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Dr. Raed Al-Bukhari, FACP Consultant Rheumatologest King Fahd Hospital of the University University of Dammam.

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Presentation on theme: "Dr. Raed Al-Bukhari, FACP Consultant Rheumatologest King Fahd Hospital of the University University of Dammam."— Presentation transcript:

1 Dr. Raed Al-Bukhari, FACP Consultant Rheumatologest King Fahd Hospital of the University University of Dammam

2 Musculoskeletal complaints resulting from endocrinological diseases are common and well described. Every disease has its own rheumatic symptoms and signs. Very high prevalence rate of diabetes mellitus in our society, frequent thyroid diseases and steroid effect on adrenal function. Rheumatologist, internist, primary care physician and general practitioner should be well informed about endocrinological diseases effect on muscles, tendons, ligaments and joints. Over view and recent data on three common areas.

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4 international diabetes federation http://www.idf.org/

5 More than 34.2 million people in the MENA Region have diabetes; by 2030 this will rise to 59.7 million. Globally number of people with diabetes 371 million. Diabetes caused 356,586 deaths in the MENA Region 2012. 12 billion USD were spent on treating diabetes in the region. The region has the highest prevalence of diabetes in adults (11%) (overall). international diabetes federation http://www.idf.org/

6 From top of the world at a glance in 2012 Prevalence 19.42% Total adult population 17,582,020 Number of adults with diabetes 3,414,510 Number of adults with undiagnosed diabetes 241,710 Number of deaths due to diabetes 20,933. Mean healthcare expenditures per person with diabetes (USD) 953.71 international diabetes federation http://www.idf.org/

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8 Limited Joint Mobility (Diabetic Cheiroarthropathy). Skin changes of LJM begin around the MCP and PIP joints of the little finger and progress medially to involve other digits and distally to involve the DIP joints. LJM usually is painless. Flexion contractures involving several fingers and thickened, tight, and waxy skin. Physical examination, inability to oppose the palmar surfaces of the hands and fingers with the wrists dorsiflexion. Prayer Sign Rheumatic manifestations of diabetes mellitus. Rheumatic diseases clinics of North America. 2010;36:681-699.

9 The prevalence of LJM ranges between 30% and 58% among patients with type 1 DM and between 45% and 76% among those with type 2 DM, as compared with between only 4% and 20% among individuals without DM. Stenosing Flexor Tenosynovitis, 5% and 36% among patients with type 1 and 2 DM, as compared with 2% in the general population. Dupuytren’s contracture, most often involves the middle and ring fingers rather than the ring and little fingers, as in nondiabetics, prevalece between 16% and 42%

10 Clinical appearance of Dupuytren's disease. A, Patient showing a cord from the radial longitudinal oriented fibers of the palmar aponeurosis of the thumb. This image also shows a cord arising from the distal transverse commissural ligament of the first web space. B, A 73-year-old man who presented with DD of the ring finger worsening over 10 years. C, A 45-year-old patient who presented with new DD of the right middle finger and recurrence of DD of the little finger following surgery 4 years earlier. Dupuytren's Disease Thoma, Achilleas, PLASTIC SURGERY: INDICATIONS AND PRACTICE, CHAPTER 90, 1173-1179 Copyright © 2009 © 2009, Elsevier Inc. All rights reserved.

11 Recently, injecting the thickened palmar fascia with collagenase from Clostridium histolyticum has been developed as a nonsurgical treatment approach. Adhesive capsulitis of the shoulder, prevalence ranges from 10% to 29% and is about 5-fold that in the general population. Associated with the presence of autonomic neuropathy among individuals with either type of DM and with myocardial infarction among those with type 1 DM. Compared to nondiabetics its associated with an inferior outcome with more pain, restricted range of motion and poorer function.

12 Carpal tunnel syndrome, described bilaterally, DM is a risk factor for CTS (large case-control study of 3391 patients). Impaired median nerve recovery observed after carpal tunnel release among some patients with DM suggests that intrinsic nerve pathology might contribute to its pathogenesis in DM. Diabetic muscle infarction, systematic review identified 116 patients, mean age at presentation was 43, the average duration of DM 14 years, and vascular complications of DM present in the majority, particularly nephropathy 71%, retinopathy 57% and neuropathy 55%. DISH. Diabetic muscle infarction: an underdiagnosed complication of long-standing diabetes. Diabetes care. 2003;26:211-215.

