Gerontorheumatology

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Jozef Rovenský
Editor

Gerontorheumatology
Editor
Jozef Rovenský
National Institute of Rheumatic Diseases
Piešťany
Slovakia

Based on a translation from the Czech language edition: Gerontorevmatologie by Jozef

Rovenský et al. © Galén, Prague, 2014; ISBN 9788074921476. All Rights Reserved.

ISBN 978-3-319-31167-8    ISBN 978-3-319-31169-2 (eBook)

DOI 10.1007/978-3-319-31169-2

Library of Congress Control Number: 2016959557

© Springer International Publishing Switzerland 2017

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To my Czech and Slovak teachers

Jozef Rovenský
Preface

The publication of prominent Czech and Slovak authors led by Prof. Jozef
Rovenský, MD, DSc, from the National Institute of Rheumatic Diseases in
Piešťany, Slovakia, has the ambition to become the standard monograph of
gerontorheumatology, a specialized field that deals with movement disorders
associated with aging and old age.
In individual patients, the musculoskeletal diseases have their characteris-
tic features, different etiology, and different course and require more attention
to diagnosis and treatment. In patients at older age, it is also necessary to be
aware of comorbidities, which may lead to doubts in accurate diagnostics.
The entire publication clearly describes the basic rheumatic diseases with
emphasis on pathogenesis, diagnosis, prevention, and therapy. It is designed
to the rheumatologists and internists, but especially to the general practitio-
ners who usually meet elderly patients with movement disorders as the first
in their offices.

Piešťany, Slovakia Jozef Rovenský

vii
Acknowledgement

The Editor gratefully acknowledges the assistance of the following people,

who reviewed the manuscripts of our book:
Marián Bernadič
Institute of Pathological Physiology
Faculty of Medicine
Comenius University
Bratislava
Slovakia
Ivan Bartošovič
St. Elizabeth University of Health and Social Sciences
Skalica
Slovakia

ix
Contents

1 Pathogenesis, Clinical Syndromology and Treatment

of Rheumatoid Arthritis�������������������������������������������������������������������� 1
Jozef Rovenský, Miroslav Ferenčík†, and Richard Imrich
2 Osteoporosis in Rheumatoid Arthritis
in Relation to Age ���������������������������������������������������������������������������� 23
Juraj Payer, Zuzana Kužmová, Zdenko Killinger,
and Jozef Rovenský
3 Biological Therapy for Rheumatoid Arthritis ������������������������������ 27
Jozef Rovenský, Dagmar Mičeková,
and Vanda Mlynáriková
4 Systemic Lupus Erythematosus������������������������������������������������������ 33
Alena Tuchyňová and Jozef Rovenský
5 Sjögren’s Syndrome ������������������������������������������������������������������������ 39
Jozef Rovenský, Dagmar Mičeková,
and Vanda Mlynáriková
6 Systemic Scleroderma���������������������������������������������������������������������� 45
Radim Bečvář
7 Vasculitides �������������������������������������������������������������������������������������� 49
Radim Bečvář and Jozef Rovenský
8 Polymyalgia Rheumatica and Giant Cell Arteritis ���������������������� 61
Jozef Rovenský, Alena Tuchyňová, Viera Štvrtinová,
and Svetoslav Štvrtina†
9 Aortic Aneurysm as a Cause of Death
in Giant Cell Arteritis���������������������������������������������������������������������� 75
Svetoslav Štvrtina†, Jozef Rovenský,
and Štefan Galbavý
10 Relapsing Polychondritis���������������������������������������������������������������� 83
Jozef Rovenský and Marie Sedláčková
11 RS3PE: A Disease or a Syndrome?������������������������������������������������ 91
Jozef Rovenský

