Rheumatology

DR. ABDULQADIR M. MOALIM

 Scleroderma(systemic sclerosis)
Systemic sclerosis ('scleroderma') is a generalized disorder
of connective tissue affecting the skin, internal organs and
vasculature. The clinical hallmark is the presence of
sclerodactyly in combination with Raynaud's phenomenon or
digital ischemia. The peak age of onset is in the fourth and
fifth decades, and overall prevalence is 10-20 per 100 000
with a 4:1 female: male ratio.

DR. ABDULQADIR M. MOALIM

 Scleroderma(systemic sclerosis)
 It is subdivided into diffuse cutaneous systemic sclerosis
(DCSS) and limited cutaneous systemic sclerosis (LCSS).
 Many patients with LCSS have features which are
phenotypically grouped into the 'CREST' syndrome (calcinosis,
Raynaud's, esophageal involvement, sclerodactyly,
telangiectasia).

DR. ABDULQADIR M. MOALIM

 ETIOLOGY

 The cause of scleroderma is unknown. Scleroderma is diffuse

in 20% of cases and limited in 80%. Limited scleroderma is
also known as CREST syndrome (Calcinosis, Reynaud,
Esophageal dysmotility, Sclerodactyly, Telangiectasia"
 Look for a young (20s to 40s) woman (3 times more likely
than men) with fibrosis of the skin and internal organs such
as the lung, kidney, and GI tract.).

DR. ABDULQADIR M. MOALIM

 SIGNS AND SYMPTOMS
 Raynaud’s phenomenon (vasospasm of arteries in hands in
response to cold or emotional stress, resulting in discoloration
of hands) some case lead to ulceration and gangrene.
 Thickened, tight skin
 Nailfold capillaries––giant loops formed by abnormal
capillaries at nailfold

DR. ABDULQADIR M. MOALIM

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DR. ABDULQADIR M. MOALIM

 SIGNS AND SYMPTOMS

 Dysphagia due to esophageal fibrosis

 Renal artery fibrosis and hypertensive crisis.
 lung fibrosis leading to Pulmonary hypertension
 Telangiectasias
 Cardiac conduction disease/pericardial effusion

DR. ABDULQADIR M. MOALIM

Systemic sclerosis. Hands showing tight shiny
skin, sclerodactyly

DR. ABDULQADIR M. MOALIM

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DR. ABDULQADIR M. MOALIM

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DR. ABDULQADIR M. MOALIM

 Diagnosis

 ANA: positive in 85% to 90%, but nonspecific

 ESR: usually normal
 SCL-70: the most specific test is the SCL-70 (anti-
topoisomerase), but present in only 30% of those with diffuse
disease and 20% of those with limited disease
 Anticentromere: present in half of those with CREST
syndrome
 Decreased vital capacity on pulmonary function test(
restrictive lung disease)

DR. ABDULQADIR M. MOALIM

 Management

 Methotrexate slows the underlying disease process of limited

scleroderma.
 Penicillamine may inhibit collagen cross-linking
 Renal crisis: ACE inhibitors (use even if the creatinine is
elevated)
 Esophageal dysmotility: PPis for GERD

DR. ABDULQADIR M. MOALIM

 Management

 Raynaud: calcium channel blockers

 Pulmonary fibrosis: Cyclophosphamide improves dyspnea and
PFTs.
 Pulmonary hypertension:
 Bosentan, ambrisentan (endothelin antagonist)
 Sildenafil

DR. ABDULQADIR M. MOALIM

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DR. ABDULQADIR M. MOALIM

SEPTIC ARTHRITIS

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Septic arthritis is the most rapid and destructive
joint disease, and is associated with significant
morbidity and a mortality of 10%. This has not
improved over the last 20 years, despite advances
in antimicrobial therapy. The incidence is 2–10
per 100 000 in the general population, and 30–70
per 100 000 in those with pre-existing joint
disease or joint replacement.

