Musculoskeletal & Skin Pathology for Medical II Students

Spring 2008 Lab Supplement
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Arthritis 5

Case History Rheumatoid Arthritis Slide 13: A 51-year-old man died of acute myocardial infarction 9 years after the onset of rheumatoid arthritis. Virtually all the peripheral joints were affected and the patient had been unable to work, as a result, for 8 years. He had received a course of methotrexate therapy 4 years before he died. A sister also had rheumatoid arthritis. Characteristic deformity of the fingers with ulnar deviation and rheumatoid factor were present. The erythrocyte sedimentation rate varied between 32 and 87 mm. per hour (Westergren; Normal = 0-15 mm per hour for males). The L.E. cell test was negative. Numerous subcutaneous nodules were present. Destructive changes were seen in roentgenograms of many joints.

Case History Rheumatoid Arthritis Slide 14: A 40-year-old man had polyarthritis for 10 years. Initially the right knee was involved, with pain, swelling, heat and redness. Soon thereafter, the left knee, ankles and wrists were affected. In subsequent years, there were periods of exacerbation and remission of the joint disease. At the time that synovectomy was performed on the right knee, most of the other joints were quiescent. Characteristic rheumatoid deformities were present in the fingers and rheumatoid factor was present. The erythrocyte sedimentation rate was 54 mm/hr (Westergren). A flexion contracture of the knee had been corrected without previous surgical intervention. X-ray revealed narrowing of the joint space and some demineralization of the adjacent bone.

Case History Rheumatoid Arthritis Slide 15: A 31-year-old man had rheumatoid arthritis for 3 years. Initially the fingers, wrists and elbows were affected but later other peripheral joints were involved as well. Most of the joint complaints remitted but pain in the others remained incapacitating. At the time synovectomy of the knee was performed, characteristic rheumatoid deformities were present in the fingers. The erythrocyte sedimentation rate was somewhat elevated. X-ray of the knee revealed narrowing of the joint space with destruction of parts of the joint surface. At operation, severe hypertrophic villous synovitis with rice body formation was seen.

Slides 13 & 14 | Slide 15

Slide 13 This is a photograph of a the knee opened anteriorly at necropsy. The patella and patellar ligament have been reflected downward. The synovial membrane and joint capsule are greatly thickened. The synovial surfaces are covered with innumerable polypoid and villous outgrowths. Similar tissue extends as pannus across the articular cartilages of the femur (F) and patella (P).

Slide 14 This is a composite photograph illustrating the characteristics of the hypertrophic villous synovitis of rheumatoid arthritis. At the left is the freshly excised synovial membrane. Innumerable papillary fringes protrude above the synovial surface. Some of them are as much as 4 cm in length. There is a variable degree of interadherence among the fringes. Most of the villous structures have a pale ivory to brown color but there are several that are white. The latter are often referred to as "rice bodies" and resemble compact fibrin. At the right is a low-power photomicrograph. Compact nodular clusters of infiltrating cells are present near the surface of the synovial villi. Detail of the cellular reaction is presented in the following slide (15). Although most characteristic of rheumatoid arthritis, the lesion is not pathognomic of it nor consistently present.

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Updated August 29, 2007