xi
xii Contents

12 Clinical and Laboratory Manifestations of Paraneoplastic

Rheumatic Syndromes�������������������������������������������������������������������� 99
Jozef Rovenský and Ľubica Švancárová
13 Osteoarthritis���������������������������������������������������������������������������������� 111
Jozef Rovenský, Helena Tauchmannová, Mária Stančíková,
Jana Sedláková, and Mária Krátka
14 Haemochromatosis Arthropathy�������������������������������������������������� 139
Tomáš Dallos, Jochen Zwerina, and László Kovács
15 Diabetic Charcot Neurogenic Osteoarthropathy������������������������ 151
Renáta Palmajová and Juraj Palmaj
16 Changes of the Musculoskeletal System
in the Metabolic Syndrome ���������������������������������������������������������� 191
Juraj Palmaj and Renáta Palmajová
17 Clinical Syndromology of Gouty Arthritis���������������������������������� 215
Jozef Rovenský, Marián Kovalančík, Karol Bošmanský,
Emília Rovenská, and Jana Sedláková
18 Radiology and Ultrasonography Findings
in Chondrocalcinosis���������������������������������������������������������������������� 223
Mária Krátka and Jozef Rovenský
19 Alkaptonuria and Ochronosis������������������������������������������������������ 233
Jozef Rovenský, Richard Imrich, Tibor Urbánek,
and Vladimir Bošák
20 Metabolic Osteopathy in Late-­Onset Celiac Disease������������������ 245
Hana Ciferská, Pavel Horák, and Martin Tichý
21 Coeliac Disease in Elderly Patients���������������������������������������������� 255
Petr Fojtík, Martin Kliment, and Pavel Novosad
22 Bone and Joint Involvement in Celiac Disease���������������������������� 261
Lenka Franeková and Marie Sedláčková
23 Diffuse Idiopathic Skeletal Hyperostosis ������������������������������������ 269
Andrea Pavelková
24 Senile Osteoporosis������������������������������������������������������������������������ 275
Petr Broulík
25 Nutrition and Osteoporosis ���������������������������������������������������������� 281
Petr Fojtík, Martin Kliment, and Pavel Novosad
26 Neck and Shoulder Pain���������������������������������������������������������������� 285
Marie Sedláčková
27 Vertebrogenic Disorders���������������������������������������������������������������� 293
Ivan Buran
28 Pain�������������������������������������������������������������������������������������������������� 301
Ľubomír Lisý
Contents xiii

29 Pharmacological Treatment of Rheumatic Diseases������������������ 307

Marta Olejárová
30 Drug-Induced Rheumatic Syndromes������������������������������������������ 315
Jozef Holjenčík Jr., Jozef Rovenský, and Milan Kriška
31 Rehabilitation in Rheumatic Diseases������������������������������������������ 321
Helena Tauchmannová and Zuzana Popracová
32 Surgical Treatment of Sequelae of Rheumatic Diseases������������ 329
Pavel Vavřík and Stanislav Popelka
33 Paget’s Disease of Bone������������������������������������������������������������������ 343
Ines Guimaraes da Silveira, Melissa Cláudia Bisi, Aline de Souza
Streck, Caroline Zechlinski Xavier de Freitas, Deonilson Ghizoni
Schmoeller, Carlos Alberto von Muhlen,
Jozef Holjenčík Jr, and Jozef Rovenský
34 Involutional Osteoporosis: Sarcopenia,
Frailty Syndrome and Falls���������������������������������������������������������� 351
Jiří Jenšovský
35 Systemic Enzyme Therapy in Comprehensive
Treatment of Degenerative Rheumatic Diseases
in the Elderly���������������������������������������������������������������������������������� 363
Martin Wald and Jozef Rovenský
Index�������������������������������������������������������������������������������������������������������� 367
Contributors

