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Questions and Answers
What is the primary cause of primary osteoporosis?
Osteoporosis is characterized by a reduction of bone mass per unit of bone volume.
True
What vitamin deficiency is associated with osteomalacia?
Vitamin D
Which of the following factors can decrease bone mass?
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What is osteopenia?
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What is a common complication of osteomyelitis?
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Osteoarthritis is primarily an inflammatory disease.
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Match the following conditions with their descriptions:
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Rheumatoid arthritis primarily affects elderly individuals.
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Juvenile rheumatoid arthritis is characterized by the presence of serum rheumatoid factor.
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Rheumatoid arthritis is classified as a degenerative disease.
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Rheumatoid nodules can occur in individuals with rheumatoid arthritis.
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Vasculitis is a common extra-articular manifestation of rheumatoid arthritis.
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Primary osteoporosis is most commonly associated with elderly men.
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Corticosteroids can inhibit osteoblastic activity, leading to secondary osteoporosis.
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Osteomalacia is characterized by excessive mineralization of bone.
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Hyperparathyroidism leads to decreased intestinal calcium absorption.
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A common symptom of rickets includes epiphyseal plates remaining open.
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Secondary hyperparathyroidism can occur as a result of chronic renal failure.
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Osteopenia is defined as normal bone density.
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Alcoholism can lead to reduced absorption of calcium and inhibition of osteoblast activity.
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Rheumatoid arthritis primarily affects the synovial joints bilaterally.
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Limited range of movement and Heberden nodes are typical features of rheumatoid arthritis.
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The presence of rice bodies in the synovial fluid is a histopathological feature of rheumatoid arthritis.
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Rheumatoid arthritis often begins as a cartilage disease.
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Activation of T cells and secretion of cytokines are part of the pathogenesis of rheumatoid arthritis.
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Rheumatoid arthritis is a systemic autoimmune condition that can lead to extra-articular manifestations.
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Decreased calcium absorption in the gastrointestinal tract can lead to hypocalcemia.
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Osteomyelitis is primarily caused by autoimmune disorders affecting the joints.
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Granulation tissue growing over the articular cartilage in rheumatoid arthritis is known as pannus.
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Staphylococcus is one of the organisms that can cause osteomyelitis.
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Mild inflammation and morning stiffness are not symptoms associated with rheumatoid arthritis.
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Osteoarthritis is characterized by the rapid degeneration of articular cartilage.
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Increased thickness of subchondral bone is observed in osteoarthritis.
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Pathologic fractures can be a complication of chronic osteomyelitis.
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Rheumatoid conditions are categorized as primary causes of osteoarthritis.
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Osteophytes are typically found in the distal interphalangeal joints in osteoarthritis.
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Study Notes
Osteoporosis
- Reduction of bone mass per unit of bone volume
- Metabolic bone disease
- Bone displays normal ratio of mineral to matrix
- Primary and secondary types
Primary Osteoporosis
- Most common
- Uncertain etiology
- Postmenopausal women
- Elderly persons (senile)
