A 70-year-old female with mild dementia complains of unilateral groin pain. There is some limitation of motion in the right hip. Which of the following is the most appropriate first step in evaluation?
a.CBC and erythrocyte sedimentation rate
b.Rheumatoid factor
c.X-ray of right hip
d.Bone scan
The answer is c.
Hip pain may result from fracture, bursitis, arthritis, tumor, or pain referred from the lumbosacral spine. A film of the right hip is mandatory in this patient. Fracture of the hip must be ruled out, particularly in a woman with mental status abnormalities, who may be prone to falls. Elderly women with osteoporosis are most prone to hip fracture.
Pain from the hip joint is most often felt in the groin radiating down the anterior thigh. It is important to realize that patients will often complain of “hip” pain when they mean pain in the buttocks or low back. Pain in the buttocks is most often referred pain from the spine.
A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. Of the following tests,which, if positive, would be most supportive of a definitive diagnosis?
a.Rheumatoid factor
b.Antinucleolar antibody
c.ECG
d.BUN and creatinine
e.Reproduction of symptoms and findings by immersion of hands in cold water
The answer is b.
The symptoms of Raynaud’s phenomenon, arthralgia, and dysphagia point toward the diagnosis of scleroderma. Scleroderma, or systemic sclerosis, is characterized by a systemic vasculopathy of small and medium-sized vessels, excessive collagen deposition in tissues, and an abnormal immune system. It is an uncommon multisystem disease affecting women more often than men. There are two variants of scleroderma ;a relatively benign type called the CREST syndrome"C-calcinosis.R- raynaud phen. E- esophagal dysmotility.S-sclerodactyly.T-talangiectasia" and a more severe, diffuse disease.
Antinucleolar antibody occurs in only 20 to 30% of patients with the disease, but a positive test is highly specific. Cardiac involvement may occur, and an ECG could show heart block or pericardial involvement but is not at all specific. Renal failure can develop insidiously. Rheumatoid factor is nonspecific and present in 20% of patients with scleroderma. Reproduction of Raynaud’s phenomena is nonspecific and is not recommended as an office test.
The clinical spectrum of scleroderma
The spectrum of sclerodermatous diseases comprises a wide variety of clinical entities such as morphea (patchy, linear, generalized), pseudo-scleroderma and the overlap-syndromes with similar cutaneous and histopathologic manifestations.
Felty's syndrome is defined as A combination of rheumatoid arthritis, splenomegaly, leukopenia, pigmented spots on lower extremities, and other evidence of hypersplenism (anemia and thrombocytopenia). It was first described in 1924 You can remember Felty's syndrome by this :
the arthritis in which the spleen can be felty
It is a potentially serious condition that is associated with seropositive (rheumatoid factor [RF]–positive) rheumatoid arthritis (RA).In which many patients are asymptomatic, some develop serious and life-threatening infections secondary to granulocytopenia.
After years of gouty attacks, patients will develop a chronic arthritis resulting in bone and cartilage destruction and deformity. Uric acid crystals deposit within and surrounding the joint causing a chronic destructive inflammatory process. X-rays characteristically show well demarcated "punched out" erosions.
Tophi at helix of ear.
Tophi or deposits of uric acid crystals are often found around joints, in the olecranon bursa or at the pinna of the ear.
X-ray showing soft tissue swelling and erosion of 2nd PIP.
Inflammatory arthritis is generally classified into seropositive and seronegative groups. These are based on the presence of rheumatoid factor, an immunoglobulin which reacts with gamma globulin, in the blood of the majority of patients with seropositive disease and in a small minority of patients with seronegative disease. The prototype seropositive form of arthritis is rheumatoid arthritis. Other members include the group of conditions labelled collagen vascular diseases, such as systemic lupus erythematosus, scleroderma, vasculitis, Sjogren’s syndrome. Only rheumatoid arthritis will be considered in this paper.
Among the seronegative inflammatory joint diseases is a group labelled spondyloarthritis. This condition is characterized by inflammatory disease of the joints of the back, both the sacroiliac joints and the apophyseal joints of the spine. Members of this group include ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and arthritis of inflammatory bowel disease. While the prototype for this group is ankylosing spondylitis, psoriatic arthritis will also be discussed.