Radim Bečvář, MD, PhD Institute of Rheumatology, Prague, Czech

Republic
Melissa Claudia Bisi Clinica Medica no Hospital Geral, Caxias do Sul,
Reumatologia do Hospital, Porto Alegre, RS, Brazil
Vladimir Bošák, RND, PhD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Karol Bošmanský, MD, DSc National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Petr Broulík, MD, DSc 3rd Department of Internal Medicine, 1st Faculty of
Medicine, Charles University and General University Hospital, Prague,
Czech Republic
Department of Endocrinology and Metabolism, 1st Faculty of Medicine,
Charles University and General University Hospital, Prague, Czech Republic
Ivan Buran, MD, PhD Railway Hospital and Health Centre, Bratislava,
Slovakia
Hana Ciferská, MD, PhD Institute of Rheumatology, Prague, Czech
Republic
Ines Guimaraes da Silveira Reumatologia no Hospital Sao Lucas, Porto
Alegre, RS, Brazil
Tomaš Dallos, MD, PhD 2nd Department of Paediatrics, Faculty of
Medicine of Comenius University in Bratislava, Paediatric University
Hospital, Bratislava, Slovakia
Caroline Zechlinski Xavier de Freitas Medica em Reumatologia no
Hospital Sao, Porto Alegre, RS, Brazil
Miroslav Ferenčík, Ing, DSc Institute of Neuroimmunology, Slovak
Academy of Sciences, Bratislava, Slovakia
Petr Fojtík, MD, PhD Vítkovická Hospital a.s., Ostrava-Vítkovice, Czech
Republic
Lenka Franeková, MD, PhD Internal Clinic - Outpatient Department of
Rheumatology and Osteology, Military University Hospital, Prague, Czech
Republic

xv
xvi Contributors

Professor Štefan Galbavý, MD, DSc St. Elizabeth Institute of Oncology,

Slovak Medical University in Bratislava, Bratislava, Slovakia
Jozef Holjenčík Jr, MD Department of Orthopaedic and Trauma Surgery
orthopaedic clinic, University Hospital Martin, Martin, Slovakia
Pavel Horák, MD, PhD 3rd Department of Internal Medicine – Nephrology,
Rheumatology and Endocrinology, Faculty of Medicine of Palacky University
and University Hospital, Olomouc, Czech Republic
Richard Imrich, PhD Institute for Clinical and Translational Research
BMC, Slovak Academy of Sciences, Bratislava, Slovak Republic
Jiří Jenšovský, MD, PhD Department of Internal Medicine of 1st Faculty
of Medicine, Charles University and Central Military Hospital – Military
University Hospital, Prague, Czech Republic
Zdenko Killinger, MD, PhD 5th Department of Internal Medicine,
Comenius University and University Hospital, Bratislava, Slovakia
Martin Kliment, MD, PhD Vítkovická Hospital a.s., Ostrava-Vítkovice,
Czech Republic
Laszlo Kovacs, MD, DSc, MPH 2nd Department of Paediatrics, Faculty of
Medicine of Comenius University in Bratislava, Paediatric University
Hospital, Bratislava, Slovakia
Marián Kovalančík, MD, PhD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Mária Krátka, MD National Institute of Rheumatic Diseases, Piešťany,
Slovakia
Milan Kriška, MD, DSc Department of Pharmacology, Faculty of Medicine,
Comenius University Bratislava, Bratislava, Slovakia
Zuzana Kužmová, MD 5th Department of Internal Medicine, Comenius
University and University Hospital, Bratislava, Slovakia
Ľubomir Lisý, MD, DSc Department of Neurology, Slovak Medical
University and University Hospital, Bratislava, Slovakia
Oľga Lukáčová, MD, PhD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Dagmar Mičeková, MD, PhD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Vanda Mlynáriková, MD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Pavel Novosad, MD Osteocentre, Mediekos Labor s.r.o., Zlín, Czech
Republic
Marta Olejárová, MD, PhD Institute of Rheumatology, Prague, Slovakia
Contributors xvii

