DIMS Lectures Rheumatology PDF
Introduction to Rheumatology
Rheumatology is a subspecialty of internal medicine that focuses on autoimmune, inflammatory, and musculoskeletal disorders. These conditions often affect the joints, connective tissues, muscles, and bones, leading to chronic pain, systemic manifestations, and disability. Many rheumatologic diseases require early diagnosis and long-term management to prevent complications.
1. Rheumatoid Arthritis (RA)
Definition:
A chronic autoimmune inflammatory disease that primarily affects the synovial joints, leading to progressive joint damage, pain, and disability.
Pathophysiology:
T-cell activation triggers inflammation in the synovium.
Pro-inflammatory cytokines (TNF-α, IL-1, IL-6) cause synovial hyperplasia (pannus formation) and joint destruction.
Cartilage and bone erosion occur due to osteoclast activation.
Clinical Features:
Symmetrical polyarthritis (commonly affects small joints like MCPs, PIPs, wrists, knees, and ankles).
Morning stiffness lasting >1 hour.
Deformities in advanced cases: Swan-neck, boutonnière, ulnar deviation.
Extra-articular manifestations:
Rheumatoid nodules.
Interstitial lung disease.
Pericarditis, vasculitis.
Sicca symptoms (secondary Sjögren’s syndrome).
Diagnosis:
Serology:
Rheumatoid Factor (RF) positive in 70-80% of cases.
Anti-CCP antibodies (highly specific).
Inflammatory markers: ESR and CRP elevated.
X-ray findings:
Joint erosions.
Osteopenia.
Soft tissue swelling.
Management:
First-line: Methotrexate (DMARDs), NSAIDs for symptomatic relief.
Biologic DMARDs: TNF inhibitors (Infliximab, Etanercept) for refractory cases.
Steroids for acute flares.
2. Osteoarthritis (OA)
Definition:
A chronic degenerative joint disease characterized by the breakdown of cartilage and bone remodeling.
Risk Factors:
Aging.
Obesity.
Joint trauma.
Mechanical stress (repetitive use, occupation-related).
Clinical Features:
Joint pain worsens with activity, relieved by rest.
Morning stiffness <30 minutes.
Bony enlargements:
Heberden’s nodes (DIP joints).
Bouchard’s nodes (PIP joints).
Crepitus and limited range of motion.
Diagnosis:
X-ray findings:
Joint space narrowing.
Osteophytes.
Subchondral sclerosis.
Management:
Non-pharmacologic:
Weight loss.
Physiotherapy and muscle strengthening.
Pharmacologic:
NSAIDs (first-line for pain relief).
Intra-articular corticosteroids for severe pain.
Surgical: Total joint replacement in severe cases.
3. Systemic Lupus Erythematosus (SLE)
Definition:
A multisystem autoimmune disorder that leads to widespread inflammation and tissue damage in various organs.
Clinical Features:
General symptoms: Fatigue, fever, weight loss.
Skin manifestations:
Malar rash (butterfly rash).
Photosensitivity.
Discoid lupus lesions.
Organ involvement:
Arthritis (non-erosive).
Nephritis (proteinuria, hematuria).
Pericarditis, pleuritis.
CNS involvement (seizures, psychosis).
Diagnosis:
ANA positive (highly sensitive but not specific).
Anti-dsDNA and Anti-Smith antibodies (highly specific).
Urinalysis (proteinuria for lupus nephritis).
Low complement levels (C3, C4).
Management:
Mild: Hydroxychloroquine, NSAIDs.
Moderate to severe: Corticosteroids, Methotrexate, Mycophenolate mofetil.
Lupus nephritis: Cyclophosphamide, Rituximab.
4. Gout
Definition:
A metabolic disorder caused by hyperuricemia, leading to uric acid crystal deposition in joints.
Clinical Features:
Acute onset of severe pain, redness, and swelling in a single joint (commonly 1st MTP joint - Podagra).
Tophi (chronic gout): Uric acid deposits in joints and soft tissues.
Diagnosis:
Synovial fluid analysis:
Negatively birefringent, needle-shaped urate crystals.
Serum uric acid levels (may be normal during acute attacks).
X-ray findings: "Punched-out erosions" (late-stage gout).
Management:
Acute attack: NSAIDs, Colchicine, Corticosteroids.
Long-term: Allopurinol or Febuxostat to lower uric acid levels.
5. Ankylosing Spondylitis (AS)
Definition: A chronic inflammatory arthritis affecting the spine and sacroiliac joints.
Clinical Features:
Chronic lower back pain (>3 months), improves with exercise.
Morning stiffness, reduced spinal mobility.
Diagnosis:
HLA-B27 positivity, sacroiliitis on X-ray.
Management:
NSAIDs (first-line), physiotherapy.
Biologics (TNF inhibitors) for severe cases.
6. Osteomyelitis
- Definition: Infection of the bone, commonly caused by Staphylococcus aureus.
- Risk Factors:
- Diabetes, open fractures, post-surgical infections.
- Clinical Features:
- Localized bone pain, swelling, warmth.
- Fever, malaise.
- Diagnosis:
- MRI (most sensitive), blood cultures.
- Management:
- IV antibiotics (Vancomycin, Ceftriaxone).
- Surgical debridement if needed.
Case Example:
1.A 45-year-old male presents with progressive knee pain, swelling, and stiffness for 6 months. He reports difficulty in walking and morning stiffness lasting less than 30 minutes. Examination reveals crepitus, joint tenderness, and reduced range of motion. X-ray shows joint space narrowing and osteophytes.
2.A 35-year-old female presents with morning stiffness lasting more than 1 hour, symmetrical joint pain in the hands, and swelling for 6 months. Examination reveals tender, swollen PIP and MCP joints with difficulty making a fist.
3.A 50-year-old male presents with sudden severe pain, redness, and swelling in the right big toe. Symptoms began overnight, and even light touch exacerbates the pain. He has a history of hypertension and alcohol use. Examination shows a swollen, erythematous, and tender first MTP joint.
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1.Diagnosis: Osteoarthritis (of the Knee)
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