Showing posts with label Rheumatology. Show all posts
Showing posts with label Rheumatology. Show all posts

Apr 18, 2014

Differential diagnosis dd, causes of Neck pain

Here are the possible causes of neck pain , classified into five categories.
You can open the article of each cause to view by clicking its link .
The classification is as follows :

neck-painI - Mechanical
- Cervical spondylosis.
- Muscle spasm.

II - Inflammatory
- Seronegative arthropathies
- Rheumatoid disease

III - Metabolic
- Osteomalacia
- Osteoporosis

IV - Neoplasm
- Metastases
- Multiple myeloma

V-  Referred pain

Jul 30, 2013

Differential diagnosis of recurrent arthritis (transient) and oligoarthropathy

These are the possible causes and differential diagnosis (DDx) of recurrent arthritis (transient arthritis) and oligoarthropathy .
You can click the linked disease name to know more about details

The causes and dd of recurrent arthritis or transient arthritis are :

1- Rheumatic arthritis
2- Gout or pseudogout.
3- Familial Mediterranean fever (FMF)

Differential diagnosis, causes of Back pain (backache)

These are the possible causes and differential diagnosis (DDx) of a case complaining of backache (Back pain)
You can click the linked disease name to know more about details

Causes of back pain can be :

1- Mechanical
- Disc prolapse.
- Lumber spondylosis.
- Muscle spasm due to fracture.

2- Inflammatory
- Sero -ve arthropathy 

Differential diagnosis, causes of Neck pain

This is the possible differential diagnosis (DDx) of a patient complaining of pain in his Neck .
You can click the linked disease name to read the details .

Causes of Neck pain can be classified into :

I- Mechanical
- Cervical spondylosis.
- Muscle spasm.

II- Inflammatory
- Sero -ve arthropathies
- Rheumatoid disease

III- Metabolic
- Osteomalacia

Fibromyalgia causes, clinical picture, diagnosis and treatment

This article is to discuss Fibromyalgia (fibrositis) regarding its definition, causes, clinical picture (symptoms and signs), Diagnostic features and treatment approach .
• Fibromyalgia (fibrositis) is a controversial diagnosis that is not universally accepted.
 It is a useful diagnosis of exclusion.
• It is characterized by chronic diffuse pain with characteristic tender points. It is considered as a non-articular rheumatism.
• It affects about 2 % of all patients seen in general practice and 20 % of patients referred to rheumatologists
• All investigations are normal and the value is for exclusion.

Aetiology (Causes) :

The condition is poorly understood, two abnormalities have been reported: sleep abnormality and reduced threshold to pain at certain sites.

Clinical picture of Fibromyalgia

Jul 29, 2013

Inherited disorders of Collagen manifestations

I. Osteogenesis imperfecta

It is a rare inherited disorder of collagen (autosomal dominant), characterized by brittle bone and abnormalities of the skin, tendon, teeth and sclera.

II. Marfan syndrome

It is an inherited condition (autosomal dominant) charasterized by:-
- Span > height
- Lens dislocation
- High arched palate.

Osteoporosis causes, risk, pathogenesis, types, diagnosis, prevention, treatment

This is a discussion of Osteoporosis regarding its definition, aetiology, types, pathogenesis, risk factors, clinical picture (symptoms and signs), diagnostic investigations, methods of prevention and treatment approach .

What is meant by Osteoporosis ?

• It is defined as a decrease in the absolute amount of bone mass leading to enhanced bone fragility with increased risk of pathological fractures.
• Unlike osteomalacia, the defect in osteoporosis is that the bone that is present is normally mineralized but is deficient in quantity, quality and structural integrity.

How Osteoporosis develops ? Pathogenesis

• Bone mass increases rapidly up to the age of puberty and rises slightly more in the twenties and thirties and then begins to decline around age of 40 years.
• In males there is a gradual decline but females show an accelerated loss in the 10 years following the menopause.
• Osteoporosis occurs as the end result of many years mismatch between the rate of bone resorption and bone formation .

Jul 27, 2013

Osteomalacia causes, pathogenesis, diagnosis and treatment

Here is a discussion of Osteomalacia regarding its definition, causes, pathogenesis, clinical pictures, investigations and treatment .
• Osteomalacia is characterized by defective bone mineralization, bone pain, muscle weakness and pathological fractures.
• There is failure to replace the turn over of Ca and P in bone matrix ===> bone become demineralised and the bony substance becomes replaced by soft osteoid tissue so it is mainly a qualitative bone defect.