Juraj Palmaj, MD Specialized Hospital for Orthopaedic Prosthetics,

Bratislava, Slovakia
Renata Palmajová, MD Centre for Diabetology and Metabolism, Bratislava,
Slovakia
Andrea Pavelková, MD Institute of Rheumatology, Prague, Czech Republic
Juraj Payer, MD, PhD 5th Department of Internal Medicine, Comenius
University and University Hospital, Bratislava, Slovakia
Stanislav Popelka, MD, PhD 1st Department of Orthopaedics, 1st Faculty
of Medicine, Charles University and University Hospital Motol, Prague,
Czech Republic
Zuzana Popracová, MD, PhD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Emília Rovenská, MD, PhD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Jozef Rovenský, MD, DSc, FRCP National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Department of Rheumatology, Slovak Medical University, Faculty of
Medicine, Bratislava, Slovakia
Deonilson Ghizoni Schmoeller Reumatologia no Hospital Sao Lucas da
PUCRS, Porto Alegre, RS, Brazil
Marie Sedláčková, MD Department of Rheumatology and Rehabilitation,
Thomayer Hospital, Prague, Czech Republic
Jana Sedláková, MD, PhD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Maria Stančíková, Ing, PhD National Institute of Rheumatic Diseases,
Piešťany, Slovakia
Aline de Souza Streck Reumatologia no Hospital Sao Lucas, Porto Alegre,
RS, Brazil
Professor Viera Štvrtinová, MD, PhD Department of Internal Medicine,
Comenius University and University Hospital, Bratislava, Slovakia
Ľubica Švancárová, MD National Institute of Oncology, Bratislava,
Slovakia
Helena Tauchmannová, MD, PhD National Institute of Rheumatic
Diseases, Piešťany, Slovakia
Martin Tichý, MD, PhD Department of Dermatology and Venereology,
University Hospital, Olomouc, Czech Republic
Alena Tuchyňová, MD, PhD, MBA National Institute of Rheumatic
Diseases, Piešťany, Slovakia
xviii Contributors

Tibor Urbánek, MD, PhD National Institute of Rheumatic Diseases,

Piešťany, Slovakia
Pavel Vavřík, MD, PhD, MBA 1st Department of Orthopaedics, 1st Faculty
of Medicine, Charles University and University Hospital Motol, Prague,
Czech Republic
Carlos Alberto von Mühlen Centro de Diagnosticos Medicos e Rheuma,
Clinica de Doencas Reumaticas de Porto, Porto Alegre, RS, Brazil
Jochen Zwerina Ludwig Boltzmann Institut fur Osteologie, Wien, Austria
 Pathogenesis, Clinical
Syndromology and Treatment 1
of Rheumatoid Arthritis

Jozef Rovenský, Miroslav Ferenčík†,

and Richard Imrich

1.1 Elderly-Onset Rheumatoid The EORA female/male incidence ratio is

Arthritis lower than in patients with rheumatoid arthritis.
An Italian study showed that the EORA female/
Rheumatoid arthritis (RA) starting after the age male ratio is 1.6:1, as compared to 4.4:1 in the
of 60 years is called elderly-onset rheumatoid younger-onset rheumatoid arthritis (YORA) [2].
arthritis (EORA) [1]. The age factor is very Another typical feature of EORA is its abrupt
important as EORA accounts for 10–33 % of all onset. Bajocchi et al. [2] have found out in their
RA cases and has certain specific clinical fea- study that acute onset of EORA occurs in 33.6 %
tures. Another factor to be taken into account is of cases, while in younger individuals, it is only
that medications to treat elderly-onset RA may in 13.6 %.
cause various adverse effects; therefore, the ther-
apy must be carefully considered and continu-
ously monitored. Older patients also typically 1.2 Pathogenesis of EORA
suffer from more than one disease, and the drugs
they receive may interact. Some of their physio- In pathogenesis of EORA are present abnormali-
logical functions are impaired which has a ties in regulation of immune functions, characteris-
­negative impact on the drug bioavailability and tic of old age, increase susceptibility of the elderly
metabolism. to infections, autoimmune and tumorous diseases.
A significant role in development of EORA is
†
Author was deceased at the time of publication. played by a complex of age-related changes in
immunity mechanisms presented below. In addi-
J. Rovenský (*)
National Institute of Rheumatic Diseases, tion to the mentioned disorders of the innate and
Piešťany, Slovakia acquired immunity, antibody and cell-specific
Department of Rheumatology, Slovak Medical immunity, the age-related changes include also
University, Faculty of Medicine, Bratislava, Slovakia defects in antigen processing or apoptosis of
e-mail: [email protected] cells. An important factor in EORA pathogenesis
M. Ferenčík† may be a disorder of the immune system caused
Institute of Neuroimmunology, Slovak Academy by gradual impairment of functions of
of Sciences, Bratislava, Slovakia T-lymphocytes, associated with development of a
e-mail: [email protected]
chronic inflammation [24]. It is assumed that
R. Imrich immunological changes in the course of physio-
Institute of Experimental Endocrinology,
Slovak Academy of Sciences, Bratislava, Slovakia logical ageing modify the (clinical and ­laboratory)
e-mail: [email protected] progress of EORA [4].

