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Afectiuni Reumatismale Curs
Afectiuni Reumatismale Curs
Simptome 1.Durerea
de repaus - accentuata dupa repaus, remisa de miscarespondilartrite de utilizare - accentuata de utilizare,remisa temporar de repaus- leziune mecanica,artroza nocturna - guta poliarticulara, monoarticulara localizata (precisa) referita - distal de locul leziunii (col.cervicala-durere occpitala, in umeri, epicondil lateral -antebrat mediu, tunel carpal -degete ,ocazional antebrat, sold -fesa, coapsa mediana,genunchi medial) ascutita -nerve entrapment Intensitate variabila
3.Tumefiere:-inflamatie a unei articulatii sau a structurilor periarticulare 4.Scaderea fortei musculare si dificultatea motilitatii (polimiozita,neuropatie,poliartrite.. 5. Astenie -simptom frecvent, LES,RF 6.Labilitate emotionala 7.Simptome sistemice nespecifice : febra, scadere ponderala,frisoane,transpiratii
Examen fizic
Local articular Inspectie :tumefiere,eritem, deformitate( osoasa, lichid sinovial, sinovita proliferativa,bursite) Palpare :caldura, crepitatii, sensibilitate asimetrie,subluxatii, retractii tendinoase,ankiloze Miscare - activa,pasiva, contra rezistenta Manifestari sistemice: cutanate (eritem multiorm, migrans ,marginat,nodos,pioderma gangrenosum, placi psoriatice ,ulceratii,purpura),gg, cardiace ( pericardita, icc,endocardite), pulmonare ( pleurezie, infiltrata nodulare, leziuni interstitiale) renale( gnc, s.nefrotic, irc , hematologice (a.microangiopatica, hemolitca, crioglobulinemii, SAFL, trombocitopenii)
Manifestari cutanate
Eritem nodos-
Artrita :inflamatie la nivelul membranei sinoviale insotita de tumefiere,eritem,caldura locala,durere, impotenta functionala Debut: acut,(RF) insidios(LES) Durata simptomelor :autolimitanta (4-6sapt.Lyme, RF), cronica(AR) Numarul articulatiilor afectate : monoartrita(AJ) ,oligoartrita(2-4 artic.)-Sp, poliartrita(AR,guta) Distributia afectarii articulare :axiala(SpA),periferica(RA), ambele(A reac) Secventa afectarii aditiva(guta,AR),migratorie(RF),intermitenta(LES) Afectare locala specifica- guta, a,septica
Investigatii Teste uzuale Sindrom inflamator: VSH,fibrinogen, leucocitoza,trombocitoza,proteina CR Teste imunologice:autoanticorpi (FR, ab.antiADNds,anti-Ro,ANCA),anticorpi antibacterieni (ASLO, anti-Borelia, Chlamydia.,Yersinia.,ag.HLA (HLA-B27,HLADR4), Aspectul lichidului sinovial Imagistica:Rx,CT,RMN,scintigrafie..EMG, viteza de conducere nervoasa,biopsie, artroscopie Criterii de diagnostic: clinice+laborator
Medicatie utilizata in afectiunile reumatismale Antiinflamatoare nesteroidice + inhibitori de Cox-2 DEMARD( disease modifying antirheumatic drugs): salazopirina, hidroxiclorochina ,methotrexat, saruri deAu,.. Corticoizi Imunosupresoare Imunomodulatoare - anti-TNF-alfa, IL-1Ra Anticoagulante Protectoare endoteliale
Monoartrite (cauze)
Artrita septica* Sinovita cristal indusa Prezentare monoarticulara a unei poliartrite (AR, Sp., artritajuvenila idiopatica) Traumatisme Hemartroze ( hemofilie?) Reactie de corp strain *examen de lichid sinovial obligatoriu
ankilozanta,enteropatica)
Prezentare a unei poliartrite Infectii :endocardita bacteriana, Mycobacteria, Neisseria
Poliartrite: afectarea a peste 5 articulatii;simetrica /asimetrica,predominent la nivelul membrelor superioare/inferioare,cu afectare periarticulara concomitenta,+/-afectare sistemica Neinflamatorii: osteoartrita generalizata (artroza) Hemocromatoza Artropatia acromegalica Inflamatorii: Artrita virala Artrita reumatoida LES Sarcoidoza Osteoartropatia hipertrofica
Semne si simptome
Copiii >3ani,adolescenti,adultii tineri, F>B- estrogenii rol imunomodulator Infectie faringiana streptococica- ant. Debut: 1.artrita ( 2-4 sapt.de lainf.str.)- febra, poliartrita migratorie, asimetrica, articulatii mari, remisie fara ankiloze,raspuns preferential la aspirina- coincide cu titrul crescut al ASLO;episodul dureaza pt.o articulatie 15 zile,si intregul episod artritic dureaza 4 sapt. - artrita reactiva poststreptococica - monoartrita /oligoartrita la adultii tineri,raspunsslab la salicilati - deformare de tip Jacoud ( fibroza periarticulara)la articulatia metacarpofalangiana 2.Artralgiile:artrita,tenosinovita,mialgie,..