DR. ABDULQADIR M. MOALIM

 NONGONOCOCCAL SEPTIC
ARTHRITIS
Nongonococcal septic arthritis is seen when
there is previous joint damage or bacteremia.

It is monarticular and affects the large joints

(knee, hip, shoulder,and wrist).

DR. ABDULQADIR M. MOALIM

 ETIOLOGY
Young Adults
 S. aureus, beta-hemolytic strep, and gram-negative bacilli
 Lyme must also be considered.
Sickle Cell Anemia Patients
 Salmonella and S. aureus (equal)
IV Drug Users and Immunocompromised
 Gram-negative organisms such as E. coli and Pseudomonas
aeruginosa, as well as S. aureus

DR. ABDULQADIR M. MOALIM

 Continued

DR. ABDULQADIR M. MOALIM

 RISK FACTORS
 Rheumatoid arthritis
 Prosthetic joints
 Immunodeficiency
 Age
 IV drug abuse

DR. ABDULQADIR M. MOALIM

 SIGNS AND SYMPTOMS

 Pain, swelling, and warmth erythematous

over the joint, usually is monoarticular
arthritis
Large joints( knee, hip, shoulder)
 Limited range of motion
 Fever

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The usual presentation is with acute or subacute

monoarthritis and fever. The joint is usually swollen,
hot and red, with pain at rest and on movement.
Although any joint can be affected, lower limb
joints, such as the knee and hip, are commonly
targeted. Patients with pre-existing arthritis may
present with multiple joint involvement

DR. ABDULQADIR M. MOALIM

 DIAGNOSIS

 Blood cultures are positive in 50% of cases.

 ESR and CRP will be elevated.
 Gram stain
 Arthrocentesis is both diagnostic and therapeutic. Joint fluid will
reveal an elevated white count , predominantly
polymorphonucleocytes and a low glucose level. The arthrocentesis
releases fluid thereby lowering pressure within the joint capsule
and alleviating pain.
 Arthrocentesis should be avoided if the overlying skin is infected or
if there is bacteremia because the procedure introduces a portal of
entry for bacteria into the joint.

DR. ABDULQADIR M. MOALIM

 TREATMENT

 pain relief
 Systemic antibiotics Ceftriaxone and vancomycin are the best
initial empiric therapy.
 Serial arthrocentesis may be necessary if synovial fluid
rapidly accumulates
 Surgical drainage is needed for septic hip, and for septic
joints that do not improve with intravenous antibiotics within
72 hours.

DR. ABDULQADIR M. MOALIM

GONOCOCCAL SEPTIC ARTHRITIS

A disseminated gonococcal infection; more common in

women than men.
 Look for a history of STDs or a sexually active young
person. The difference in presentation from septic arthritis
is:
 Polyarticular involvement
 Tenosynovitis (inflammation of the tendon sheaths, making
finger movement painful)
Petechial rash

DR. ABDULQADIR M. MOALIM

 Diagnosis and Treatment
DIAGNOSIS
 Synovial fluid shows elevated WBCs.
 Gram stain and blood culture are positive in < 50% of
cases.
 Joint cultures are usually negative.
TREATMENT
pain relief
Very sensitive to antibiotic therapy (e.g., ceftriaxone)
 Surgical drainage is not usually necessary

DR. ABDULQADIR M. MOALIM

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Emergency management of suspected
septic arthritis
Admit patient to hospital
Perform urgent investigations
• Aspirate joint
Send synovial fluid for Gram stain and culture
Use imaging guidance if required (e.g. for hip)
• Send blood for culture, routine biochemistry and
haematology, including ESR and CRP
• Consider sending other samples (sputum, urine, wound swab) for
culture, depending on patient history, to determine primary source of
infection

DR. ABDULQADIR M. MOALIM

 Septic arthritis

• Single joint (in most of the cases)

•Knee, hip, shoulder,..

