Musculoskeletal & Skin Pathology for Medical II Students

Arthritis 6

Case History Rheumatoid Arthritis Slide 16: A 56-year-old woman had had a recurrent arthralgia for 18 years. The initial episode followed and attack of scarlet fever and subsided after a short period. Five years later articular pains recurred and continued intermittently for ten years without interfering with her activities. She then developed a progressive disabling arthritis which gradually involved the hands, neck, knees, and ankles. Associated with this were scleritis and iritis. The hematocrit fell to 34% and the sedimentation rate rose to 58 mm/hr (Westergren; Normal for females = 0 to 20 mm/hr). Serological tests for syphilis were negative. Terminally, the patient had a myocardial infarction followed by a right hemiplegia and coma. The principal autopsy findings were: arteriosclerotic heart disease with anterior myocardial infarction and mural thrombosis, acute arteritis limited to the coronary arteries, encephalomalacia of the left temporal lobe, multiple renal infarcts and deforming arthritis of the hands and knees. Gross examination of the left knee joint showed villous hypertrophy of the synovial membrane with pink to orange discoloration, irregular areas of cartilage loss with pannus and adhesion formation at the articular margins, and moderate degenerative joint disease with chondromalacia and marginal lipping.

Case History Rheumatoid Arthritis Slide 17: 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 and rheumatoid factor was present. 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.

Case History Rheumatoid Arthritis Slide 18: A 66-year-old man had had a recurrent progressive arthritis for 27 years. Joint involvement was generalized, most marked in the hands and feet. He moved stiffly and cautiously but was able to lead an ambulatory existence with the aid of sulindac 150 mg bid. The sedimentation rate varied from 7-48 mm/hr (Westergren). He died suddenly while walking on the street and autopsy revealed severe arteriosclerotic heart disease with myocardial fibrosis.

Sldie 16 & 17 | Slide 18

Slide 16 This section of synovial membrane from the left knee shows a chronic inflammatory process with proliferation of all fixed tissue cells, some fibrosis, and scant lymphocyte infiltration. A deposit of amorphous fibrin-like material is present on the synovial surface and the subjacent synoviocytes tend to be arranged in the palisade formation. Recall the normal thin synovial membrane shown in slide 3. The few cells within the fibrinous mass are almost all necrotic.

Slide 17 The inflammatory infiltration of the synovial membrane (synovitis) in rheumatoid arthritis is not confined to the villous outgrowths but may extend diffusely into the deep portions of the membrane and even into the capsule. Compact areas of fibrosis (F) attest to a degree of healing of a past focus of synovitis while chronic inflammatory infiltration continues about it. Marked multiplication of lining cells is seen. It is the inflammatory destruction of the ligaments of the joint capsules and tendons that can lead to subluxations and ulnar deviations of fingers that may be seen in end stage rheumatoid arthritis.

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Updated August 29, 2007