© Springer International Publishing Switzerland 2017 1

J. Rovenský (ed.), Gerontorheumatology, DOI 10.1007/978-3-319-31169-2_1
2 J. Rovenský et al.

The incidence of the rheumatoid factor (RF) is relation in EORA, the research findings are
substantially lower in patients with EORA, and it ­contradictory. Terkeltaub et al. [11] observed a
is generally known that the presence of IgM RF lower frequency of HLA-DR4 in EORA, while
increases during physiological ageing. Vencovský Hazes et al. [12] reported a slightly increased
[4] states that the criterion of the presence of RF prevalence of DR4 with increasing age of the RA
is from the viewpoint of diagnostic process less onset. A positive association was found with
important in old age, as the positivity of RF DR-B1*0101, *0405 and *1502 in the Japanese
ranges in individuals over the age of 60 without EORA patients as compared to YORA [13].
any obvious disease between 15 and 20 %, Scientists in Spain found out that EORA,
although the levels are not in most cases high [5]. unlike YORA, correlates with DRB1*01, but did
Therefore, it is recommended to consider in not prove correlation with DRB1*04 [14].
elderly patients the first positive RF titre to be According to another finding, seronegative
1:1,280 in latex fixation test, as compared to EORA patients had an increased frequency of
1:160 in the middle-aged individuals. Vencovský DRB1*13/*14. A similar finding is related to
[4] also reports that in part of seronegative EORA patients with polymyalgia rheumatica (PMR).
patients, RF can be proved by a more sensitive These differences are highly interesting both
method, and so the frequency does not differ that from the clinical and genetic viewpoints, as
much, and it is rather a case of RF of another type it seems that there exist two groups of EORA
[6]. ELISA test is used to determine RF isotypes. patients, one of which resembles YORA and the
IgG RF is associated with the presence of vasculi- other is similar to polymyalgia rheumatica. The
tis, IgA RF with development of bone erosion. In latter one is typically associated with a painful
EORA, arthritic syndrome is typically confined involvement of the shoulder girdle, acute onset, the
more or less to large joints. An important issue is absence of the rheumatoid factor, minimal extra-
also the outcome prognosis in EORA patients. articular involvement and non-erosive course.
Recently, investigations have focused also on
the incidence and prevalence of EORA in vari-
1.3  he Basic Specific Features
T ous countries. In Norway, RA incidence in the
of EORA 1988–1993 period was reported at 25.7 (females,
36.7; males, 13.8) per 100,000 inhabitants. The
1. Approximately equal incidence of the disease incidence was increasing with age from 7.8 per
in women and men 100,000 of inhabitants between 20 and 29 years
2. Frequent acute onset of the disease of age to 61 in the age group of 70–79 years [15].
3. Frequent involvement of large joints The same authors found the RA prevalence in the
4. Frequent oligoarticular distribution age group of 20–79 years to be 0.437 %, while in
5. Frequent systemic manifestations at the begin- women older than 60 years, the RA prevalence
ning – high erythrocyte sedimentation rate, exceeded 1 %. In a British study, increased RA
weight loss or fatigue incidence in the course of physiological age-
6. Higher incidence of “seronegativity”, i.e. RF ing was observed in men; in women the disease
absence detected by common agglutination typically started at the age of 45–65 years [16].
tests Similarly, the Finish researchers examined the
7. Impaired functional ability and decreased impact of physiological ageing on RA. Analyses
quality of life of EORA patients showed that in patients aged 65, 75, 80 and 85
8. Slightly higher incidence of severe cases, with years, the prevalence was higher – 2.4 % – par-
rapid development of significant functional ticularly at the age of 65 years and tended to
involvement and destructive changes decline with age [17]. Based on the new find-
ings that were published in the USA, RA preva-
Of great importance is also genetic examina- lence in patients aged 60 years and more reached
tion of the role of HLA-DR4 and severity of 2 %, regardless of age [18]. In Sweden the RA
rheumatoid arthritis. As concerns the HLA-DR4 ­prevalence in patients in the age group of 70–79
1 Pathogenesis, Clinical Syndromology and Treatment of Rheumatoid Arthritis 3

