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156 Cards in this Set
- Front
- Back
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What is a joint?
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Just a space between to bones that allows for them to bend.
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What is unique about the end of a bone at a joint?
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It doesn't have a periosteal covering; but instead it is hyaline cartilage.
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What is a joint encased within?
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A tough fibrous capsule covered.
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What resides within the joint space?
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Synovial fluid
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So normal bone is covered by:
But the ends of bone at a synovial joint are covered by: |
Normal = periosteum covers
Joint = hyaline cartilage |
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What does articular cartilage look like?
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Shiny and smooth
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What cells make up the normal synovium?
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-Synoviocytes
-Adipocytes -Mast cells -Fibroblasts/macrophages |
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What is the outermost layer of the synovial lining?
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Epithelial cells
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What happens to the epithelial synovium when the joint is infected or other?
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They can swell and become enlarged
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What is another name for Osteoarthritis?
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Degenerative joint disease - DJD
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Why is osteoarthritis such a problem?
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Because it is a cause of long term disability 2nd only to CV disease, and costs $$$$
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What is the cause of most cases of osteoarthritis?
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Idiopathic
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How does osteoarthritis develop most often?
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Insidiously as an aging phenomenon
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Once it starts what usually happens in osteoarthritis?
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It progresses slowly and can't be prevented or halted
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What component of the joint is the main thing involved in the pathogenesis of osteoarthritis?
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The cartilage
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What are 4 factors that affect the cartilage degeneration in osteoarthritis?
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-Aging
-Repetitive impact on joints -Cytokine release -Genetics |
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What does cartilage degeneration lead to in osteoarthritis?
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2ndary changes in the synovium
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What do the synovial changes consist of?
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-Inflammation
-Proliferation of Fingerlike projections -Ossification and disturbance of bone |
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What can be seen on xray as a result of ossification of the synovium?
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Osseous loose bodies
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What happens to the articular surface of the joint as a result of ossification of the synovium?
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It becomes shaggy and fibrillated due to the laying down of osseous loose bodies
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What are 3 changes that can be seen WITHIN the articular hyaline cartilage in osteoarthritis?
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-Clefting
-Cartilage clone formation -Duplication of the tidemark |
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What vascular change can take place within the articular cartilage in osteoarthritis?
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Penetration of vascular clones into the cartilage stroma - normally shouldn't be there.
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What happens at the ends of the joints at the cartilage surface?
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Formation of osteophytes
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Why is osteophyte evolution bad?
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Because in smaller joints like vertebral it leads to severe pain and limited joint movement
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What is another name for osteophytes?
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Bone spurs
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What are osteophytes on the fingers/toes at the DIP joint called?
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Heberden's nodes
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What are osteophytes on the fingers/toes at the PIP joint called?
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Bouchard's nodes
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What forms as the degenerative process of osteoarthritis continues?
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Subchondral cysts
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When will symptoms normally arise when osteoarthritis is due to normal aging?
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In the 50's
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What are common causes of osteoarthritis if it develops at a younger age?
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Tumor or Fracture
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Is osteoarthritis more diffuse/generalized, or localized to one or a few joints?
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Localized
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What joints are usually spared from osteoarthritis?
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-Wrists
-Elbows -Shoulders |
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In what sex are heberden nodes more commonly seen?
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Women
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What are symptoms of osteoarthritis?
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-Deep achy pain
-Crepitus/loss of ROM |
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What are some osteophyte compression manifestations?
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-Radicular pain
-Muscle spasms -Muscle atrophy -Neurologic deficits |
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What happens to the joint space in osteoarthritis?
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It becomes narrower!
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What are the 4 main radiographic features of OA?
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-Narrowing of joint space
-Subchondral sclerosis -Subchondral cysts -Osteophytes |
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What is a joint effusion?
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Squeezing of the synovial fluid laterally and medially due to narrowing of the joint space
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Where osteoarthritis is due to degeneration, rheumatoid arthritis is due to:
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Aberrant inflammation - an autoimmune process.
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So what is a major difference in the extent of symptoms seen in RA compared to OA?