DR. ABDULQADIR M. MOALIM

 VIRAL ARTHRITIS
Most forms of viral arthritis are self-limiting. The
usual presentation is with acute polyarthritis,
fever or viral prodrome and rash. Erythrovirus
arthropathy is the most common and, unlike
children, adults may not have the characteristic
facial rash.
 Diagnosis is confirmed by a rise in specific IgM.
Polyarthritis may also rarely occur with hepatitis
B and C, rubella and HIV infection

DR. ABDULQADIR M. MOALIM

 VIRAL ARTHRITIS
• Usually begins suddenly
• In developed countries, Parvovirus-B19,
• In children, fever, headache, rash, fatigue

• Polyarthralgia
• Symmetrical joint pain

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 Chikungunya is a viral disease transmitted to humans by infected mosquitoes. It
causes fever and severe joint pain. Other symptoms include muscle pain,
headache, nausea, fatigue and rash.
 Joint pain is often debilitating and can vary in duration.
 The disease shares some clinical signs with dengue, and can be misdiagnosed in
areas where dengue is common.
 There is no cure for the disease. Treatment is focused on relieving the
symptoms.
 The proximity of mosquito breeding sites to human habitation is a significant risk
factor for chikungunya.
 The disease occurs in Africa, Asia and the Indian subcontinent. In recent
decades mosquito vectors of chikungunya have spread to Europe and the
Americas. In 2007, disease transmission was reported for the first time in a
localized outbreak in north-eastern Italy. Outbreaks have since been recorded in
France and Croatia.
DR. ABDULQADIR M. MOALIM
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 Management : is symptomatic, with NSAID and analgesics

DR. ABDULQADIR M. MOALIM

 Septic arthritis

• Single joint (in most of the cases)

•Knee, hip, shoulder,..

DR. ABDULQADIR M. MOALIM

 . A 70-year-old, non–sexually active male complains of fever and
pain in his left knee. Several days previously, the patient skinned
his knee while working in his garage. The knee is red, warm, and
swollen. An arthocentesis is performed, which shows 200,000
leukocytes/μL and a glucose of 20 mg/dL. No crystals are noted.
The most important next step is
 a. Gram stain and culture of joint fluid
 b. Urethral culture
 c. Uric acid level
 d. Antinuclear antibody

DR. ABDULQADIR M. MOALIM

 Continue

the most likely organism to cause septic arthritis in the

case above is
a. Streptococcus pneumoniae
b. Neisseria gonorrhea
c. Escherichia coli
d. Staphylococcus aureus

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 36

67-year-old woman with history of RA for many

years presents with right shoulder pain and
swelling for 2 days. She has low-grade fever.
The examination reveals decreased passive and
active range of motion of the right shoulder
joint, as well as erythema. She asks you if this is
related to an RA flare and if she should start
steroids to decrease the pain.
What is the next step?

DR. ABDULQADIR M. MOALIM

A 59-year-old woman with RA, under reasonable control with
methotrexate, develops a hot, swollen, red knee. Joint aspiration
removes 10 cc of an opaque yellow-colored fluid with a white count of
100,000/μL, predominantly neutrophils. The joint fluid protein is high
and glucose is much lower than in the blood. Which of the following is
the most likely diagnosis?
(A) uric acid deposition
(B) CPPD deposition
(C) septic arthritis
(D) reactivation of RA
(E) calcium hydroxyapatite deposition

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Knee joint aspiration and injection are

performed to establish a diagnosis, relieve
discomfort, drain off infected fluid, or instill
medication. Because prompt treatment of a joint
infection can preserve the joint integrity, any
unexplained monarthritis should be considered
for arthrocentesis

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Indications for Arthrocentesis

Crystal-induced arthropathy
Hemarthrosis
Limiting joint damage from an infectious process
Symptomatic relief of a large effusion
Unexplained joint effusion
Unexplained monarthritis

DR. ABDULQADIR M. MOALIM

DR. ABDULQADIR M. MOALIM