Rheumatology Efim Benenson Rheumatology Symptoms and Syndromes Author Efim Benenson, MD Professor of Medicine Department of Internal Medicine University of Cologne Germany The work was first published as a part of a work published in 2009 by Shaker Media in German laquage with the following title: Rheumatologie: Syndrome and Algorithmen Translation: Beverley Taylor ISBN: 978-1-84996-461-6 e-ISBN: 978-1-84996-462-3 DOI: 10.1007/978-1-84996-462-3 Springer Dordrecht London Heidelberg New York British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: 2010936498 © Springer-Verlag London Limited 2011 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as per- mitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Cover design: eStudioCalamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) I dedicate this book to my wife, Irina, for her patience and support, our children, Anna and Vladimir, and to our grandchildren, Patrick, Paulina, and Wlada Preface “Symptoms and Syndromes” is aimed at teachers who are providing their trainees with further education and instruction in the relevant areas of clinical practice. Features of the book: • The classic textbook content of rheumatology is presented in the form of syndromes (or signs), as stable combinations of symptoms and usually with morphological and patho- physiological backgrounds, building a bridge or link between symptoms and diseases • The principle of syndrome diagnosis which, in addition to the indispensable description of entities, should be integrated into the initial stages of clinical practice • How to approach and structurally classify diseases from the viewpoint of morphologi- cal manifestations, as a fast route to diagnosis • The clinical work from patient to disease, enabling preclinical and clinical knowledge on the concrete clinical case to be interlinked and stored in the long-term memory • Algorithms of clinical reasoning, leading to integrated staged diagnostics based on morphology and pathophysiology • A basic program of rheumatology comprising all teaching points (symptoms, syn- dromes, and diseases) linked to morphological structures, and connecting them to all clinical disciplines according to the broadly recognized terms of rheumatic diseases (see Contents) • Inclusion of therapeutic and prognostic aspects of inflammatory arthritides, also touch- ing on current therapeutic strategies and integrating them into the treatment concepts. Practice-oriented clinical tuition (from syndromes and algorithms to diseases) is provided as a supplement to traditional descriptive teaching theory (from symptoms or disease pat- tern to diagnosis). On the one hand the book provides summaries of the most important clinical, imaging, and immunological syndromes as modules of rheumatology, while at the same time describing the medical approach to structured thinking, as an important tool for clinical practice. Such an approach enables the diversity of patients with rheumatic dis- eases to be clearly structured and categorized diagnostically. The structure of the book reflects the said distinguishing features of other rheumatology books, providing fundamental information on the symptoms, signs, and therapeutic aspects of the diseases described therein. The Contents, in which all syndromes are easy to find and are linked to morphological structures, is both a manual and list of contents for this book. vii viii Preface Symptoms and Syndromes provides case-specific syndromes based on morphology and pathophysiology (Section 1, Articular and Musculoskeletal Disorders, Chapter 1-4 and Section 2, Connective Tissue Disease and Vasculitis, Chapter 8-10; Chapter 5 presents the paraneoplastic syndromes in rheumatology). These syndromes are linked in the text to specific diagnoses and represent a wide spectrum of differential diagnostics in internal medicine and its related fields. The approach relies on (auto) immunological phenomena and serological diagnostics (Chapter 11), and treatment-induced and associated conditions and diseases (Chapter 12) with a case-by-case study. The algorithms and integrated staged diagnostics, using examples from Articular and Musculoskeletal Disorders (Chaps. 6 and 7), as well as Connective Tissue Diseases and Vasculitis (Chaps. 13 and 14), describe how the patient’s information is to be analyzed. Actual therapeutic aspects of inflammatory rheumatic diseases are provided as examples in Chaps. 7.3 and Chaps 14.1–14.3. This textbook is a reference work on the symptoms and syndromes of rheumatic dis- eases. It complements Rheumatology: Clinical Scenarios (E. Benenson, Springer 2011) with its 73 clinical situations and 164 illustrations, wherein all syndromes and symptoms from this collection are discussed with many other examples from my own practice as teaching modules in several chapters of Symptoms and Syndromes. This stimulating concept combines Symptoms and Syndromes with Clinical Scenarios as case-based training, complementing one another in the same way as knowledge and its application, offering teachers an alternative training concept for trainees. The book takes an alternative approach to rheumatic diseases. Thus it can help to reduce the time an experienced rheumatologist and physician requires for making a diagnostic decision, by applying structured knowledge, the syndrome principle of diagnosis and learning “to think clinically.” By this means traditional teaching – from knowledge about diseases to the patient – is complemented. The critical comments on this book are really welcome ([email protected]). Efim Benenson Acknowledgments Sincere thanks to my colleagues Professor of Medicine Michael Hallek, Director of Department I of Internal Medicine, University of Cologne for his advice and support, and my former boss, Professor of Medicine Volker Diehl, for welcoming me kindly to this Clinic in 1994, and especially Ursula Voigt-Pfeil for her active support in realizing this project. ix Contents Part I Articular and Musculoskeletal Disorder 1 Articular Disorders .....................................................................................................3 1.1 Arthralgia ...............................................................................................................3 1.2 Morning Stiffness ...................................................................................................5 1.3 Arthritis ..................................................................................................................5 1.3.1 Exudative (Inflammatory) Arthritis ..............................................................6 1.3.2 Proliferative Arthritis ...................................................................................6 1.3.3 Fibrosing and Ankylosing Arthritis ..............................................................7 1.3.4 Erosive Arthritis ...........................................................................................7 1.3.5 Non-erosive Arthritis ....................................................................................8 1.4 Osteoarthritis ..........................................................................................................8 1.4.1 Noninflammatory OA ...................................................................................8 1.4.2 Inflammatory OA .........................................................................................9 1.4.3 Secondary OA ............................................................................................10 1.4.4 Erosive OA .................................................................................................10 1.4.5 Chondrocalcinosis ......................................................................................11 1.4.6 Chondromatosis ..........................................................................................11 1.4.7 Arthritis and Osteoarthritis .........................................................................11 1.5 Arthropathy ..........................................................................................................12 1.5.1 Neuropathic Arthropathy ............................................................................13 1.5.2 Endocrinological Arthropathy ....................................................................14 1.5.3 Metabolic Arthropathy ...............................................................................14 1.5.4 Hematological Arthropathy ........................................................................15