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“Thingsmaycometothosewhowait,butonlythethingsleftbythosewhohustle.”

2022/12/24“Thingsmaycometothosewho1PathologyofArthritisDr.VenkateshM.Shashidhar.AssociateProfessorofPathologyFijiSchoolofMedicine2022/12/24PathologyofArthritisDr.Venk2Joints:Mobility-CranialsuturesShoulderjoint.Articularcartilage–hyaline–frictionres.Synovialfluid–lubric/nutri,TypeA&Bsynoviocytes.HyaluronidaseContinuousproductionandabsorption.AffectedbyInflammation,immobility.Capsule,ligaments,menisci.Vascular,richnervesupply–Art.Cartilage*2022/12/24Joints:Mobility-Cranialsutu3Joints-Anatomy2022/12/24Joints-Anatomy2022/12/174Arthritis-IntroductionInflammationofjoints-CommonCommonsiteforautoimmuneinjuryHeartvalves&Joints-damage–Exposureofhiddenantigens.Infections.Degeneration–Age/Stress/lifestyleUseitorLooseit….!2022/12/24Arthritis-IntroductionInflam5Arthritis–Clinicalfeatures:PainInflammation-capsule,synovium,periosteum.Swelling:inflammation,effusion,proliferation.Restrictedmovementpain,fluid,synovialswelling,damage.Deformitymal-alignment,erosion,ankylosis2022/12/24Arthritis–Clinicalfeatures:6ArthritisClinicalClassification:Monoarthritis:Local,asymmetric,secondary.Acute:

Bacterial,Trauma,Crystal,ReactiveChronic:Tuberculosis,Lyme,Fungal,Trauma,Tumors.Polyarthritis:Chronic,symmetric,systemic.Autoimmune,degenerative,Crystal.Rarelyinfective.2022/12/24ArthritisClinicalClassificat7PolyarthritisClassification:Autoimmune:Rheumatic,Rheumatoid,Ankylosingspondylitis,Reitersyndromeetc.Degenerative:

Osteroarthritis

Crystal

Deposition:

Gout–Monosodium

urateCPPD-

PseudoGoutInfective-Septic,TB,Lymeetc.rare.2022/12/24PolyarthritisClassification:A8Rheumatoid

Arthritis2022/12/24Rheumatoid

Arthritis2022/12/19EpidemiologyofRAPrevalenceabout1%ofUSpopulationFemale:Maleratio=2:1StrongassociationwithHLADR4.Concordanceinidenticaltwinsonly30%2022/12/24EpidemiologyofRAPrevalencea10RA-Definition:ChronicMultisystemautoimmuneinflammatorydisorderprimarilyaffectingjointsproducingaproliferativesynovitisthatoftenprogressestodestructionofthearticularcartilageandankylosis.2022/12/24RA-Definition:ChronicMultis11Etiology:GeneticSusceptibility:HLADR4,orDR1in65%to80%cases.Microbialincitingagent:Epstein-Barrvirus,Borrelia&MycoplasmaAutoimmunity:IGMantiIgG–RAFactor.HelperTcell(CD4)againsttypeIIcollagen&cartilageglycoprotein-392022/12/24Etiology:GeneticSusceptibilit12Immuno-dysregulationinRATlymphocytestypeIIcollagen&superantigenreleasingcytokinesinflammation.BcellsIgMRheumatoidfactor–antiIgG.MacrophagessurroundRFfactorcomplextypeIIIinjury(immunecomplex)cytokinereleaseinflammationdamage.2022/12/24Immuno-dysregulationinRATly13Morphology:Proliferativesynovitiswithlymphocytes(CD4),plasmacell¯ophagesPannus.Organizingfibrin(ricebodies).Neutrophilsonthejointsurfaceandfluid.Juxta-articularerosions,cysts&osteoporosisFibrousankylosis.Skin-Rheumatoid