13 Anteroposterior ( A ) and lateral ( B ) views of the thoracic spine in patient with DISH. Flowing ossification is noted anteriorly and on the right side of the spine. At least seven contiguous vertebral bodies are involved. The disc spaces are preserved. Radiolucency extends from the disc space into the ossification, creating a Y- shaped lucency and a bumpy bony excrescence at the disc level. Brower, Anne C., MD, Arthritis in Black and White, 15, 275-292 Copyright © 2012 Copyright © 2012, 1997, 1988 by Saunders, an imprint of Elsevier Inc.

14 Lateral view of the foot in patient with DISH. All joint spaces are preserved. Ossification is seen at the attachment of the plantar aponeurosis and the Achilles tendon. There is also ossification on the dorsal aspect of the navicular and the cuneiform, the base of the fifth metatarsal, and the distal tibia ( arrows ). Diffuse Idiopathic Skeletal Hyperostosis Brower, Anne C., MD, Arthritis in Black and White, 15, 275-292 Copyright © 2012 Copyright © 2012, 1997, 1988 by Saunders, an imprint of Elsevier Inc.

15 Lateral view of the cervical spine in patient with DISH. There is excessive flowing ossification anterior to the vertebral bodies. Barium introduced into the esophagus allows demonstration of impingement on the esophagus by the ossification ( arrow ). The disc spaces are maintained, and the apophyseal joints are uninvolved. Diffuse Idiopathic Skeletal Hyperostosis Brower, Anne C., MD, Arthritis in Black and White, 15, 275-292 Copyright © 2012 Copyright © 2012, 1997, 1988 by Saunders, an imprint of Elsevier Inc.

16 Characterized by an inflammatory process resulting in dislocation of the neuropathic joint, fracture and resorption of affected bones. Most commonly associated with DM. Prevalence 0.15%, most commonly true ankle, tarsometatarsal, metatarsophalangeal. Early immobilization is important to prevent progression hence imaging studies should be obtained early in the course of illness even with little pain. Early MRI show marrow edema or microfractures. Bisphosphonates did not shorten the immobilization time, no data were available regarding long term effects on deformities and ulcerations. Treatment of acute Charcot foot with bisphosphonates: a systematic review of the literature. Diabetologia. 2012;55:1258-1264.

17 Diabetes mellitus: spine. Progressive deterioration of the lumbar spine is apparent during a 3-year period of observation. Initially (A), the changes at the lower lumbar level resemble degenerative disc disease. Subsequently ( B and C ), this level deteriorates slowly; one level above, however, rapid destruction of the intervertebral disc and bone is evident. The vacuum phenomenon in the upper disc, as well as the well- defined and sclerotic bone in (B), makes infection unlikely. In (C), the pattern of disc destruction is identical to that of infection, although the latter was not apparent clinically. (Courtesy of U.S. Naval Hospital, San Diego, Calif.) Neuropathic Osteoarthropathy, Resnick, Donald, MD, Bone and Joint Imaging, CHAPTER 66, 1056-1066 Copyright © 2005 Copyright © 2005, 1996, 1989 by Elsevier Inc.

18 A, Osteolytic destruction of the naviculocuneiform joints ( arrow ). Fragmentation, osteolysis, and sharply defined osseous debris are noted. B, Graphic illustration of radiographic findings. THE CHARCOT FOOT SANDERS, LEE J., Levin and O'Neal's The Diabetic Foot, CHAPTER 12, 257-283 Copyright © 2008 Churchill Livingstone

19 A, Lateral radiograph demonstrates an avulsion fracture of the posterior tubercle of the calcaneus. Arrow points in the direction of pull of the Achilles tendon. Early osteolytic changes are seen to affect the naviculocuneiform joint. B, Graphic illustration of radiographic findings. N, navicular; OC, calcaneous; T, talus; 1C, medial cuneiform. THE CHARCOT FOOT SANDERS, LEE J., Levin and O'Neal's The Diabetic Foot, CHAPTER 12, 257-283 Copyright © 2008 Churchill Livingstone

