Case Discussion

Dr. Raid Jastania

• What is the outcome of inflammation?

• A 37-year-old woman gradually developed painful wrists over 3 months; She also complained of generalized weakness and low-grade fever. She consulted her doctor.

• On examination, both wrists and the metacarpophalangeal joints of both hands were swollen and tender but not deformed.

• What is the pathological Process?

• What are the local features of inflammation?

• What are the possible causes of this pathology?

• She has normal haemoglobin and white-cell count

• she was found to have a raised C-reactive protein (CRP) level (27mg/l) (NR <10)

• Rheumatoid factor was negative and antinuclear antibodies were not detected.

• What are the systemic features of inflammation?

• What is C-reactive protein?

• What is acute phase protein?

• What is Rheumatoid factor?

• What is ANA?

• The clinical diagnosis was early rheumatoid arthritis and she was treated with ibuprofen. Despite some initial symptomatic improvement, the pain, stiffness and swelling of the hands persisted and 1 month later both knees became similarly affected. She was referred to a rheumatologist.

• What is ibuprofen?

• Why do you use it for this patient?

• Six months after initial presentation, she developed two subcutaneous nodules on the left elbow these were small, painless, firm and immobile but not tender.

• What is granuloma?

• What are the causes of granuloma?

• A test for rheumatoid factor was now positive (titre 1/64). X-rays of the hands showed bony erosions in the metacarpal heads. She still had a raised CRP (43mg/l) but normal serum complement (C3 and C4) levels and, had she had a biopsy, pannus would have been demonstrable histologically.

• Describe the morphology (microscopy) of joints in Rheumatoid Arthritis?

• What are the consequences of continuous inflammation? (chronic inflammatory diseases)

• Regeneration is one of the components of repair. What are the factors determining wither regeneration can occur or not?

• This woman now had definite X-ray evidence of rheumatoid arthritis and, in view of the continuing arthropathy, her treatment was changed to weekly low-dose methotrexate. This has controlled the arthritis for several years and no further erosions have developed.

• What is methotrexate?

• Why do you use immunosuppressive drugs in this patient?

Case

• A 61-year-old man, with a 15-year history of seropositive Rheumatoid Arthritis, was admitted with increasing shortness of breath, myalgia and weight loss. There was no fever. He had previously smoked 40 cigarettes a day but had never been exposed to coal or silica dust.

• On examination, he was pale and thin, with generalized muscle tenderness. Small bilateral pleural effusions were present with widespread crepitations over both lung fields.

• Mention possible pathological processes involving the lung of this patient.

• His joints were tender and he had subluxation of the metacarpophalangeal joints of both hands. There was bilateral cervical and axillary lymph node enlargement but no splenomegaly. Neurological and cardiac examinations were normal.

• Why is there deformities of the joints of the hands?

• What is the pathological process of the joints?

• What are the components of fibrosis?

• List possible causes of lymph node enlargement (lymphadenopathy).

• Investigations showed a raised CRP (81mg/l) and a normochromic anaemia (Hb 95g/l) but a normal white-cell count. His serum IgG was raised at 44g/l (NR 7.2-19.0), although IgA and IgM levels were normal. He had a strongly positive rheumatoid factor titre of 1/1280 (NR <1/32).

• X-rays showed erosions of both wrist joints.

• Why does erosion of bone occur in Rheumatoid arthritis?

• The pleural aspirate showed no malignant cells but occasional polymorphonuclear leucocytes and a few lymphocytes were seen; the protein content was high (25g/l) and rheumatoid factor was present in the fluid. A diagnosis of rheumatoid pleural effusions and fibrosing alveolitis was made.

• What is the pathological process involving the pleura?

• What is fibrosing alveolitis?

• How does it occur?

• Describe the morphology (microscopy) of fibrosing alveolitis?

• This man's shortness of breath was rapidly progressive and he continued to deteriorate despite intravenous corticosteroids and cyclophosphamide. At autopsy, both lungs showed fibrosing alveolitis, which is a rare complication of RA with a poor prognosis.

• Why do we use steroids to treat rheumatoid arthritis?

• What is the outcome of inflammation?