nodulesVasculitis(commonlyofdigitalarteries)2022/12/24Morphology:Proliferativesynov14EarlyDestructioninRA:SwanNeckDeformity2022/12/24EarlyDestructioninRA:SwanN15RA-ClinicalFeatures:Morningstiffness.Arthritisin3ormorejointareas.Arthritisofsmallhandjoints.Symmetricarthritis.Rheumatoidnodules.Serumrheumatoidfactor.TypicalradiographicchangesAtleast4featuresfordiagnosis.2022/12/24RA-ClinicalFeatures:Morning16N.Synovium--R.Arthritis:2022/12/24N.Synovium--R.Arthritis:20217RA-Pannus:2022/12/24RA-Pannus:2022/12/1718RA-Pannus:Hyperplasticinflammedsynovium2022/12/24RA-Pannus:Hyperplastic2022/19Extra-ArticularRARheumatoidNodulesVasculitisPleuritisPericarditisTendonitis2022/12/24Extra-ArticularRARheumatoidN20SkinRANodule:2022/12/24SkinRANodule:2022/12/1721SkinRANodule:2022/12/24SkinRANodule:2022/12/1722RheumatoidNodule(skin):PalisadingMacrophagesCentralFibrinoidNecrosis2022/12/24RheumatoidNodule(skin):Palis23JointinvolvementinRA:2022/12/24JointinvolvementinRA:2022/124SwanNeckDeformityinRA:2022/12/24SwanNeckDeformityinRA:202225JointDestructioninRA:SwanNeckDeformity2022/12/24JointDestructioninRA:SwanN26RAJointdestruction,ankylosis:2022/12/24RAJointdestruction,ankylosi27OsteoarthritisDegenerativearthrosis.(Osteoarthrosis)2022/12/24OsteoarthritisDegenerativeart28Osteoarthritis:Degenerativeendresult-(ageing)>80%in>65y.Progressiveerosion&fibrillationofarticularcartilageformsLoosebodies.Largeweightbearingjoints.Hardenedarticularbone–eburnation.&Subarticularcystformationinbone.Periarticularosteophyteformation.Mildinflammationbutpainful,morningstiffness.LimitedrangeofmovementsHeberdennodes(F)2022/12/24Osteoarthritis:Degenerativeen29Normal--FemurHead--OANormalOsteoarthritis2022/12/24Normal--FemurHead--OANorm30FemurOsteroarthritis:2022/12/24FemurOsteroarthritis:2022/12/31JointMiceorLooseBodies:2022/12/24JointMiceorLooseBodies:20232SpineOsteophytes(OA):2022/12/24SpineOsteophytes(OA):2022/1233RadiologicFeatures:nonuniformjointspaceloss,osteophyteformation,cystformationsubchondralsclerosisSclerosis,ankylosis&deformity.2022/12/24RadiologicFeatures:nonuniform34Osteoarthritis:NarrowjointspaceLipping–osteophyteDislocationOsteoporosis.2022/12/24Osteoarthritis:Narrowjointsp35Osteophyteformation:2022/12/24Osteophyteformation:2022/12/136BonecystsinOA:2022/12/24BonecystsinOA:2022/12/1737Osteoarthritis:Ankylosisvarusdeformityofthekneeandcollapseofthejointspacewithdestructionofthemedialcartilageandthesubchondralcortex(openarrowheads).2022/12/24Osteoarthritis:Ankylosisvarus38Osteoarthritis:Lateralviewoftheleftkneeshowssclerosiswithmarkedosteophyteformation(arrows).Theosteophytesarebestseeninthisview.2022/12/24Osteoarthritis:Lateralviewof39Osteoarthritis:Subchondralcysts(solidarrowhead)

2022/12/24Osteoarthritis:Subchondralcys40OAFingers:2022/12/24OAFingers:2022/12/1741OAHip:2022/12/24OAHip:2022/12/1742OAHip:1997,bilateral,jointspacenarrowing(arrows)atthehipsthatisworseontheleftside