How Osteomalacia develops ?

Pathogenesis of Osteomalacia
The most common cause is vitamin D deficiency, the low levels of vitamin D causes a reduction of calcium absorption from the intestine.
The low calcium absorption stimulates parathyroid hormone secretion which restores serum calcium levels towards normal by increasing bone resorption and renal tubular calcium reabsorption. The level of parathyroid hormone also promotes phosphaturia and causes phosphate depletion. It is the combination of
calcium loss from bone and phosphate depletion that leads to impaired bone mineralization .

Causes of osteomalacia

Septic arthritis causes, risk, diagnosis and treatment

Here is a discussion of Septic arthritis regarding its aetiology, Risk factors, symptoms, signs, diagnostic investigations and treatment approach .
This can accompany bacteraemia or septicemia, the most common organism is staphylococcus aureus. It is a medical emergency as it leads to severe joint destruction within short time.
Causative organisms
• Staph aureus.
• Streptococci, gonococci.
Septic-arthritis• Haemophilus influenza and other Gram negative bacilli.
Risk factors
• Increasing age.
• Pre-existing joint disease e.g. rheumatoid disease.
• DM and immunosuppression.
• Artificial joints (prostheses).
Clinical picture 
1- Fever, malaise.
 2- Painful swelling usually in one large joint.
3- Signs of inflammation (redness, hotness, tenderness ± effusion).

Neuropathic joints | Charcot's joints

What is meant by Neuropathic joints (Charcot's joints)?

• They are joints damaged by repeated trauma as a result of the loss of the protective pain sensation.
They occur with the folIowing conditions:

• Tabes dorsalis especially in the knees and ankles .
• In diabetes mellitus (tarsal joints).
• Syringomyelia (shoulder).
• The joints are swollen with abnormal painless movement; they are liable to crystal deposition.
• The treatment is symptomatic, Surgery may be required .

Osteoarthritis (Degenerative Arthritis) risk factors, pathogenesis, types, diagnosis, treatment

This article is to discuss Osteoarthritis , ( synonym : Degenerative Arthritis Or osteoarthrosis Or degenerative joint disease ) regarding its definition, risk factors, pathology & pathogenesis, classification (types), Clinical picture (symptoms and signs), diagnostic investigations and treatment approach.
• Osteoarthritis (osteoarthrosis)  may be primary or secondary. Usually it is the end result of a variety of pattern of joint failure.
• It is characterized by degeneration of articular cartilage with simultaneous proliferation of new bone, cartilage and connective tissue leading to remodelling of joint contour, inflammation of synovial membrane is minor and secondary.

Risk factors of Osteoarthritis

1- Wear and tear.
Osteoarthritis-Degenerative-Arthritis2- Aging.
3- Genetic factors.
4- Obesity (loading stress on weight
bearing joint e.g. knee).
5- Smoking

Pathogenesis of Osteoarthritis

1- Matrix loss is due to release of proteases and collagenases. The interleukin I and TNF are the mediators of these catabolic effects, also these cytokines leading to synovial inflammation.
2- Growth factors e.g insulin like growth factor and transforming growth factor are involved in stimulating collagen repair and production of the over growth at the joint margin (osteophytes).

Jul 25, 2013

Pyrophosphate arthropathy, Chondrocalcinosis causes, diagnosis, treatment

It is a crystal deposition of calcium pyrophosphate dehydrate (CPPD) in cartilage (chondrocalcinosis). It is a common age associated phenomenon (>55) that particularly targets the knee .
Aetiology (Causes)
It is idiopathic, it can occur with certain metabolic diseases e.g hemochromatosis, Wilson's disease, hyperparathyroidism and chronic renal failure patients under regular hemodialysis .
Clinical picture 
There are different clinical patterns
1- Mono arthritis.                      
• Especially in the knee.          } Attacks of pseudogout
• Male = Female, old age.
2- Pseudo-rheumatoid arthritis with polyarthritis for months.

Gout investigations, Differential diagnosis, Diet and treatment

This is an approach to diagnosis and treatment of Gout , in which we are going to discuss the investigations, differential diagnosis and treatment of the disease .