20 Musculoskeletal manifestations in diabetic patients at a tertiary center. Libyan journal of medicine. 2012;7:1-7.

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22 Central obesity (waist circumference ≥ 94cm for Europid men and ≥ 80cm for Europid women) (Arab use Europid) + Two of the following four factors: Raised TG level: ≥ 150 mg/dL or specific treatment for this lipid abnormality Reduced HDL cholesterol: < 40 mg/dL in males and < 50 mg/dL in females, or specific treatment for this lipid abnormality Raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg, or treatment of previously diagnosed hypertension Raised fasting plasma glucose (FPG) ≥ 100 mg/dL or previously diagnosed type 2 diabetes

23 Requirement three or more. Abdominal obesity (waist circumference >102 cm in men and >88 cm in women) Hypertriglyceridemia (>150 mg/dl). Low high-density lipoprotein (HDL) cholesterol (<40 mg/dl in men and <50 in women). High blood pressure (>130/85 mm Hg). High fasting glucose (>100 mg/dl).

24 Using data from 8,807 participants age >20 years in the Third National Health and Nutrition Examination Survey, they determined the prevalence of metabolic syndrome among individuals with gout and quantified the magnitude of association between the 2 conditions. The prevalence of metabolic syndrome 62.8% among individuals with gout and 25.4% in individuals without gout. Odds ratios of metabolic syndrome for individuals with gout Unadjusted were 4.96 (95% CI 3.17–7.75) Age and sex adjusted odds ratios 3.05 (95% CI 2.01–4.61) Prevalence of the metabolic syndrome in patients with gout: the Third National Health and Nutrition Examination Survey. Arthritis and rheumatism. 2007;57:109-115.

25 Case control study 20 male early onset gout patients, gout family history, without a habit of alcohol consumption or obesity before the first attack of gout, and 42 unrelated males control. Gout and Type 2 diabetes shared the common genetic factors. Type 2 diabetes was the most significantly associated disease with gout as recognized by 36 gene symbols corresponding to 334 significant SNPs. Gout and type 2 diabetes have a mutual inter-dependent effect on genetic risk factors and higher incidences. Rheumatology. 2012;51:715.

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27 Metabolic syndrome, diabetes, and hyperuricemia. Current opinion in rheumatology. 2013;25:210.

28 RR for incident gout among patients with diabetes, as compared with individuals with no diabetes was 0.67 (95% CI 0.63 to 0.71). Case-control all incident cases of gout 24768 and randomly sample from 50000 controls. The multivariate analysis of RRs with the duration of diabetes showed inverse relationship. Results after adjusting for age, sex, body mass index, general practitioner visits, smoking, alcohol intake, ischaemic heart disease and presence of cardiovascular risk factors. Impact of diabetes against the future risk of developing gout. Annals of the rheumatic diseases. 2010;69:2090-2094.

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30 Relative risk of gout by duration of diabetes adjusted for sex, age, calendar year, GP visits, BMI, alcohol consumption, smoking, IHD, hypertension, hyperlipidaemia and renal failure Impact of diabetes against the future risk of developing gout. Annals of the rheumatic diseases. 2010;69:2090-2094.

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32 Autoimmune thyroid disease (AITD) denotes a spectrum of immunological disorders of the thyroid gland that includes Graves’ disease Chronic lymphocytic thyroiditis (Hashimoto disease) Manifested as thyrotoxicosis, hypothyroidism and thyroid nodule or neck swelling. Anti-thyroid peroxidase (anti-TPO) antibodies are expressed in 90-95%, and anti-thyroglobulin (anti-TG) antibodies in about 20-50%, of patients with CLT. A minority of patients express thyrotropin receptor antibodies (blocking antibodies that contribute to hypothyroidism).

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34 Generalized stiffness. Symmetrical arthropathy with stiffness of the small joints of the hands (MCP, PIP, MTP) and knees joints without the presence of inflammatory synovitis. On palpation the joints feel ‘gelatinous’ and fluid is usually noninflammatory, chondrocalcinosis, and CPPD crystals disease can be seen. There is a significant association between the number of joints affected and anti-Thyroid peroxidase, erythrocyte sedimentation rate, and TSH levels. Rheumatic manifestations of autoimmune thyroid disease: the other autoimmune disease. The Journal of rheumatology. 2012;39:1125-1129

