Arthritis and Rheumatic Diseases

History and Epidemiology of Rheumatism

Rheumatic diseases are observed in almost all vertebrates (including species extinct for 1000s of years)

described in ancient Africa, Arabia, and Egypt; Hippocrates defined it
believed to result from blocked "flux of tar" (rheumatikos) from brain caused by overindulgence or idleness
acute gouty attack separated from other forms of gout in 1600s; etiology of gout discovered in mid 1800s
understanding of rheumatoid arthritis did not come until mid-1900s

Today – rheumatic diseases affect 25-30 million people in the U.S. alone; all but 5 million of these are osteoarthritis

second only to cardiovascular disease in socioeconomic impact

Rheumatic Disease

Rheumatic disease is defined as a metabolic, endocrine, inflammatory, degenerative, or biomechanical disorder that primarily involves the musculoskeletal system at some point in the natural history of the disease

can be articular (osteoarthritis), non-articular (soft tissue rheumatism), or both (rheumatic arthritis)
can affect diarthroidal joints with a synovial membrane (osteoarthritis) or cartilagenous joints (spondylitis)

Two specialties especially interested in rheumatic diseases:

(1) Rheumatologists treat musculoskeletal disorders that are medical (metabolic, endocrine)

(2) Orthopedic surgeons treat musculoskeletal disorders that are surgical (trauma, neoplasm, developmental)
both are interested in inflammatory, degenerative, and mechanical disorders

Four Misconceptions about Rheumatic Diseases

(1) "Arthritis is a single disease." – In fact, more than 100 diseases cause rheumatic arthritis

for some diseases, rheumatic disease may be the 1^st symptom (e.g., hemochromatosis)
spectrum of diseases, some systemic, with variable joint involvement:

(a) Systemic with minor, inconsistent, subtle joint involvement – hemochromatosis, carcinomas

(b) Systemic with more prominent joint involvement – systemic lupus erythematosis

(d) Non-systemic in which joint involvement is the only disease manifestation – osteoarthritis

(2) "Only arthritis is caused by rheumatic disease." – Arthritis is just the articular manifestation of rheumatic disease

rheumatic disease is defined as inflammation, degeneration, or metabolic derangement of connective tissue structures

most rheumatic diseases have articular (arthritis) and non-articular (soft tissue rheumatism) components
therefore, in addition to joints, muscles, tendons, fascia, and bursa are affected, locally or systemically
in diseases with both arthritis and soft tissue rheumatism, arthritis usually more debilitating (hence the misconception)

there are also systemic rheumatic diseases which involve other organ systems in addition to connective tissue

(a) autoimmune connective tissue diseases – rheumatoid arthritis, SLE, Sjorgen’s syndrome, progressive systemic sclerosis (scleroderma), primary dermatopolymyositis, mixed connective tissue disease
(b) seronegative spondyloarthropathies – ankylosing spondylitis, Reiter’s syndrome, enteropathic arthropathy, psoriatic arthritis, post-infectious reactive arthropathy
(c) vasculitis and arteritis – serum sickness; inflammation of blood vessels

(3) "Arthritis is always crippling." – Most patients learn to function quite well, even without treatment

e.g., Renoir and other artists performed some of their greatest works when seriously hindered by rheumatism

(4) "Very little can be done for patients with arthritis." – Many therapies exist

symptomatic – NSAIDs, steroids, non-drug modalities (rehabilitation)
remittive (capable of altering course of disease) – e.g. cyclophosphamide for Wegener’s Ganulomatosis

Diagnosing Rheumatic Diseases

Most important symptom is pattern of joint involvement, including:

duration of symptoms and signs: acute or chronic?
symmetric or asymmetric?
number of joints: mono- (1), oligo- (2-3), or poly- (>3) -articular

different rheumatic diseases have different characteristic progressions – examples:

acute monoarthritis – gout, calcium salt, septic joint, viral infection (Hep B), trauma, intra-articular hemorrhage

chronic symmetric polyarthritis – rheumatoid arthritis, osteoarthritis, SLE, scleroderma, mixed CT disease, ankylosing sponylitis, Reiter’s syndrome, psoriatic arthritis, gout, calcium salt

chronic asymmetric polyarthritis – psoriatic arthritis (I kind)

sometimes arthritic diseases can demonstrate unusual patterns (monoarticular rheumatoid arthritis, polyarticular gout)