2022/12/24OAHip:1997,bilateral,joint43OAHip:Subchondralsclerosis(solidarrowhead)andcyst(arrow)formationarealsonotedontheleftside

2022/12/24OAHip:Subchondralsclerosis44OAHip:lefthiparthroplasty2022/12/24OAHip:lefthiparthroplasty245OA-ClinicalFeatures:painworsenswithactivity&improvesonrest.Instabilityofjoints–Knee.Crepitus,limitationofmotion.Musclespasm,andtendonandcapsularcontractures.Earlymorningstiffnesslasts1hourormore.bonyovergrowth–interphalangealjointsdistal(Heberden's)proximal(Bouchard's).2022/12/24OA-ClinicalFeatures:painwo46DifferentiatingFeatures:RheumatoidArthritis:Young,smalljointsAutoimmune.SynovialInflammationsynovium

CartilageOsteoarthritis:Old,LargejointsDegenerative.Cartilagedegeneration.CartilageSynovium2022/12/24DifferentiatingFeatures:Rheum47Arthritis

Other

Infective,traumatic,secondarytosystemicdiseases.2022/12/24Arthritis

OtherInfective,tr48SeronegativearthropathiesAnkylosingSpondylitis:Adolescentboys,HLAB27,axialjoints(sacroiliac)ReiterSyndrome:Triadofarthritis,urethritis/cervicits&conjuctivitisAutoimmunebutinitiatedbybacterialinfection.EnteropathicArthritis:Secondarytobowelinfections(salmonella,shigella)HLAB27positivePsoriaticArthritis:5%ofpatients,startsinDIPjoints,similartoRA.2022/12/24SeronegativearthropathiesAnky49SepticArthritis:ORGANISMPEAKAGEINCIDENCE

GRAMSTAIN

HemophilusinfluenzaeChildrenGramnegativecoccobacilliNeisseria

gonorrheae

YoungadultsGramnegativediplococciSalmonella

youngwithSickleCellAn.GramnegativerodsStaph.aureusAdultsGrampositivecocciinclustersEscherichiacoliAdultsGramnegativerodsPseudomonasAdultsGramnegativerods2022/12/24SepticArthritis:ORGANISMPEAK50GonococcalArthritis:2022/12/24GonococcalArthritis:2022/12/151JuvenileRheumatoidArthritis:Beforeage16Multisysteminvolement-Spleenomegaly,StartswithsystemicinvolvementunlikeRA.NoserumRAFactor–SeronegativeAntinuclearAntibody(ANA)+veautoimmune.2022/12/24JuvenileRheumatoidArthritis:52BigToeinGout:2022/12/24BigToeinGout:2022/12/1753JointDestructioninGout:2022/12/24JointDestructioninGout:202254GoutTophi:2022/12/24GoutTophi:2022/12/1755UrateCrystals(Gout):2022/12/24UrateCrystals(Gout):2022/12/56PseudoGoutCalciumPyroPhosphateDepositiondiseaseCPPDChondrocalcinosis.2022/12/24PseudoGoutCalciumPyroPhospha57CPPD–(Chondrocalcinosis)TypeA–Pseudogout–Knee,menTypeB–Pseudorheumatoid-polyarthritisTypeC–PseudoOA+acuteattacks,womenTypeD–PseudoOA-acuteattacks,handsTypeE–AsymptomaticTypeF–Pseudoneuropathic2022/12/24CPPD–(Chondrocalcinosis)Type58CPPD-Arthritis(pseudogout):2022/12/24CPPD-Arthritis(pseudogout):259PseudoGout–Calciumpyrophoshate2022/12/24PseudoGout–Calciumpyrophos60AnkylosingSpondylitisMarie-StrumpellArthritisYoungmales,90%HLAB27+<1%Rheumatoidfactor–seronegative.>25%haveiritis10%AorticinsufficiencyStronglyfamilial,100%concordanceinmonozygotictwins.2022/12/24AnkylosingSpondylitisMarie-St61AS-fusionofvertebralbodiesduetobridgingsyndesmophytes.2022/12/24AS-fusionofvertebralbodie62ScoliosisinAnkylosingSpondylitis2022/12/24ScoliosisinAnkylosingSpondy63OrganismsinReiter’s