35 Shoulder adhesive capsulitis. Neck pain. Carpal tunnel syndrome can be the 1 st manifestation of hypothyroidism, present in more than 7% of patients. Hypothyroidism symptom tends to overlap that of fibromyalgia symptoms. A myopathy has been reported presenting with proximal weakness and fatigue. Physical examination findings may include muscle hypertrophy, proximal muscle weakness, and delayed relaxation of deep tendon reflexes. Rheumatic manifestations of autoimmune thyroid disease: the other autoimmune disease. The Journal of rheumatology. 2012;39:1125-1129

36 Serum muscle enzyme levels are frequently elevated in patients with hypothyroid myopathy and are elevated in up to 90% of asymptomatic patients. These enzymes include CK, myoglobin, and lactate dehydrogenase. The increase is typically mild (CK<1000 IU/L). Reports of a polymyositis like illness or rhabdomyolysis with dramatic elevations in CK levels do exist in the literature Musculoskeletal manifestations of thyroid disease. Rheumatic diseases clinics of North America. 2010;36:637-646.

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38 The myxedma may appear as nodules varying in size from 1 cm to large lesions covering most of the pretibial surface and colored from pink to a light purple hue. They can appear and as erythema nodosum, painless and due hyaluronic acid. Nail changes, onycholysis and clubbing (thyroid acropachy) may be associated with periostitis around the metacarpal joints as well as soft tissue swelling of the digits.

39 Proximal muscle weakness loss of muscle mass and weight loss. In contrast with hypothyroidism, serum CK levels are typically normal and myopathic findings on EMG were rare (10% of patients). Symptoms of weakness resolve with a mean 3.6 months of therapy for hyperthyroidism. Shoulder adhesive capsulitis. Decline in bone mineral density (BMD). Serum calcium levels are increased due to increased bone resorption. Musculoskeletal manifestations of thyroid disease. Rheumatic diseases clinics of North America. 2010;36:637-637.

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41 Autoimmune thyroid diseases associated with well defined systemic autoimmune diseases, MCTD, Sjogren’s syndrome, SLE, RA, systemic sclerosis, and polymyositis/dermatomyositis. Risk of quantification study of autoimmune diseases in cohort of more than 3000 UK subjects and their parents with AITD. Provide novel information about disease clustering, and the presence of true disease associations. These risks highlight the importance of screening for other autoimmune diagnoses. Prevalence and relative risk of other autoimmune diseases in subjects with autoimmune thyroid disease. The American journal of medicine. 2010;123:183.e1-183.e9.

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44 Autoimmune diseases can be associated with increased prevalence's of thyroid autoimmunity include Type 1 diabetes Vitiligo Addison’s disease Multiple sclerosis In general studies have been hampered by small sample sizes and by the use of control populations not matched for age, gender, or geographic location.

45 1517 patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), mixed connective tissue disease (MCTD), Sjogren's syndrome (SS) and polymyositis/dermatomyositis (PM/DM) were included in the study. The HT and GD were diagnosed based on thorough clinical evaluation, imaging and fine-needle aspiration cytology (FNAC). 426 patients with autoimmune thyroid disease including 256 GD and 170 HT were also evaluated for the incidence of systemic autoimmune conditions. Association of systemic and thyroid autoimmune diseases. Clinical rheumatology. 2006;25:240-245

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48 They set out to quantify the risk of coexisting autoimmune diseases in an extensive cohort of more than 3000 UK subjects with well-characterized autoimmune thyroid disease, as well as in their parents, and to compare findings for Graves’ disease and Hashimoto’s thyroiditis in women and men. 9.67% of the 2791 subjects with Graves’ disease and 14.3% of the 495 patients with Hashimoto’s thyroiditis had another autoimmune disorder (P<.005). Among index cases with Graves’ disease and Hashimoto’s thyroiditis, rheumatoid arthritis was most common. The American journal of medicine. 2010;123:183.e1-183.e9.

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52 The higher prevalences and relative risks of rheumatoid arthritis in parents compared with index cases suggest a strong disease association. For each autoimmune disease investigated, the present data provide novel information about disease clustering, strongly supporting the prese Low threshold for screening for these diagnoses should be used. This applies especially to patients with autoimmune thyroid disease who remain nonspecifically unwell or who develop new symptoms despite adequate treatment.

53 Autoimmune thyroid disease in patients with rheumatic diseases. REVISTA BRASILEIRA DE REUMATOLOGIA. 2012;52:417-430.

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