Investigations to diagnose Gout 

- Serum uric acid > 7 mg/dl in males
                   or > 6 mg/dl in females
            (it may be normal)
Normal level is
3.5 - 7 mg/dl in males
2.5-6 mg/dl in females
• ESR +++
• TLC +++
• Aspiration of tophi : urate crystals (by polarized microscope).
• Uric acid in urine > 1100 mg / 24 hours = overexcertion.
Normal serum uric acid does not exclude the diagnosis of gout.
- Joint X-ray
In early disease -7 Normal, but narrowing of joint space with sclerosis may develop with time.
• Gouty erosions (bony tophi) occurring as para articular punched out defects with well defined borders.
• Tophi: eccentric soft tissue swellings.

Differential diagnosis of Gout 

Classification of hyperuricemia (Gout)

Hyperuricemia is classified into :
I- Metabolic over production
Idiopathic, 10-20% of patients with primary gout.
Enzymatic defects. e.g:
(Hypoxanthine - guanine - phosphoribosyl -transferase) which is essential for reconversion of guanine, hypoxanthine into their mother substance so this enzymatic defect ===> accumulation of uric acid.

Lesh-Nyhan syndrome

- X linked recessive.
- Uric acid +++
- Choreoathetosis
- Mental retardation and self mutilation
Glucose 6 phosphatase deficiency.

• Idiopathic under excretion (Isolated tubular defect), more than two thirds of individuals with primary gout.


Clinical presentations of Gout (Hyperuricemia manifestations)

• It is chiefly a disorder of adult Male 5 % in Female .
• Gout is uncommon before 3rd decade.
• Peak of onset in Males (45 years) usually after 20 - 30 years of sustained hyperuricemia, and in post menopausal females above 60 years.
There are 4 clinical presentations of Gout (Hyperurecemia) 

I. Asymptomatic hyperuricemia 

refers to elevation of serum uric acid prior to the development of arthritis.
 Probably 95% of hyperuricemic subjects never develop gout.

II. Acute gouty arthritis

• There is  painful arthritis.
• 90 % of cases of the initial attacks are monoarticular usually in the first metatarsophalangeal joint (podagra)
• Other initial sites:
- Ankles, wrist, heels, finger, knee, elbow.
It may be precipitated by:
- Trauma .- Surgery - Ingestion of alcohol- Exercise - Diuretics.
• Minority of patients showing acute gout with normal serum uric acid.
• Dramatic relief of pain with colchicine is suggestive.
• In severe attacks, overlying crystal cellulitis makes gout difficult to distinguish clinically from infective cellulitis .
• The typical attack is rapid onset reaching maximum severity 2-6 hours, often waking the patient in the early morning, it is self limiting over 5-14 days. Milder episodes for few days called peptite attacks.
• There is ++ temperature,++ TLC , l' ++ ESR.
• Intercritical periods are asymptomatic periods between attacks.

III. Chronic tophaceous gout 

Behcet's disease def., manifestations, diagnostic criteria and treatment

What is Behcet's disease ? (syndrome)• It is a systemic vasculitis of unknown etiology
- Viral.!? - Autoimmune.!?

• Diagnostic criteria of Behcet's disease ?

- Recurrent oral ulcers, at least three times in a 12 month period.
Plus two of:
- Uveitis or retinal vasculitis
- Skin lesions e.g erythema nodosum.
- Recurrent genital ulcers.
- Positive pathergy test

Oligoarthritis, thrombophlebitis and neurobehcet (multiple sclerosis like) may also occur.

Mixed Connective tissue disease features, diagnosis and treatment

Mixed Connective tissue disease MCTD 
• This syndrome involving mixed features of :-
- Myositis.
 - SLE.
- Scleroderma.
Clinical picture
- It is of gradual onset. - Renal affection is rare.
Features (according to the frequency)
1- Arthritis or arthralgia.
2- Raynaud's phenomenon.
3- Oesophageal dysmotility.
4- Lymphadenopathy.

CREST syndrome features (Limited scleroderma)

- It is a subtype of systemic sclerosis (Scleroderma) , without skin manifestations .
The term CREST syndrome is used to describe a group of manifestations in different body systems, which are :
- C : Calcinosis cutis .
- R : Raynaud's phenomenon.
- E : Esophageal dysfunction.
- S : Sclerodactly.
- T : Telangectasia.

There is minimal visceral involvement, positive anticentromere antibodies.