ShigellaFlexneriSalmonellaS.typimurium–othersYersiniaenterocoliticaCampylobacterJejuniChlamydiatrachomatisUreaplasmaurealyticum2022/12/24OrganismsinReiter’sShigella64ArthritisComparison:2022/12/24ArthritisComparison:2022/12/165"Thegemcannotbepolishedwithoutfriction,normanperfectedwithouttrialsorproblems(orexams)…!."--Chineseproverb2022/12/24"Thegemcannotbepolishedwi662022/12/242022/12/17672022/12/242022/12/1768PathologyofReiter’sSyndromeAcuteSynovitisChronicchanges(insome)UnilateralSacroilitisAscendingarthropathyOssification&enthesopathyIleal,colonicorurethral-nonspecificmucosalinflammation2022/12/24PathologyofReiter’sSyndrome69Reiter’sSyndrome:2022/12/24Reiter’sSyndrome:2022/12/1770Iritis:2022/12/24Iritis:2022/12/17712022/12/242022/12/17722022/12/242022/12/1773“Thingsmaycometothosewhowait,butonlythethingsleftbythosewhohustle.”

2022/12/24“Thingsmaycometothosewho74PathologyofArthritisDr.VenkateshM.Shashidhar.AssociateProfessorofPathologyFijiSchoolofMedicine2022/12/24PathologyofArthritisDr.Venk75Joints:Mobility-CranialsuturesShoulderjoint.Articularcartilage–hyaline–frictionres.Synovialfluid–lubric/nutri,TypeA&Bsynoviocytes.HyaluronidaseContinuousproductionandabsorption.AffectedbyInflammation,immobility.Capsule,ligaments,menisci.Vascular,richnervesupply–Art.Cartilage*2022/12/24Joints:Mobility-Cranialsutu76Joints-Anatomy2022/12/24Joints-Anatomy2022/12/1777Arthritis-IntroductionInflammationofjoints-CommonCommonsiteforautoimmuneinjuryHeartvalves&Joints-damage–Exposureofhiddenantigens.Infections.Degeneration–Age/Stress/lifestyleUseitorLooseit….!2022/12/24Arthritis-IntroductionInflam78Arthritis–Clinicalfeatures:PainInflammation-capsule,synovium,periosteum.Swelling:inflammation,effusion,proliferation.Restrictedmovementpain,fluid,synovialswelling,damage.Deformitymal-alignment,erosion,ankylosis2022/12/24Arthritis–Clinicalfeatures:79ArthritisClinicalClassification:Monoarthritis:Local,asymmetric,secondary.Acute:

Bacterial,Trauma,Crystal,ReactiveChronic:Tuberculosis,Lyme,Fungal,Trauma,Tumors.Polyarthritis:Chronic,symmetric,systemic.Autoimmune,degenerative,Crystal.Rarelyinfective.2022/12/24ArthritisClinicalClassificat80PolyarthritisClassification:Autoimmune:Rheumatic,Rheumatoid,Ankylosingspondylitis,Reitersyndromeetc.Degenerative:

Osteroarthritis

Crystal

Deposition:

Gout–Monosodium

urateCPPD-

PseudoGoutInfective-Septic,TB,Lymeetc.rare.2022/12/24PolyarthritisClassification:A81Rheumatoid