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RA has many more symptoms and involves many organs - the heart, vessels, lung, interstitium, etc.
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What genetic component makes immune Tcells prone to present self antigen aberrently?
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MHC Class II genes
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What 2 pathologic process result as a result of aberrent MHC Class II?
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-Bcells make RF
-Macrophages are activated and secrete cytokines/growth factors |
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What does RF lead to?
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Immune complex formation, deposition and joint injury
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What do the cytokines from activated macrophages stimulate?
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Proliferation of fibroblasts, chondrocytes, and synoviocytes
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What 4 proccesses occur as a result of the immune response in rheumatoid arthritis?
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-Pannus formation
-Destruction of bone/cartilage -Fibrosis -Ankylosis |
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What is ankylosis?
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Stiffening of a joint
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So what is the bad response to immune complex deposition in the joints in RA?
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Proliferation of the synovium - all the cells within it, and blood vessels too.
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What is it called when the blood vessels grow onto the articular cartilage?
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Pannus
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What does Pannus result in?
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Destruction of the articular cartilage.
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What develops and can be seen microscopically in the synovium in RA?
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Lymphoid aggregates - some with germinal centers.
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What are they called when lymphoid aggregates "fall off" the pannus and are loose in the synovial space?
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Rice bodies
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What is the process of necrosis seen in RA called and what is it a hallmark of?
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Fibrinoid necrosis - the common feature of collagen disorders like RA.
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What ultimately happens to panus after they grow onto underlying cartilage?
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They grow more collagen, become fibrotic, and chondrolyze
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What happens to a progressive chrondrolyzed pannus?
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It becomes a Fibrous panus
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What develops when 2 fibrous panus's come together?
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They form a Fibrous Ankylosis
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What does Fibrous Ankylosis have the potential to form if it remains for a long time?
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A completely ossified fusion of the joint space.
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What is the clinical course for the majority of RA cases like?
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Slow and insidious
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What will likely be seen in Acute RA cases with severe symptoms?
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Rapid polyarticular progression
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What type of pattern does the joint involvement in RA typically follow?
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Small joints affected before large
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What are the first joints usually affected in RA, and what follows?
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1. Fingers
2. Wrist/ankles, Elbows/knees |
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What part of the spine may be affected in RA?
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Cervical
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What tends to be spared?
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-Lumbosacral spine
-Hips |
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What symptoms are seen at the involved joints in RA?
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-Swollen
-Warm -Painful |
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What are 2 major extra-articular manifestations commonly seen in RA?
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-Rheumatoid nodules
-Rheumatoid vasculitis |
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What % of RA cases tend to get rheumatoid nodules?
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25% - the severe cases
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What are the most common sites for rheumatoid nodules to be found?
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Skin - at pressure points
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What do Rheumatoid nodules feel like?
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Firm and nontender, round to oval
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What are 4 common pressure point areas to find rheumatoid nodules?
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-Forearm
-Elbows -Occiput -Lumbosacral areas |
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What does a Rheumatoid nodule consist of morphologically?
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-Fibrinoid necrosis center
-Surrounded by palisading histiocytes that degrade the necrotic debris |
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So what are rheumatoid nodules also called?
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Palisading granulomas
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What is a potentially catastrophic complication of rheumatoid arthritis??
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Rheumatoid vasculitis
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When does Rheumatoid vasculitis tend to present?
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-SEVERELY erosive disease
-with Rheumatoid nodules -HIGH titers of RF |
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What size vessels are typically affected in Rheumatoid vasculitis?
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Medium and small
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So what disease does Rheumatoid vasculitis resemble?
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Polyarteritis nodosa
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What 3 complications result from obliterating endarteritis in Rheumatoid vasculitis?
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-Neuropathy
-Ulcers -Gangrene |
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What develops as immune complexes are deposited in veins in RA?
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Leukocytoclastic venulitis - inflammation of the veins.
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What 3 manifestations develop as a result of Leukocytoclastic venulitis?
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-Purpura
-Skin ulcers -Nail bed infarction |
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What has Lyme disease in some patients been mistaken for?
