArthritisBig Toe in Gout:Arthritis ArthritisJoint Destruction in Gout:Arthritis ArthritisGout Tophi:Arthritis ArthritisUrate Crystals(Gout):Pseudo Gout Calcium PyroPhosphate Deposition disease CPPD Chondrocalcinosis.Arthritis Arthri

25、tisCPPD(Chondrocalcinosis)Type A Pseudo gout Knee,men Type B Pseudo rheumatoid-polyarthritis Type C Pseudo OA+acute attacks,women Type D Pseudo OA-acute attacks,hands Type E Asymptomatic Type F PseudoneuropathicArthritis ArthritisCPPD-Arthritis(pseudo gout):Arthritis ArthritisPseudo Gout Calcium pyr

26、ophoshateArthritis ArthritisAnkylosing SpondylitisMarie-Strumpell ArthritisYoung males,90%HLA B27+25%have iritis10%Aortic insufficiencyStrongly familial,100%concordance in monozygotic twins.AS-fusion of vertebral bodies due to bridging syndesmophytes.Arthritis ArthritisScoliosis in Ankylosing Spondy

27、litisArthritis ArthritisOrganisms in Reiters Shigella FlexneriSalmonellaS.typimurium othersYersinia enterocoliticaCampylobacter JejuniChlamydia trachomatisUreaplasma urealyticumArthritis ArthritisArthritis Comparison:The gem cannot be polished without friction,nor man perfected without trials or pro

28、blems(or exams)!.-Chinese proverbArthritis ArthritisPathology of Reiters SyndromeAcute SynovitisChronic changes(in some)Unilateral SacroilitisAscending arthropathyOssification&enthesopathyIleal,colonic or urethral-non specific mucosal inflammationArthritis ArthritisReiters Syndrome:Arthritis ArthritisIritis:Arthritis Arthritis