Arthritis2022/12/24Rheumatoid

Arthritis2022/12/182EpidemiologyofRAPrevalenceabout1%ofUSpopulationFemale:Maleratio=2:1StrongassociationwithHLADR4.Concordanceinidenticaltwinsonly30%2022/12/24EpidemiologyofRAPrevalencea83RA-Definition:ChronicMultisystemautoimmuneinflammatorydisorderprimarilyaffectingjointsproducingaproliferativesynovitisthatoftenprogressestodestructionofthearticularcartilageandankylosis.2022/12/24RA-Definition:ChronicMultis84Etiology:GeneticSusceptibility:HLADR4,orDR1in65%to80%cases.Microbialincitingagent:Epstein-Barrvirus,Borrelia&MycoplasmaAutoimmunity:IGMantiIgG–RAFactor.HelperTcell(CD4)againsttypeIIcollagen&cartilageglycoprotein-392022/12/24Etiology:GeneticSusceptibilit85Immuno-dysregulationinRATlymphocytestypeIIcollagen&superantigenreleasingcytokinesinflammation.BcellsIgMRheumatoidfactor–antiIgG.MacrophagessurroundRFfactorcomplextypeIIIinjury(immunecomplex)cytokinereleaseinflammationdamage.2022/12/24Immuno-dysregulationinRATly86Morphology:Proliferativesynovitiswithlymphocytes(CD4),plasmacell¯ophagesPannus.Organizingfibrin(ricebodies).Neutrophilsonthejointsurfaceandfluid.Juxta-articularerosions,cysts&osteoporosisFibrousankylosis.Skin-Rheumatoid

nodulesVasculitis(commonlyofdigitalarteries)2022/12/24Morphology:Proliferativesynov87EarlyDestructioninRA:SwanNeckDeformity2022/12/24EarlyDestructioninRA:SwanN88RA-ClinicalFeatures:Morningstiffness.Arthritisin3ormorejointareas.Arthritisofsmallhandjoints.Symmetricarthritis.Rheumatoidnodules.Serumrheumatoidfactor.TypicalradiographicchangesAtleast4featuresfordiagnosis.2022/12/24RA-ClinicalFeatures:Morning89N.Synovium--R.Arthritis:2022/12/24N.Synovium--R.Arthritis:20290RA-Pannus:2022/12/24RA-Pannus:2022/12/1791RA-Pannus:Hyperplasticinflammedsynovium2022/12/24RA-Pannus:Hyperplastic2022/92Extra-ArticularRARheumatoidNodulesVasculitisPleuritisPericarditisTendonitis2022/12/24Extra-ArticularRARheumatoidN93SkinRANodule:2022/12/24SkinRANodule:2022/12/1794SkinRANodule:2022/12/24SkinRANodule:2022/12/1795RheumatoidNodule(skin):PalisadingMacrophagesCentralFibrinoidNecrosis2022/12/24RheumatoidNodule(skin):Palis96JointinvolvementinRA:2022/12/24JointinvolvementinRA:2022/197SwanNeckDeformityinRA:2022/12/24SwanNeckDeformityinRA:202298JointDestructioninRA:SwanNeckDeformity2022/12/24JointDestructioninRA:SwanN99RAJointdestruction,ankylosis:2022/12/24RAJointdestruction,ankylosi100OsteoarthritisDegenerativearthrosis.(Osteoarthrosis)2022/12/24OsteoarthritisDegenerativeart101Osteoarthritis:Degenerativeendresult-(ageing)>80%in>65y.Progressiveerosion&fibrillationofarticularcartilageformsLoosebodies.Largeweightbearingjoints.Hardenedarticularbone–eburnation.&Subarticularcystformationinbone.Periarticularosteophyteformation.Mildinflammationbutpainful,morningstiffness.LimitedrangeofmovementsHeberdennodes(F)2022/12/24Osteoarthritis:Degenerativeen102Normal--FemurHead--OANormalOsteoarthritis2022/12/24Normal--FemurHead--OANorm103FemurOsteroarthritis:2022/12/24FemurOsteroarthritis:2022/12/104JointMiceorLooseBodies:2022/12/24JointMiceorLooseBodies:202105SpineOsteophytes(OA):2022/12/24SpineOsteophytes(OA):2022/12106RadiologicFeatures:nonuniformjointspaceloss,osteophyteformation,cystformationsubchondralsclerosisSclerosis,ankylosis&deformity.2022/12/24RadiologicFeatures:nonuniform107Osteoarthritis:NarrowjointspaceLipping–osteophyteDislocationOsteoporosis.2022/12/24Osteoarthritis:Narrowjointsp108Osteophyteformation:2022/12/24Osteophyteformation:2022/12/1109BonecystsinOA:2022/12/24BonecystsinOA:2022/12/17110Osteoarthritis:Ankylosisvarusdeformityofthekneeandcollapseofthejointspacewithdestructionofthemedialcartilageandthesubchondralcortex(openarrowheads).2022/12/24Osteoarthritis:Ankylosisvarus111Osteoarthritis:Lateralviewoftheleftkneeshowssclerosiswithmarkedosteophyteformation(arrows).Theosteophytesarebestseeninthisview.2022/12/24Osteoarthritis:Lateralviewof112Osteoarthritis:Subchondralcysts(solidarrowhead)