Factors contributing to Primary Osteoporosis
- Genetics: peak bone mass
- Estrogens: decline
- Age
- Calcium intake: recommended intake of 800mg per day
- Exercise
- Environmental factors: smoking leads to estrogen reduction
Primary Osteoporosis - Osteopenia
- Decrease thickness of cortex
- Reduction in the number and size of trabeculae
- Fractures can be the first sign
- Compression fractures of vertebrae
Secondary Osteoporosis
- Corticosteroids:
- Inhibition of osteoblastic activity
- Impairment of vitamin D dependant intestinal calcium absorption (secondary hyperparathyroidism)
- Hematologic malignancies
- Malabsorption: Gastrointestinal and liver diseases
- Alcoholism:
- Inhibition of osteoblasts
- Reduced calcium absorption
Osteomalacia and Rickets
- Inadequate mineralization of newly formed bone matrix (osteomalacia)
- Rickets: children, epiphyseal plates open; also problem with cartilage
- Vitamin D deficiency (dependent)
- Phosphate deficiency (resistant)
- Defects in mineralization process
Osteomalacia and Rickets - Symptoms
- Beaded appearance of costochondral junctions
- Pectus carinatum (pigeon chest)
- Dental abnormalities
- Osteopenia
- Exaggeration of osteoid seams
- Poorly localized pain
- Pain in femoral neck, pubic ramus, spine, ribs
Hyperparathyroidism
- Parathyroid adenoma, hyperplasia, rare malignancy
- Parathyroid hormone:
- Promotes excretion of phosphate in the urine and stimulates osteoclastic activity resulting in hypercalcemia
- Stimulates tubular reabsorption of calcium and excretion of phosphate
- Stimulates intestinal calcium absorption
Hyperparathyroidism - Symptoms
- Stones: Kidney
- Bones: Brown tumors
- Psychiatric depression
- Gastrointestinal tract irregularities
Secondary Hyperparathyroidism
- Renal osteodystrophy
- Chronic renal failure:
- Decreased filtration of phosphate
- Hyperphosphatemia
- Effect on active vitamin D
- Decreased calcium absorption in GI tract
- Hypocalcemia
- Secondary hyperparathyroidism
- Decreased filtration of phosphate
Osteomyelitis
- Inflammation of bone caused by an infectious organism
- Common organisms include: Staphylococcus, streptococcus, Escherichia coli, Neisseria gonorrhea, Haemophilus influenza, Salmonella
- Modes of infection:
- Direct penetration: Wounds, fractures, surgery
- Hematogenous: Bloodstream, teeth; metaphyses - Knee, ankle, hip
Osteomyelitis - Complications
- Septicemia
- Acute bacterial arthritis
- Pathologic fractures
- Squamous cell carcinoma
- Amyloidosis
- Chronic osteomyelitis
Arthritis - Introduction
- Inflammation of joints - Common
- Common site for autoimmune injury
- Heart valves & Joints - damage - Exposure of hidden antigens. Infections. Degeneration - Age/Stress/lifestyle
Arthritis - Clinical Features
- Pain: Inflammation - capsule, synovium, periosteum
- Swelling: Inflammation, effusion, proliferation
- Restricted movement: Pain, fluid, synovial swelling, damage
- Deformity: Mal-alignment, erosion, ankylosis
Osteoarthritis
- Most common joint disease
- Slow progressive degeneration of articular cartilage
- Weight bearing joints
- Fingers
- Primary: Defect in cartilage, not an inflammatory disease
- Secondary: Trauma, crystal deposits, infection
- Interphalangeal joints, knees, hips, cervical and lumbar spine
Osteoarthritis - Symptoms
- Narrowing of joint space (loss of disk)
- Increased thickness of subchondral bone: Eburnated bone
- Subchondral bone cysts
- Osteophytes (Haberden nodes): Fingers, distal interphalangeal joints
Osteoarthritis - Causes
- Primary
- Secondary:
- Intra articular fracture
- Previous infective arthritis
- Rheumatoid
- Congenital dislocation of hip
- Abnormal stresses: Paget’s disease with deformity, chronic overuse
- Metabolic and endocrine: Hemochromatosis, Gout, Calcium phosphate deposition
- Neuropathic disorders: Peripheral neuropathy as in diabetes mellitus
- Intraarticular corticosteroid in excess
Osteoarthritis - Pathology
- Degenerative end result (ageing) >80% in >65y
- Progressive erosion and fibrillation of articular cartilage → forms Loose bodies
- Hardened articular bone – eburnation
- Subarticular cyst formation in bone
- Periarticular osteophyte formation
- Mild inflammation but painful, morning stiffness
- Limited range of movements
- Heberden nodes (female)
Osteoarthritis - Radiologic Features
- No uniform joint space
Osteoporosis
- Reduction of bone mass per unit of bone volume.
- Metabolic bone disease where the bone displays a normal ratio of mineral to matrix.
- Can be primary (most common, uncertain etiology, postmenopausal women, elderly) or secondary.
PrimaryOsteoporosis
- Factors include:
- Genetics: peak bone mass.
- Estrogens: decline.
- Aging.
- Calcium intake (800mg/day).
- Exercise.
- Environmental factors: smoking leads to estrogen reduction.
- Osteopenia: decreased thickness of cortex and reduction in the number and size of trabeculae.