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Juvenile Rheumatoid Arthritis
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At what age is Juvenile RA classically seen?
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Before 16 yrs old
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What is the Female:Male ratio?
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2:1
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What is oligoarticular vs polyarticular juvenile RA?
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Oligo is <5 joints
Poly is 5 or more joints |
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What type of onset is more commonly seen in juvenile RA?
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Systemic onset
Large joints |
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What size of joints are more commonly affected in juvenile RA?
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Large more common than small
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What is normally absent in juvenile RA?
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Rheumatoid nodules
Rheumatoid factor |
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What is more commonly POSITIVE in juvenile RA?
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Antinuclear Ab - ANA pos
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What is the most important seronegative rheumatoid variant? What does it lead to?
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Ankylosing spondylitis - leads to Bamboo Spine - complete fusion of the vertebrae
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What is a nondegenerative, nonautoimmune arthritis?
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Infectious arthritis
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What are 4 types of infectious arthritis?
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-Suppurative
-Tuberculous -Lyme -Viral |
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What is suppurative arthritis usually secondary to?
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Bacterial infections
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How do bacteria typically get into the joint to cause suppurative arthritis?
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By seeding the joint during bacteremia
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What other way do bacteria seed the joint in neonates?
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By spreading from underlying epiphyseal osteomyelitis bc vessels penetrate through it.
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What bacteria more commonly cause suppurative arthritis in adolescents and young adults?
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Gonococcal
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What bacteria more commonly cause suppurative arthritis in older children and adults?
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Staphs/streps
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What bacteria can cause suppurative arthritis in any age with Sickle Cell disease?
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Salmonella
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What bacteria more commonly causes suppurative arthritis in children under 2 yrs old?
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Haemophilus influenzae
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What is chronic progressive monoarticular infectious arthritis called?
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Tuberculous
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What age group more commonly gets Tuberculous arthritis?
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Adults - not so much in the US
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How does Tuberculous arthritis usually develop?
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By SPREADING from adjoining osteomyelitis or via the blood from visceral infection
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What joints are typically involved in Tuberculous arthritis?
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Weight bearing joints
-Hips -Knees -Ankles |
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What bacterium causes Lyme arthritis?
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Borrelia burgdorferi
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How long does it take for the bacterium to disseminate from the skin to joints?
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Few weeks to 2 years
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What type of joints are typically involved in Lyme arthritis, and how many?
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Large joints
1-2 joints at a time |
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How long does Lyme arthritis last?
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Few weeks to months
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What does the pathology seen in Lyme arthritis resemble?
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Rheumatoid arthritis
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What can detect the bacteria in some cases of Lyme arthritis?
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Silver stain
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What else can cause infectious arthritis?
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Viruses
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What are 2 forms of Crystal induced synovitis?
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-Gout
-Pseudogout |
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What IS synovitis?
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Inflammation of the synovium
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What are the most common crystals associated with synovitis?
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Monosodium Urate crystals
MSU |
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What is Uric acid produced by?
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Purine metabolism
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Why do MUS crystals precipitate in the synovium in gout?
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Because synovial fluid is a poor solvent for MSU
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And what is the result of MSU crystallization in the synovium?
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Inflammation resembling RA
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What 2 inflammatory processes respond to MSU crystal precipitation in joints?
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-Complement activation
-Monocyte phagocytosis |
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What does Complement then do?
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Activates neutrophils
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What happens when neutrophils phagocytose crystals from the synovial fluid?
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They actually lyse and release their lysosomal enzymes
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What is the classic site of tissue injury and inflammation due to the inflammatory responses to MSU crystals in joints?
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The 1st metatarsal-phalangeal joint at the big toe.
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What are 2 main classifications of Gout?
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-Primary (idiopathic or due to a known enzyme defect)
-Secondary - due to another metabolic abnormality |
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What is the main thing that distinguishes primary and 2ndary gout?
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Primary: enzyme overactivity so overproduction
Secondry: not enzyme itself |
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Does Gout correlate directly with degree of hyperurecemia?