2022/12/24Osteoarthritis:Subchondralcys113OAFingers:2022/12/24OAFingers:2022/12/17114OAHip:2022/12/24OAHip:2022/12/17115OAHip:1997,bilateral,jointspacenarrowing(arrows)atthehipsthatisworseontheleftside

2022/12/24OAHip:1997,bilateral,joint116OAHip:Subchondralsclerosis(solidarrowhead)andcyst(arrow)formationarealsonotedontheleftside

2022/12/24OAHip:Subchondralsclerosis117OAHip:lefthiparthroplasty2022/12/24OAHip:lefthiparthroplasty2118OA-ClinicalFeatures:painworsenswithactivity&improvesonrest.Instabilityofjoints–Knee.Crepitus,limitationofmotion.Musclespasm,andtendonandcapsularcontractures.Earlymorningstiffnesslasts1hourormore.bonyovergrowth–interphalangealjointsdistal(Heberden's)proximal(Bouchard's).2022/12/24OA-ClinicalFeatures:painwo119DifferentiatingFeatures:RheumatoidArthritis:Young,smalljointsAutoimmune.SynovialInflammationsynovium

CartilageOsteoarthritis:Old,LargejointsDegenerative.Cartilagedegeneration.CartilageSynovium2022/12/24DifferentiatingFeatures:Rheum120Arthritis

Other

Infective,traumatic,secondarytosystemicdiseases.2022/12/24Arthritis

OtherInfective,tr121SeronegativearthropathiesAnkylosingSpondylitis:Adolescentboys,HLAB27,axialjoints(sacroiliac)ReiterSyndrome:Triadofarthritis,urethritis/cervicits&conjuctivitisAutoimmunebutinitiatedbybacterialinfection.EnteropathicArthritis:Secondarytobowelinfections(salmonella,shigella)HLAB27positivePsoriaticArthritis:5%ofpatients,startsinDIPjoints,similartoRA.2022/12/24SeronegativearthropathiesAnky122SepticArthritis:ORGANISMPEAKAGEINCIDENCE

GRAMSTAIN

HemophilusinfluenzaeChildrenGramnegativecoccobacilliNeisseria

gonorrheae

YoungadultsGramnegativediplococciSalmonella

youngwithSickleCellAn.GramnegativerodsStaph.aureusAdultsGrampositivecocciinclustersEscherichiacoliAdultsGramnegativerodsPseudomonasAdultsGramnegativerods2022/12/24SepticArthritis:ORGANISMPEAK123GonococcalArthritis:2022/12/24GonococcalArthritis:2022/12/1124JuvenileRheumatoidArthritis:Beforeage16Multisysteminvolement-Spleenomegaly,StartswithsystemicinvolvementunlikeRA.NoserumRAFactor–SeronegativeAntinuclearAntibody(ANA)+veautoimmune.2022/12/24J