- Fractures can be the first sign, compression fractures of vertebrae are common.
Secondary Osteoporosis
- Caused by:
- Corticosteroids: inhibition of osteoblastic activity and impairment of vitamin D-dependent intestinal calcium absorption (secondary hyperparathyroidism).
- Hematologic malignancies.
- Malabsorption: gastrointestinal and liver diseases.
- Alcoholism: inhibition of osteoblasts and reduced absorption of calcium.
Osteomalacia and Rickets
- Inadequate mineralization of newly formed bone matrix.
- Rickets: children, epiphyseal plates open.
- Causes:
- Vitamin D deficiency (dependent).
- Phosphate deficiency (resistant).
- Defects in mineralization process.
- Clinical findings:
- Beaded appearance of costochondral junctions.
- Pectus carinatum.
- Dental abnormalities.
Hyperparathyroidism
- Cause: parathyroid adenoma, hyperplasia, rare malignancy.
- Parathyroid hormone:
- Promotes excretion of phosphate in the urine and stimulates osteoclastic activity resulting in hypercalcemia.
- Stimulates tubular reabsorption of calcium and excretion of phosphate.
- Stimulates intestinal calcium absorption.
Secondary Hyperparathyroidism
- Occurs in renal osteodystrophy due to chronic renal failure.
- Effects:
- Decreased filtration of phosphate, leading to hyperphosphatemia.
- Effect on active Vitamin D.
- Decreased calcium absorption in the gastrointestinal tract, leading to hypocalcemia.
- Secondary hyperparathyroidism as a consequence of the above.
Osteomyelitis
- Inflammation of bone caused by an infectious organism.
- Common organisms: Staphylococcus, Streptococcus, Escherichia coli, Neisseria gonorrhea, Haemophilus influenza, Salmonella.
- Routes of infection:
- Direct penetration: wounds, fractures, surgery.
- Hematogenous: bloodstream, teeth (metaphyses); knee, ankle, hip.
Complications of Osteomyelitis
- Septicemia.
- Acute bacterial arthritis.
- Pathological fractures.
- Squamous cell carcinoma.
- Amyloidosis.
- Chronic osteomyelitis.
Arthritis: Introduction
- Inflammation of joints.
- Common site for autoimmune injury.
- Factors:
- Heart valves and joints damage: exposure of hidden antigens.
- Infections.
- Degeneration: age/stress/lifestyle.
Arthritis - Clinical Features
- Pain due to inflammation of capsule, synovium, periosteum.
- Swelling due to inflammation, effusion, proliferation.
- Restricted movement due to pain, fluid, synovial swelling and damage.
- Deformity due to mal-alignment, erosion, ankylosis.
Osteoarthritis
- Most common joint disease.
- Slow progressive degeneration of articular cartilage.
- Affects weight bearing joints: hips, knees, ankles.
- Also common in fingers.
- Two types:
- Primary: defect in cartilage, not an inflammatory disease.
- Secondary: trauma, crystal deposits, infection.
Osteoarthritis - Clinical Features
- Narrowing of joint space (loss of disk).
- Increased thickness of subchondral bone.
- Subchondral bone cysts.
- Osteophytes (Heberden nodes) on fingers.
Osteoarthritis - Causes
- Primary: unknown etiology.
- Secondary:
- Intraarticular fracture.
- Previous infective arthritis.
- Rheumatoid arthritis.
- Congenital dislocation of the hip.
- Abnormal stresses:
- Paget's disease with deformity.
- Chronic overuse.
- Metabolic and endocrine:
- Hemochromatosis.
- Gout.
- Calcium phosphate deposition.
- Neuropathic disorders:
- Peripheral neuropathy (eg. diabetes mellitus).
- Intraarticular corticosteroid excess.
Osteoarthritis - Radiologic Features
- Loss of joint space.
- Osteophyte formation.
- Cyst formation.
- Subchondral sclerosis.
- Sclerosis, ankylosis and deformity.
Rheumatoid Arthritis
- Systemic chronic inflammatory disease.
- Autoimmune disease.
- Affects diarthrodial joints bilaterally.
- Starts as a synovial disease.
- Women are affected three times more often than men.