3.Cardita
5.Eritem marginat inel rosu , serpiginos, neindurat , tranzitor,la nivelul trunchiului si extremitatilor, simultan cu cardita 6.Choreea Sydenham- tardiva, durata 2sapt.-2ani 7.Febra 8.Pneumonia reumatica alveolita, cazuri severe 9.Alte simptome: epistaxis,anemie,tahicardie,dureri abdominale
Criterii diagnostice ale atacului de RAA Majore Cardita Poliartrita Choree Eritem marginat Noduli subcutanati Minore Febra Artralgie RAA in antecedente Leucocitoza Bl.AV gr.I,II *puls evidente de infectie streptococica recenta
tratament
-penicilina i.v., orala - macrolide : eritromicina,azitromicina - cefalsporine ( se prefera cele cu spectru ingust) - aspirina -corticoizi - profilaxia endocarditei bacteriene
RHEUMATOID ARTHRITIS
Semne si simptome
Debut: insidios - artrita simetrica la nivelul articulatiilor mici ale miini - acut ( frecvent la batrini)- redoare matinala,poliartrita,edeme - palindromic- episoade acute,recurente de artrita care dureaza citeva ore sau zile Afectare articulara specifica : sinovita eroziva 1.mina- mcf, ifp : deformari in git de lebada, grifa, deviere ulnara a degetelor 2.picior- mcf, ifp - bursite,eversia piciorului, picior plat( ruptura tendonului posteriortibial) 3 genunchi- chist Baker-ruptura indusa de flexie- sindrom de compresie
RHEUMATOID ARTHRITIS
Simptome si semne
Dureri articulare simetrice Tumefierea articulatiilor mici periferice Redoare matinala articulara de durata variabila Alte dureri difuze Astenia ,starea de rau si depresia pot preceda alte simptome cu saptamini sau luni Articulatiile cricoaritenoidiene responsabile pentru motilitatea corzilor vocale fixe stridor obstructie C1+C2eroziuni osoase +eroziuni ligamentare subluxatii severe compresiuni medulare
Frecvent IFP
Grassi W et al. Eur J Radiol. 1998;27(suppl 1):S18S24.
