SEROPOSITIVE

ARTHRITIS

INTRODUCTION

SEROPOSITIVE ?

RA FACTOR

Anti-CCP antibodies

RF assosciations

Rheumatology: Rheumatoid Arthritis; SLE; Sjogrens; MCTD; Myositis;

Cryoglobulinemia;
Others:; 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

approximately 1% of the population

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 in advanced stages

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 synovial hypertrophy)

Foot

Similar fusiform swelling can be found in the 1st and

5th metatarsal heads

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 are 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)

Generalised or solitary sclerosis one or more distal phalanges is an

important 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

Coronal contrast- enhanced fatsaturated 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 spread
Destruction of articular cartilage

Once destroyed the articular cartilage rarely

reforms on healing

Erosive changes are less common in larger joints

but bone destruction Is more

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 fatsaturated 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 preerosion 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

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 be 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 longstanding 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. Bakers 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.

RA is a systemic disease with

extraarticular manifestations
Secondary Sjgrens syndrome
Heart
Pericarditis
Myocarditis
Endocarditis
Valvular fibrosis
Liver
Enzyme abnormalities due to drug
reactions or Sjgrens syndrome

Blood / blood vessels

Mild anemia
Vasculitis
Feltys syndrome

Eyes
Keratoconjunctivitis
Sicca syndrome
Scleritis
Episcleritis
Keratitis corneal ulceration
Choroiditis
Retinal vacuities
Episcleral nodules
Lungs
Pleuritis pleural effusions
Pulmonary nodules
Interstitial pulmonary fibrosis
Skin
Rheumatoid nodules
Vasculitis
Interstitial granulomatous dermatitis

Firestein. ACP Medicine, Rheumatology II

RA: Current Pharmacologic Options

Agents that are effective in controlling the signs and symptoms of RA, but have no
effect on disease progression
NSAIDs reduce inflammation and pain
COX-2 inhibitors are similar to NSAIDs, but with improved GI safety and tolerability and
higher cardiac side effects
Analgesics- these medicines do not affect inflammation, but work on pain pathways to
decrease subjective feeling of pain.

DMARDs impact the signs, symptoms, and disease progression of RA, as well as improve
the quality of life and functionality of the patient

Corticosteroids have anti-inflammatory and immunoregulatory activity, but nominal

disease-modifying capability

Irvine S, et al. Ann Rheum Dis. 1999;58:510513; Madhok R, Capell HA. Lancet 1999;353:257258;
ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46:328346; Goldbach-Mansky R, Lipsky PE.
Annu Rev Med. 2003;54:197216.

RA: Disease Modifying therapies

Traditional DMARDs
For example
Methotrexate
Leflunomide (Arava)
Sulfasalazine (SSZ,
Azulfidine)
Hydroxychloroquine (HCQ,
Plaquenil)
Azathioprine,
cyclosporine

Biological DMARDS
For example
TNF antagonists
Etanercept (Enbrel)
Adalimumab (Humira)
Infliximab (Remicade)
Certolisumab pegol (Cimzia)
Golimumab (Simponi)
Abatacept (Orencia)
Rituximab (Rituxan)
Tocilizumab (Actemra)
Tofacitinib (Xeljanz)

British Journal of Nursing (2013) volume: 22 issue: 6 308, 310, 318

British Journal of Nursing (2013) volume: 22 issue: 6 308, 310, 318

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

Unlikerheumatoid 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

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

Most predominant feature will be fibrosis

early stages may show ground glass

changes

later stages may showhoneycombingand

evidence of lung volume loss

lung bases and sub-pleural regions

typically involved

cysts may be present measuring 1-5cm in

diameter

pleural effusions are usuallynota

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
systemic sclerosis

Sjogrens syndrome

Chronic Autoimmune disease

Primarily affect Salivary and lacrimal glands resulting in XEROSTOMIA and

keratoconjuctivtis sicca

Secondary Sjogrens seen most commonly in people with diagnosed with RA

And SLE

As a single entity sjogrens doesnt involve the joints.

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