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POLIARTRITA REUMATOIDA

Monica Copotoiu, MD, PhD

DEFINITIE
Leziunea elementara sinovita inflamatorie
Distructia articulara
Pusee evolutive
Caracter heterogen

SN

SP

Macrofage

Ly T
Macrofage

Ly T

Neu

Macrofage

Ly T

Neu

Macrofage
Ly B

Neu

Ly T

Macrofage
Plasmocite

Ly B

Neu

Ly T

Macrofage
CIC + C
Plasmocite

Ly B

Neutrofile

Ly T

Macrofage
Complexe imune circulante +
Complement

Plasmocite

Ly B

Neu

Ly T

Macrofage
CIC + C
Plasmocite

Ly B

EPIDEMIOLOGIE
Cea mai frecventa - colagenoze
F:H 3:1
Debut 50 ani
Prevalenta 0.3 - 0.8 %

PR
PR la debut !!!

Un diagnostic precoce !!!

Fereastra de oportunitate terapeutica !!!

PR
PR la debut !!!

Artrite

Un diagnostic precoce !!!


Sinovite
Fereastra de oportunitate
terapeutica !!!
Tenosinovite/tendinoptii

PR
Poliartrita
Bilaterala
Simetrica
+/ manifestari extra-articulare

PR
Poliartrita
Bilaterala
Simetrica
+/ Manifestari extraarticulare

Puseu evolutiv
Distrugeri structurale

PR
Poliartrita
Monoartrita
Bilaterala
Simetrica
Caracter inflamator
Oligoartrita
+/ Manifestari extra-

PR
Pumnul/RC
MCP (II;III)
IFP
IFD

CAND SE RECOMANDA CONSULT


REUMATOLOGIC?
3 AT (articulatii
tumefiate)
Manevra Gaenslen +
(MCP; MTP)
Redoare matinala 30
min

PR MANIFESTARI ARTICULARE
Deviatie dg. bataia vantului
Deformare in gat de
lebada
Deformare in butoniera"
Degete in ciocan
Police in Z
Luxatia stiloidei radiale in
clapa de pian
Picior plat in valgus

PR MANIFESTARI ARTICULARE
Deviatie dg. bataia vantului
Deformare in gat de lebada
Deformare in butoniera"
Degete in ciocan
Police in Z
Luxatia stiloidei radiale in clapa
de pian
Picior plat in valgus

PR MANIFESTARI ARTICULARE
Deviatie dg. bataia
vantului
Deformare in gat de
lebada
Deformare in butoniera"
Degete in ciocan
Police in Z
Luxatia stiloidei radiale in
clapa de pian
Picior plat in valgus

PR MANIFESTARI ARTICULARE
Deviatie dg. bataia
vantului
Deformare in gat de
lebada
Deformare in butoniera"
Degete in ciocan
Police in Z
Luxatia stiloidei radiale in
clapa de pian
Picior plat in valgus

PR MANIFESTARI ARTICULARE
Deviatie dg. bataia
vantului
Deformare in gat de
lebada
Deformare in butoniera"
Degete in ciocan
Police in Z
Luxatia stiloidei radiale in
clapa de pian
Picior plat in valgus

PR MANIFESTARI ARTICULARE
Deviatie dg. bataia vantului
Deformare in gat de lebada
Deformare in butoniera"
Degete in ciocan
Police in Z
Luxatia stiloidei radiale in clapa
de pian
Picior plat in valgus

PR MANIFESTARI ARTICULARE
Deviatie dg. bataia vantului
Deformare in gat de
lebada
Deformare in butoniera"
Degete in ciocan
Police in Z
Luxatia stiloidei radiale in clapa
de pian
Picior plat in valgus

ART. SH

ART. SH
Artrita glenohumerala
Capsulita retractila

Nu abductie
Eroziuni ale partii distale ale
claviculei + ruptura calotei
rotatorilor

ART. SH
Artrita glenohumerala
Capsulita retractila

Nu abductie
Eroziuni ale partii distale ale
claviculei + ruptura calotei
rotatorilor

BURSITE

BURSITE

CHIST BAKER

PR - MANIFESTARI EXTRAARTICULARE
Febra
Astenie
Stare de rau

PR - MANIFESTARI EXTRAARTICULARE
Noduli reumatoizi
Fermi
Mobili
Indolori
MTX

PR - MANIFESTARI EXTRAARTICULARE
Les infections
pleuropulmonaire
La fibrose pulmonaire
interstitielle diffuse - MTX
Les bronchectasies

Le nodule rhumatode - MTX


La pleursie rhumatode
Syndrome Caplan

PR - MANIFESTARI EXTRAARTICULARE
Amiloidoza AA

Proteinurie
Sindrom nefrotic
Insuficienta renala progresiva

PR - MANIFESTARI EXTRAARTICULARE
Amiloidoza AA
Proteinurie
Glomerulonefrita
interstitiala
Glomerulonefrita
extramembranara

Sindrom nefrotic
Insuficienta renala
progresiva

PR - MANIFESTARI EXTRAARTICULARE
Anemie

Splenomegalie
Leuconeutropenie

Sindromul Felty

Trombocitopenie
Hepatomegalie

Pseudosindromul Felty /
limfocitoza cu limfocite
granulomatoase

FR +
AAN +
Infectii

PR - MANIFESTARI EXTRAARTICULARE
Anemie

Splenomegalie
Leuconeutropenie

Sindromul Felty

Trombocitopenie
Hepatomegalie

Pseudosindromul Felty /
limfocitoza cu limfocite
granulomatoase

FR +
AAN +
Infectii

PR - MANIFESTARI EXTRAARTICULARE
Livedo reticular
Purpura vasculara
Ulcere profunde
Necroze digitale
Vasculita leucocitoclastica
Neuropatie periferica