- Remissions and exacerbations.
- Inherited susceptibility and environmental factors like EBV may play a role.
Rheumatoid Arthritis - Pathogenesis
- Genetically susceptible patient develops an infection.
- Formation of antibodies to the infectious agent.
- Antibodies act as new antigens.
- Production of rheumatoid factor (IgM anti-IgG).
- Deposits of immune complexes in the synovium.
- Activation of complement cascade.
- Inflammation, activation of macrophages and homing of T cells.
- Secretion of cytokines.
Rheumatoid Arthritis - Definition
- Chronic multisystem autoimmune inflammatory disorder primarily affecting joints producing a proliferative synovitis that often progresses to destruction of articular cartilage and ankylosis.
- Contributing factors:
- Genetic susceptibility: HLA DR4 or DR1 in 65% to 80% of cases.
- Microbial inciting agent: Epstein-Barr virus, Borrelia and Mycoplasma.
- Autoimmunity: IgM anti IgG (rheumatoid factor) & helper T cell (CD4) against type II collagen and cartilage glycoprotein-39.
Rheumatoid Arthritis - Pathology
- Inflammation of the joint and hyperplasia of the synovium.
- Destruction of the articular structures.
- Synovium infiltrated with lymphocytes and plasma cells.
- Fibrin exudation on the synovial fluid forming soft loose bodies called "rice bodies".
- Neutrophil polymorphs are present.
- Granulation tissue grows over the surface of the articular cartilage, called "pannus", which interferes with the nutrition of the cartilage leading to permanent joint damage.
Rheumatoid Arthritis - Histopathological Features
- Rice bodies.
- Hyperplastic synovium.
- Pannus.
- Allison-Ghormley bodies.
- Rheumatoid nodules.
Rheumatoid Arthritis - Extra-articular Manifestations
- Rheumatoid nodules.
- Vasculitis.
- Cardiac disease.
- Pulmonary disease.
- Serosal inflammation.
- Amyloidosis.
- Anemia.
- Eye involvement.
Rheumatoid Arthritis - Morphology
- Proliferative synovitis with lymphocytes (CD4), plasma cells and macrophages (pannus).
- Organizing fibrin (rice bodies).
- Neutrophils on the joint surface and fluid.
- Juxta-articular erosions, cysts and osteoporosis.
- Fibrous ankylosis.
- Skin: Rheumatoid nodules.
- Vasculitis (commonly of digital arteries).
Rheumatoid Arthritis - Clinical Features
- At least four clinical features for diagnosis:
- Morning stiffness.
- Arthritis in 3 or more joint areas.
- Arthritis of small hand joints.
- Symmetric arthritis.
- Rheumatoid nodules.
- Serum rheumatoid factor.
- Typical radiographic changes.
Rheumatoid Arthritis - Extra-articular Features
- Rheumatoid nodules.
- Vasculitis.
- Pleuritis.
- Pericarditis.
- Tendonitis.
Comparison of Rheumatoid Arthritis and Osteoarthritis
| Feature | Rheumatoid Arthritis | Osteoarthritis |
|---|---|---|
| Age | Any age, most common 25-55 | Elderly |
| Affected joint | Symmetrical arthritis: metacarpophalangeal, interphalangeal, wrist, shoulder | Hip, knee, ankle |
| Synovium | Hyperplasia, dense inflammation | Mild secondary inflammation |
| Articular cartilage | Eroded by pannus | Loss of weight bearing surface |
| Systemic disease | Yes | No |
| Pathogenesis | Autoimmune disease | Degenerative |
Juvenile Rheumatoid Arthritis
- Starts below 16 years of age, most common 1-3 years.
- Clinical features:
- High spiking fever daily or twice daily.
- Hepatosplenomegaly.
- Serosal inflammation (pericarditis).
- Generally involve knee, wrist, elbow, small joints of hands and feet.
Juvenile Rheumatoid Arthritis - Pathogenesis
- Begins before the age of 16.
- Multisystem involvement: splenomegaly.
- Systemic involvement at onset, unlike adult RA.
- No serum rheumatoid factor (seronegative).
- Antinuclear antibody (ANA) positive, indicating autoimmune nature.
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