Fibromyalgia and Path Piccies !

1. Rick Allen Fibromyalgia and Path Piccies!

2. A.k.a Chronic Widespread Pain • Related with Chronic fatigue syndrome • Definition: • Chronic pain ->3mths • Widespread -L. and R. sides, above and below waist • Absence of inflammation (Pt. may perceive swelling) • Presence of pain at 11/18 common sites (though may have pain at other sites). • Ache/burning, unremitting. Start in one spot before becoming widespread Fibromyalgia

4. Other CF: • Fatigue (80-90%, often severe) • Morning stiffness (80-90%) • Poor concentration • Low mood and sleep disturbance (70%) • Difficult to live with/ family discord • Brain scans suggest abnormal pain sensation • RF: • Female (10:1) IBS • Middle age (40-65) Chronic Headaches • Low SES Anxiety • Low education level Depression • Stress Physical De-conditioning • Sleep disturbances Pre-menstrual syndrome

5. Pathogenesis • Unknown, many postulated, especially in relation to abnormal pain perception (CNS) • Chicken and the egg argument for psychological abnormalities (pain cause issues?) • Ix • All normal! Basically a diagnosis of exclusion • Triggers • Emotional stress, infections, medical illness, surgery, hypothyroidism, trauma • Progression • Can wax and wane, or be persistent through therapy • Prognosis • Poor? 2 years: 24% remission, 47% no longer in criteria

6. Treatment • Education and Communication (include family) • CBT – avoid over-exertion etc. • Stop drugs of dependance, or utilising stimulating substances (caffeine = insomnia) • Long-term graded exercise programs • Pharmacotherapy • NSAIDs SHOULD NOT WORK!!! • Low dose TCA (amitriptyline) before bed helps gain restorative sleep • Treat symptoms (inc. mood disorders) as appropriate

7. PATH Picture Time!!!!

8. Cartilage erosion Osteophyte formation (blue arrows) Eburnation (polished and smooth surface of exposed underlying bone) Cyst development (red arrows) Severe Osteoarthritis

9. Acute Haemarthrosis • 8 y.o. • Haemophiliac

10. Bunion • Woman • Aged 70 • Chronic rubbing against ill fitting shoes

11. Scoliosis • Disc degeneration (blue arrows) • Osteophytes (red arrows)

12. Severe Chronic Rheumatoid Arthritis • Woman • Aged 66 • Abundant fibrous tissue surrounding joint (blue arrows)

13. Osteoarthritis

14. Severe Chronic Rheumatoid Arthritis • Ankylosis of hip joint (blue arrows) • Marked Osteoperosis • Hyperplasia of bone marrow (hypersplenism/long-term glucocoticoid use?) •  thin cortex (red arrows

15. Palisadedepithelioid cells (black arrows) derived from macrophages Central Pink amorphus zone (blue arrows) that stains for fibrin Rheumatoid Nodule • Hyperplasticsynoviocytes (blue arrows) • Chronic inflammation (red arrows) • Vessel prominence • Many plasma cells • Rheumatoid synovium

16. Rheumatoid nodule from pt. w. long history of Rheumatoid Arthritis • Male • 66 y.o. • Excised from subcutaneous tissue over the elbow

17. Acute Suppurative Arthritis of elbow (arrows) • Death from Septicaemia • Group A β haemolytic streptococci involved

18. Severe Chronic Rheumatoid Arthritis • Destruction and dislocation of knee joint • Marked Osteoporosis

19. Ankylosis of hip due to Tuberculosis arthritis • Age 57 at death • Hip joint space (arrows) obliterated • Dx w tuberculous arthritis at age 3

20. Gross degeneration • Woman • Aged 70 • Kyphosis • Schmorl’s nodes (black arrows) • Anterior osteophytes (red arrows)

21. Female • 68 y.o. • Severe interstitial pulmonary fibrosis (blue arrows)  destruction of lung parenchyma • Chronic Rheumatoid Arthritis, resp failure and corpulmonale • Adherent pleura (black arrows)

22. Severe osteoarthritis w fibrosis and haemosiderosis of the synovium • Male • 50y.o. • Haemophiliac • Cartilage erosion (black arrow) • Death from retroperitoneal haemorrhage • Hx. Of recurrent haemarthroses

23. Septic arthritis from Staph. aureus • Male • 71 y.o. • Upper R. humerous • Diabetic • Destruction of articular surface • Synovium microscopy = active chronic inflam. • Purulent exudate in joint space

24. Thickened and hyperplasticsynovium (arrows) Rheumatoid Arthritis • Gross reduction of number and size of trabeculae • Osteoporotic bone

25. Secondary osteoarthritis of the hip • Male • Middle aged • Alkaptonuria and ochronosis • Scant articular cartilage remaining, pigmented

26. Chronic tophaceous gout • Gross deformities caused by urate deposition

27. High power veiw Needle-shaped urate crystals • Foreign body Giant cells(arrows) • Urate crystal aggregates surrounding them

28. Severe ankylosingspondylitis • Male • 51 y.o. • Rigid spine • Longitudinal ligaments undergone ossification • Many intervertebral discs partially ossified (blue arrows) • Fracture-dislocation (black arrows) w compression and necrosis of the cervical cord from fall 2.5 weeks before death

29. Tuberculosis of the spine • Male • 51 y.o. • Gross destruction of the spine • Spinal cord compression • Histol and microbiol assessments needed to Dx. …

30. Hypertrophic Pulmonary Osteoarthropathy • Male • 54 y.o. • Tibia and fibula • Extensive new bone formation (arrows) under the periosteum • Clubbing • Dx. w malignant pleural mesothelioma

31. Chronic gout • Male • 64 y.o. • 1stmetatarso-phalangeal joint • Blue arrows = urate deposits in joints • Red arrows = urate deposits within extra-articular tissue