Extra articulare
Sistemice: febra, astenie, scadere ponderala, susceptibilitate la infectii Musculoscheletale:atrofii musculare, tenosinovite,bursite,osteoporoza Hematologice:anemie,trombocitoza,eozinofilie Limfatice-splenomegalie, s.Felty Noduli subcutanati FR+, Oculare episclerita ,sclerita( subtierea sclerei), scleromalacie ( ulceratii), keratoconjunctivita sicca
Vasculita ;arterita digitala,ulcere,pioderma gangrenosum,mononevrite multiplex,arteriteviscerale Cardiace : risc vascular crescut : pericardita, miocardita,endocardita,tulburari de conducere, vasculita coronara,aortita granulomatoasa Pulmonare noduli,pleurezie,alveolita fibrozanta,bronsiolita,S.Caplan Neurologice: compresii de coloana crevicala, neuropatii de compresie,(compresia n.periferici din cauza sinovitei proliferative sau subluxatiilorn.median in tunelul carpal, n.ulnar la cot),neuropatii periferice,mononevrite multiplex
Investigatii
Teste uzuale- anemie ,trombocitoza/trombopenie, neutropenie (s.Felty,Boala Still), sideremie moderat scazuta, proteine totale N/crescute VSH crescut,fibrinogen crescut, PCR + FR- +in 80% din pacienti ( ab anti fragment Fc al IgG )nespecific Anti-CCP ab : peptide ciclice citrulinate , AFLA ANA +80% Crioglobuline +/ Radiologie imagini diagnostice tardive RMN + Scintigrama osoasa + HLA-DR4
Ab CCP prezenti in stadii subclinice in special la subiectii cu un anume teren genetic ( epitop agresiv) care faciliteaza un raspuns imun antiproteine citrulinate Ab antivimentina citrulinata
RHEUMATOID ARTHRITIS
Radiologic Features
Early stage
Soft tissue swelling
Intermediate stage
Mild juxtaarticular osteoporosis Narrowing of joint space and bone erosions
Late stage
Large erosions, anatomic deformities, ankylosis
Classification 2010 criteria for RA (score-based algorithm: add score of categories AD; a score of 6/10 is needed for classification of a patient as having definite RA) A. Joint involvement 1 large joint 0 2-10 large joints 1 1-3 small joints (with or without involvement of large joints)# 2 4-10 small joints (with or without involvement of large joints) 3 10 joints (at least 1 small joint)** 5 B. Serology (at least 1 test result is needed for classification) Negative RF and negative ACPA 0 Low-positive RF or low-positive ACPA 2 High-positive RF or high-positive ACPA 3 C. Acute-phase reactants (at least 1 test result is needed for classification) Normal CRP and normal ESR 0 Abnormal CRP or abnormal ESR 1 D. Duration of symptoms 6 weeks 0 6 weeks 1
RHEUMATOID ARTHRITIS
Disease Progression
Normal Knee Joint Early Rheumatoid Arthritis
Neutrophils Hyperplastic Synovial Membrane Bone Cartilage Capsule Synovial Membrane Synoviocytes Capillary Formation Hypertrophic Synoviocyte
Neutrophils
Plasma Cell Synovial Villi
Adapted with permission from: Choy EHS, Panayi GS. N Engl J Med. 2001;344:907916. .
Pannus
Tratament
Tratament agresiv initial pentru a preveni leziunile
articulare Masuri generale:educatie,effort fizic,repaus,protectie articulara,fizioterapie Medicatie simptomatica DMARD Imunosupresie Imunomodulare Chirurgie in cazuri selectate
Spondilartropatii
Spondilita ankilozanta Artropatia psoriatica Artrita reactiva Artropatie enteropatica
Spondilita ankilozanta
Durere inflamatorie low back la adultii tineri Afectare axiala +/- afectare articulara periferica distala, asimetrica Leziuni patologice entesite +/- sinovite, bursite Demonstrarea radiologica a sacroileitei ( CT, RMradiografie standard tardiva)+ vertebre patrate +sindesmofite Asociere cu uveita anterioara ( ochi rosu, dureros, lacrimare crescuta , fotofobie) Manifestari sistemice : aortita, amiloidoza ,osteoporoza +/- fracturi spinale Risc crescut conferit de gene HLA-B27 Istoric familia pozitiv
Artrita reactiva
-conditie inflamatorie declansata de o infectie bacteriana la distanta ( uretrita, prostatita, enterite, inf.urinare, ) Oligoartrita distala asimetrica + articulatie sterno-claviculara+ temporomandibulara+ coloana vertebrala +sacroiliace Entesita Dactilita Rush cutanat, keratodermie blenoragica, Uveita , conjunctivita HLA-B27 +/-