In addition to the presence of rheumatoid factor, there are extra-articular features which distinguish the seropositive from the seronegative forms of inflammatory arthritis.
A 34 year old male has a long history of several subacute attacks of self-limited inflammatory arthritis. Crystals have been retrieved from a joint aspirate. Radiography of his knee is likely to demonstrate: a) subperiosteal thickening b) marginal articular erosions c) central articular erosions d) chondrocalcinosis e) subchondral bony sclerosis
The correct answer is D
Explanation Chondrocalcinosis is simply the term for the finding of radio-opaque crystals in hyaline or fibrocartilage. These salts may consist of calcium pyrophosphate dihydrate, dicalcium phosphate dihydrate or hydroxyapatite. Crystals may also be deposited in bursae, capsules, ligaments and tendons. Chondrocalcinosis may accompany a variety of diseases, but is not a disease entity merely a physical sign thereof. Used properly, the term pseudogout refers to the clinical syndrome of one or more acute or subacute attacks of self-limited inflammatory arthritis caused by crystal-induced synovitis, proven by recovery of the crystals from a joint aspirate. Most people with chondrocalcinosis never have a single acute episode of pseudogout.
CPPD crystal deposition disease is the general term that encompasses chondrocalcinosis, pseudogout, a distinctive arthropathy and a host of variations. During acute attacks (pseudogout) of crystal-induced synovitis, the usual radiological findings are soft-tissue oedema and joint effusion. Chondrocalcinosis may or may not be present. The cartilage and articular bone are often normal. The chronic arthropathy is more distinctive. It is most frequent in the patellofemoral, radiocarpal metacarpophalangeal and elbow joints.
Although the findings superficially resemble osteoarthritis, there are several important differences beyond the unique distribution. The arthropathy is characterized by cartilage loss, multiple subchondral cystic rarefactions, structural collapse of the articular surface, and the presence of many small intra-articular fragments, all without much bone sclerosis. In addition to the usual target sites, these changes may be observed in the hips, knees and sacroiliac joints. Chondrocalcinosis, which does not have to accompany the arthropathy, is seen most commonly in the large joints such as the knee, hip and shoulder as well as the symphysis pubis.
Systemic scleroderma often affects the hands. The initial stage is swelling (edema), which can last for weeks, months, or years. Often the swelling is intermittent and worse in the morning. It can cause the fingers to look like sausages, with far fewer wrinkles. Skin tightness in the hands can make it impossible to pinch the skin on the fingers. In some people, the fingers eventually begin to harden from fibrosis, and curl inward. They may then become frozen in this clawed position, which is referred to as "sclerodactyly."
So,When the skin on the fingers become tight, stretched, wax-like, and hardened it is called sclerodactyly. Sclerodactyly is commonly associated with atrophy of the underlying soft tissues.
Not everyone with scleroderma develops this degree of skin hardening. However, it is this symptom that has earned scleroderma the nickname of 'the disease that turns people to stone'.
These are a focus of central fibrinoid necrosis surrounded by a palisade of epitheloid cells, occurring as a typical feature of sero-positive rheumatoid arthritis.
Subcutaneous nodules commonly occur on extensor surfaces subject to external pressure, for example, the upper forearm and elbow. Occasionally, they arise within the lungs or heart.
Nodules are rare in sero-negative rheumatoid arthritis.
A 69-year-old man was referred for the evaluation of changes to his fingernails that developed after the initiation of chemotherapy with docetaxel–cisplatin–fluorouracil for gastric cancer. Physical examination revealed multiple white lines on the fingernails, known as Beau's lines. The lines corresponded to the start of each chemotherapy cycle, with the distance between the lines proportional to the interval between the cycles. One white line showed less severe dystrophia than the others (arrow); on reviewing the medical records, it was noted that the corresponding chemotherapy cycle consisted of docetaxel–fluorouracil only, owing to the patient's compromised renal function at the time, whereas all the other cycles consisted of the complete docetaxel–cisplatin–fluorouracil regimen.
Cytotoxic chemotherapeutic agents can induce the temporary arrest of proliferative function of the nail matrix, which may be manifested as multiple Beau's lines in the nail plate. This nail pattern can provide insight into the interval between and intensity of chemotherapy cycles.
