SEROPOSITIVEARTHRITIS

INTRODUCTION

SEROPOSITIVE ?

• RA FACTOR

• Anti-CCP antibodies

RF assosciations

Rheumatology: Rheumatoid Arthritis; SLE; Sjogren’s; MCTD; Myositis; Cryoglobulinemia;

Others: SABE; 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

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 n advanced stages

CLINICAL DIAGNOSTIC CRITERIA American College of Rheumatology revised criteria require that 4 out of 7

of the following are present 4:

1. morning stiffness lasting at least 1 hour before maximal improvement

2. soft tissue swelling of 3 or more joints observed by a physician

3. swelling of the proximal interphalangeal, metacarpophalangeal, or wrist joints

4. symmetric swelling

5. rheumatoid nodules

6. the presence of rheumatoid factor; and

7. radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints.

RADIOLOGICAL FINDINGS

X-RAYS

1. Soft-tissue changes

2. Osteoporosis

3. Joint space changes and alignment deformities

4. Periostitis

5. Erosions

6. 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 synocial hypertrophy)

Foot

Similar fusiform swelling can be found in the 1st and

5th metatarsal heads

At the Achilles tendon insertion

When synovitis thickens the bursa , oedema obliterates the local fat and blurs out margins of the tendon

Note : the swelling is symmetric but if a rheumatoid nodule Is present at the swelling it may appear eccentric

(as in olecranon)

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 arc 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)

In menopausal women , generalized osteoporosis masks the osteoporotic changes due to RA

Generalised or solitary sclerosis one or more distal phalanges is an impoirtan finding

Terminal phalangeal sclerosis

New 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

Synovitis of the metacarpophalangeal joint.

Longitudinal high-resolution (10.5-MHz) sonogram shows thickened synovial tissue (arrows).

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 Foot

1. Earlier seen in feet most often 5th metacarpo-phalangeal joint.

2. Apart from posterior and inferior surfaces of

3. CALCANEUM tarsal erosion are uncommon

4. (Tarsal erosion is seen commonly in sero-negative)

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

Once destroyed the articular cartilage rarely reforns on helaing

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

intraosseous defects-cysts (Geodes) are seen 3 – 4 cm or more in diameter.

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 atlas

potentiated 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

Resorption of hone at non-articular surfaces occurs in the cervical spine at the spinous processes, which become short, sharp and tapered in patients with chronic disease

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 he 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.

NON-RHEUMATOLOGIC FEATURES

cardiovascular disease

1. accelerated coronary artery and cerebrovascular atherosclerosis which contribute significantly to the excess mortality of RA

2. pericarditis

3. vasculitis : occurs more commonly with severe erosive disease, rheumatoid nodules, high RF titres.

cutaneous involvement

• rheumatoid nodules are usually seen in pressure areas : elbows, occiput, lumbosacral3. They generally occur in RF positive patients 9.

ocular involvement

1. keratoconjunctivitis sicca

2. uveitis

3. Episcleritis

Respiratory system: parenchymal or pleural diseases ;

manifests as pleural thickening or Effusion, ground glass opacities

Bronchiolitis , bronchienctasis (advanced stages), nodules – cavitation is seen commonly.

CAPLAN’S SYNDROME

Caplan syndrome (also known as rheumatoid pneumoconiosis) is the combination of seropositive rheumatoid arthritis and a characteristic pattern of fibrosis.

5 - 50 mm well-defined nodules in the upper lung lobes / lung periphery.

nodules may remain unchanged, multiply, calcify, or become thick walled cavities.

background changes of pneumoconiosis

may have an accompanying pleural effusion

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

In lateral radiograph

1. Mal-alignments, most commonly at the metacarpo-phalangeal and proximal

inter-phalangeal joints of the fingers and the carpometacarpal,

2. metacarpophalangeal and the interphalangeal joints of the thumb

Note : in an AP view most of the time these will be less apparent ….?

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 (

Calcinosis

Raynauds 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 hypoperistalsis

Sclerodactyly

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 changes

1. acro-osteolysis (resorption of the distal phalanges)

2. periarticular osteoporosis

3. joint space narrowing

4. erosions

Soft tissue changes

1. subcutaneous and periarticular calcification

2. atrophy especially at tips of fingers

3. With retraction of skin

4. 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

Either UIP or NSIP pattern

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 4

cysts may be present measuring 1-5cm in diameter 4

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 systgemic 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 SLE

As a single entity sjogren’s doesn’t involve the joints.

But definitely aggravates the primary Rheumatologic Arthropathy therby increasing the Morbidity and Mortality

SPOTTERS

THANK YOU

Jaccoud’s arthropathy

This condition is characterized by subluxation of metacarpophalangeal joints, “swan-neck” and Boutonniere deformities, besides “Z” deformity of thumb

CAN also occur in shoulder, knee and joints of feet.

Hidebound bowel sign

The hidebound bowel sign refers to an appearance on a barium study of the small bowel in patients with scleroderma. The sign describes the narrow separation between the valvulae conniventes which are of normal thickness despite dilatation of the bowel lumen.

Although the term hidebound is used specifically to describe scleroderma, the same appearance can be present in sprue. Stack of coins is an alternate descriptive term that can be used for both conditions.

case of persistent monoarticular arthritis

Because of the chronic use of corticoids in such patients, the signs and symptoms of infection are frequently masked and the process generally presents a chronic and indolent course.

In, the absence of a clinical response to the therapy with corticoids or other immunosuppressive drugs should raise the suspicion of an underlying infectious process.