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No not always
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What other factors contribute to the severety of gouty arthritis?
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-Age/duration of hyperuricemia
-Genetics -Alcohol consumption -Obesity -Drugs -Lead |
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How long of a duration of hyperurecemia is usually required before gouty arthritis develops?
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20-30 years
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What is a common cause of acute gout attacks?
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Heavy alcohol consumption
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What drugs can cause gouty arthritis?
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Thiazides
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What is lead toxicity induced gouty arthritis called?
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Saturnine gout
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What endocrine disorder can cause it?
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Hyperparathyroidism
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So what are the 4 stages in the clinical course of Gout?
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1. Asymptomatic hyperuricemia
2. Acute gouty arthritis 3. Intercritical gout 4. Chronic tophacious gout |
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When does Asymptomatic hyperuricemia tend to develop in males? Females?
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Males: around puberty
Females: after menopause |
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What are 2 symptoms of Acute gouty arthritis? What is not seen?
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-Excruciating joint pain
-Tenderness -No constitutional sx except mild fever |
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What is involved in the majority of 1st acute gouty arthritis attacks?
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One joint - monoarticular
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What is the joint affected in 50% of 1st acute gouty arthritis attacks?
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The 1st metatarsometaphalangeal joint
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What pattern of involvement do the joints involved in acute gouty arthritis attacks tend to follow in general?
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From toes - insteps - ankles - heels on up to elbows.
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What typically follows periods of acute gouty arthritis?
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Asymptomatic intercritical gout periods
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What does Gout ultimately end in if therapy is absent?
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Chronic tophacious gout
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What is a Tophi?
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A big chunk of MSU crystals
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How do the gouty arthritis attacks change in Chronic tophacious stages?
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-Shorter intervals between
-Increased frequency -Polyarticular |
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How long does it take on average for Gout to turn into chronic tophacious gout?
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12 years
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What are 3 systemic features commonly seen in Gout?
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-Atherosclerosis
-Hypertension -Renal colic/nephropathy |
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What do 20% of gout patients with renal involvement die of?
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Chronic renal failure
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How does Gout affect the patient in general?
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-Does not shorten life
-Impairs the QUALITY of life |
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Why should Gout be diagnosed as early as possible?
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There are drugs that can prevent arthritic attacks and mobilize tophacious deposits.
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What crystals cause Pseudogout?
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Calcium pyrophosphate dihydrate crystals CPPD
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What is a synonym for Pseudogout?
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Chondrocalcinosis
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How do CPPD crystals form?
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Unknown
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What process IS included in CPPD crystal formation?
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Altered activity of matrix enzymes leading to production and degradation of PPi
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What does increased production and degradation of Pyrophosphate result in?
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Accumulation of inorganic PPi which crystalizes with calcium
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What are 3 types of Pseudogout?
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1. Sporadic (idiopathic)
2. Hereditary 3. Secondary to metabolic disorder |
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What shape are the crystals in Gout? Peudogout?
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Gout = needle shaped
Pseudogout = rhomboid |
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What are the crystals made of in gout? Pseudogout?
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Gout: sodium urate (msu)
Pseudogout: CPPD |
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What type of pathology do the crystals in gout result in?
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Early - soft tissue swelling like in RA
Later: radiolucent erosions around edges of articular cartilage |
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What type of pathology do the crystals in gout result in?
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Fine/radioopaque linear deposits in the meniscus and articular cartilage
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In what type of disease will hyperuricemia more commonly be seen?
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Gout
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What color are the crystals in Gout when parallel? Perpendicular to the short axis?
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Parallel = Yellow
Perpend = Blue |
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What color are the crystals in Gout when parallel? Perpendicular to the short axis?
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Parallel = Blue
Perp = Yellow |
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In what disease are the needles birefringent pos?
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Pseudogout
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What type of crystals are water soluble?
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MSU crystals in gout
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So what do you have to do in preparing a microscopic sample to look for MSU crystals?
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Use an ALCOHOL fixative or else the crystals will dissolve!
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