years was 2–3 %. According to the data from the The disease begins usually insidiously.
Netherlands, the RA prevalence at the age of Arthritis develops slowly in the course of 1 week
more than 85 years was only 0.3 % [20]. up to months, sometimes in combination with
Characteristics of rheumatoid arthritis and prodromal symptoms such as increased tem-
basic differences of the disease in the elderly RA perature, fatigue, weight loss and anorexia. Less
is a chronic systemic inflammatory disease that frequently RA begins with acute or peracute
primarily affects synovial membranes of joints, signs in the course of several days, although one
tendons and joint capsules. Its most prevalent study reports up to 26 % EORA patients with
clinical manifestation is chronic symmetrical such an onset of the disease [7]. Typical of RA
polyarthritis. The systemic manifestations is a polyarticular, symmetrical joint involve-
include the variable presence of extra-articular ment, even if at the beginning it may affect one
symptoms, the most frequent of which is serosi- or only a few joints, which is more frequent in
tis, vasculitis, nodule formation, general decalci- EORA. Subcutaneous nodules were reported less
fication, marked production of proteins in the frequently in elderly patients than in younger
acute phase and production of autoantibodies. patients with RA. In older age, involvement of
RA occurs almost all over the world and large joints is more frequent, particularly shoul-
affects on average about three times more women ders, where the disease quite often starts. In these
than men. The most typical manifestations are cases it is difficult to distinguish it from polymy-
reflected by the diagnostic criteria. Prevalence of algia rheumatica, the incidence of which at the
the disease ranges around 1 %. Although RA onset of the disease is almost impossible [8–10].
reduces lifespan on average by 5–10 years, it is a Arthritis is accompanied by morning stiffness
chronic, long-lasting disorder, and so its preva- described by patients as a feeling of stiffness and
lence in the population over the age of 60 years tightness of fingers and inability to bend the small
ranges around 2–3 % [3]. joints of the hand. Intervals of morning stiffness
Most of the patients suffer from RA in the differ in length and may last for several hours.
long run, and therefore progressive conditions Stiffness can be relieved by warming or soaking
can be observed that due to destructive changes hands in warm water.
in the joints lead to severe deformities and func- RA may involve almost all synovial joints, as
tional changes. The disease starts as a rule a rule with the exception of the distal interpha-
between 30 and 50 years of age, but in almost one langeal joints of hands and feet. Hands display
third of cases, it develops after the age of 60. As typical spindle-shaped swelling of the proximal
RA that has developed later in the life differs in interphalangeal joints and marked interosseous
certain aspects from RA in middle-aged individ- muscle atrophy. Gradual progress of the disor-
uals, i.e. younger-onset rheumatoid arthritis der together with destructive changes leads to
(YORA), it is sometimes defined as a separate radial rotation of carpal bones and ulnar devia-
entity, i.e. the elderly-onset rheumatoid arthritis tion of fingers, metacarpophalangeal (MCP)
(EORA) [1–4, 19]. joints in particular. There may occur sublux-
ation and dislocation of the metacarpophalan-
geal (MCP) and proximal interphalangeal (PIP)
1.4  linical Features of RA
C joints. Typical changes include swan neck
in Elderly Patients in View deformity (flexion in MCP joints, hyperexten-
of Changes in Its Course sion in PIP joints and flexion in distal interpha-
langeal (DIP) joints) and buttonhole deformity
The range of RA clinical manifestations is vari- (flexion in PIP joints and hyperextension in DIP
able and includes more subtle forms of mild joints). A severe complication is the carpal tun-
synovitis and short-term morning stiffness, as nel syndrome caused by compression of the
well as severe and disabling conditions with a median nerve associated with swelling and
rapid destruction of the joint tissue and severe synovial hyperplasia in the wrist. It manifests
extra-articular symptoms. itself by sensory loss and piercing pain of the