PR LABORATOR
Hemoleucograma + FP
VS
PCR
Bilant hepatocelular
Creatinina
Sumar de urina

PR LABORATOR
FR
Anti CCP
AAN

PR LABORATOR
FR
Anti CCP

Ig M
Specificitate 75 - 85%
Sensibilitate 70 % - 80%

AAN
Manifestari extraarticulare
Prognostic

PR LABORATOR
Ig G

FR
Specificiate 75 - 85%

Anti CCP
AAN

50% PR
Prognostic

PR LABORATOR
FR
Anti CCP

15 30 %

AAN

LED

PR EXPLORARI IMAGISTICE
Radiografia toracelui
Radiografie comparativa maini
Radiografia pumnului fata
Radiografie comparativa picioare
Radiografia coloanei cervicale

PR EXPLORARI IMAGISTICE
Radiografia toracelui
Radiografie comparativa maini
Radiografia pumnului fata

Eroziuni periarticulare
Geode juxta-articulare
Pensarea interliniului articular

Radiografie comparativa picioare

Osteoporoza in banda epifizar


Radiografia coloanei cervicale

http/pio.arthrolink.com/radiotheque

http/pio.arthrolink.com/radiotheque

PR EXPLORARI IMAGISTICE
Radiografia toracelui
Radiografie comparativa maini
Radiografia pumnului fata
Radiografie comparativa picioare
Radiografia coloanei cervicale

Compresia medulara

PR EXPLORARI IMAGISTICE
ECOGRAFIE

RMN

PR EXPLORARI IMAGISTICE
ECOGRAFIE

Eroziuni
Sinovite

RMN

Tenosinovite
Rupturi tendinoase

EROZIUNI

EROZIUNI

SINOVITE

TENOSINOVITE

TENOSINOVITE

PR EXPLORARI IMAGISTICE
ECOGRAFIA

IRM

http/pio.arthrolink.com/radiotheque

http/pio.arthrolink.com/radiothequ
e

http/pio.arthrolink.com/radiotheque

http/pio.arthrolink.com/radiotheque

CRITERII DE CLASIFICARE ACR (1987)


1.

Redoare matinala 1 h.

2. Artrita 3 articulatii (tumefactii sau


epansament articular).
3. Artrita art. mana (IPP MCP sau RC).
4. Artrita simetrica.
5. Noduli reumatoizi.
6. Prezenta factorului reumatoid.
7. Leziuni radiologice (demineralizare
in banda sau eroziuni osoase).

CRITERII DE CLASIFICARE ACR/EULAR (2010)


Afectarea articulara (0-5)
1 articulatie medie sau mare

2-10 articulatii medii sau mari

1-3 articulatii mici

4-10 articulatii mici

> 10 articulatii (cel putin 1 articulatie mica)

Serologie (0-3)
FR, CCP

Cel putin 1 test slab pozitiv

Cel putin 1 test puternic pozitiv

Debutul sinovitei (0-1)


< 6 saptamani

6 saptamani

Reactanti de faza acuta (0-1)


PCR, VSH crescute

CRP sau ESR crescute

PR FACTORI DE PROGNOSTIC
FR +
Anti-CCP +
VSH
PCR
NAD
NAT
Statut socio-economic
Non aderenta la tratament

PR FACTORI DE PROGNOSTIC
FR +
Anti-CCP +
VSH
PCR
NAD
NAT
Statut socio-economic
Non aderenta la tratament

DAQ 28 3.2
SDAI
CDAI
HAQ 0.5

PR TRAITEMENT
Remisiune

NAD 1
NAT 1
PCR 1 mg/dl
VSH 1 (0-10)

PR TRATAMENT
Remisiune

Control al durerii

Nivel scazut de
activitate!

evolutie

PR TRATAMENT
Remisiune

Control al durerii

Nivel scazut de
activitate!

evolutie

PR TRATAMENT SIMPTOMATIC
Anti inflamatoare non
steroidiene / AINS
Anti inflamatoare steroidiene /
AIS

Fizioterapie
Reeducare
Orteze

Corticoizi

PR TRATAMENT SIMPTOMATIC

PR TRAITEMENT SYMPTOMATIQUE
Anti inflammatoires non
stroidiennes / AINS
Anti inflammatoires
stroidiennes / AIS

Physiothrapie
Reducation
Orthses

Corticoides

PR TRATAMENT
Remisia

Control al durerii!!!

Activitate scazuta
a bolii!!!

evolutie

PR TRAITEMENT DE FOND T2T


(TREAT TO TARGET)
1.Tratament de fond clasic

2.Tratament de fond biologic

PR TRAITEMENT DE FOND T2T


(TREAT TO TARGET)
1.Tratament de fond clasic
.Metotrexat
.Leflunomid
.Sulfasalazina
.Anti malarice de sinteza

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
MTX gold
standard
im
sc
comprimate

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
Leflunomid

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
Sulfasalazina

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
Anti malarice de
sinteza

Hidroxicloroquina/P
laquenil

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
Inhibitor de TNF
Infliximab
Golimumab
Adalimumab
Certolizumab pegol
Etanercept

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
Anticorp
monoclonal
umanizat anti
receptor de lIL 6
Tocilizumab

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
Antagonist de
receptor de lll-1
Anakinra

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
Inhibitor ai costimularii
(CD80/CD86
CD28)
Abatacept

PR TRATAMENT DE FOND T2T


(TREAT TO TARGET)
Anticorp monoclonal anti
receptor de CD20
Rituximab