4 Rheumatoid Arthriis 2010

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Rheumatoid Arthritis (RA) • A chronic, systemic disease characterized by inflammation of connective tissue in the synovial joints • Typically have periods of remission and exacerbation

description

pathophysiology

Transcript of 4 Rheumatoid Arthriis 2010

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Rheumatoid Arthritis (RA)

• A chronic, systemic disease characterized by inflammation of connective tissue in the synovial joints

• Typically have periods of remission and exacerbation

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Rheumatoid Arthritis (RA)

• Affects all ethnic groups• Can occur at any time of life• Incidence ↑ with age• Women are affected 2-3 times

more frequently then men• Smoking appears to be a link

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Etiology and Pathophysiology

• Cause of RA is unknown• No infectious agent has been

cultured from blood and synovial tissue or fluid

• Autoimmune etiology is currently the most widely accepted

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Etiology and Pathophysiology

• Autoimmunity – Changes begin when a susceptible

host experiences an initial immune response to an antigen

– Antigen triggers the formation of an abnormal immunoglobulin G (IgG)

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Etiology and Pathophysiology

• Autoimmunity – RA is characterized by the presence of

autoantibodies (rheumatoid factor [RF])– RF and IgG form immune complexes

that initially deposit on synovial membranes or superficial articular cartilage in the joints

– An inflammatory response results

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Etiology and Pathophysiology

• Autoimmunity – Joint changes from chronic

inflammation begin when the hypertrophied synovial membrane invades the surrounding • Cartilage• Ligaments• Tendons• Joint capsule

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Etiology and Pathophysiology

• Autoimmunity – Pannus (a proliferation of synovial tissue) forms

within the joint– Eventually covers and erodes the entire surface

of the articular cartilage– Pannus scars and shortens supporting structures

• Tendons• Ligaments

– Causing joint laxity, subluxation, and contracture

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A. Synovial swelling & fluid accululation

B. Pannus, eroded articular cartilage & joint space narrowing

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Joint space narrowing and osteophytes

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Etiology and Pathophysiology

• Genetic factors– Genetic predisposition appears to be

important in the development of RA– Strongest evidence for a familial

influence is the ↑ occurrence of certain human leukocyte antigens (HLA)

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Clinical Manifestations Joints

• Onset of RA is typically insidious• Nonspecific manifestations may

precede the onset of arthritic complaints– Fatigue– Anorexia– Weight loss– Generalized stiffness

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Clinical Manifestations Joints

• Stiffness becomes more localized in the following weeks to months

• Some patients report a history of precipitating stressful events– Research has been unable to

correlate such events directly with the onset of RA

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Clinical Manifestations Joints

• Specific joint involvement – Pain– Stiffness– Limitation of motion– Signs of inflammation

• Heat• Swelling• Tenderness

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Clinical Manifestations Joints

• Joint symptoms occur symmetrically and frequently– Small joints of the hands and feet– Larger peripheral joints

• Wrists, elbows, shoulders, knees, hips, ankles, and jaw

– Cervical spine

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Clinical Manifestations Joints

• Often experience joint stiffness after periods of inactivity

• Morning stiffness may last from 60 minutes to several hours or more

• Joints become tender, painful, and warm to the touch

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Clinical Manifestations Joints

• Joint pain– ↑ with motion – Varies in intensity– May not be proportional to the

degree of inflammation – Tenosynovitis

• Difficult for patients to grasp objects

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Clinical Manifestations Joints

• Inflammation and fibrosis of the joint capsule and supporting structures may lead to deformity and disability

• Subluxation– Atrophy of muscles and destruction of

tendons around the joint cause one articular surface to slip past the other

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Early Rheumatoid Athritis

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Advanced Rheumatoid Athritis

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Deformities of RA

Fig. 63-4

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Clinical Manifestations Extraarticular Manifestations

• RA can affect nearly every system of the body

• Three most common – Rheumatoid nodules – Sjögren syndrome– Felty syndrome

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Extraarticular Manifestations of RA

Fig. 63-5

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Rheumatoid Nodules• Develop in 25% of all patients with RA• Usually have high titers of RF• Appear as firm, nontender,

granuloma-type masses • Usually over the extensor surfaces of

joints such as fingers and elbows

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Rheumatoid Nodules• Nodules at the base of the spine

and back of the head are common in older adults

• Develop insidiously • Can persist or regress

spontaneously• Usually not removed

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Rheumatoid Nodules

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Rheumatoid Nodules - elbow

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Rheumatoid Nodules

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Complications • Flexion contractures and hand

deformities – Cause diminished grasp strength – Affect the patient’s ability to perform

self-care tasks

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Complications • Cataract development and loss of

vision possible from scleral nodules

• Rheumatoid nodules can ulcerate, similar to pressure ulcers

• Hoarseness from nodules on the vocal cords

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Complications • Bone destruction from nodules in

the vertebral bodies• Cardiopulmonary effects later in

the disease– Pleurisy, pleural effusion, pericarditis,

pericardial effusion, cardiomyopathy

• Carpal tunnel syndrome