Pannus – Causes, Symptoms and Treatment
Pannus is inflammatory granulation tissue that forms in joints, destroying cartilage and bone, most commonly in rheumatoid arthritis. Early treatment is essential.
Things worth knowing about "Pannus"
Pannus is inflammatory granulation tissue that forms in joints, destroying cartilage and bone, most commonly in rheumatoid arthritis. Early treatment is essential.
What is Pannus?
Pannus (from Latin, meaning cloth or rag) refers to a pathological overgrowth of inflammatory granulation tissue. It most commonly develops within joints, where it spreads across the synovial membrane (joint lining) and invades cartilage and underlying bone. Pannus formation is a hallmark feature of rheumatoid arthritis and other chronic inflammatory joint diseases.
Causes and Development
Pannus tissue develops as a consequence of chronic inflammation of the synovial membrane, known as synovitis. In rheumatoid arthritis, the immune system mistakenly attacks the body's own joint lining, triggering a persistent inflammatory response. This process involves:
- Proliferation of synovial cells (synoviocytes)
- Infiltration of immune cells including macrophages, T-lymphocytes, and B-lymphocytes
- Release of pro-inflammatory cytokines such as TNF-α and interleukin-1
- Formation of new blood vessels (angiogenesis) within the tissue
The resulting pannus tissue is highly aggressive, secreting enzymes known as matrix metalloproteinases that degrade cartilage and erode bone.
Associated Conditions
Pannus formation occurs primarily in the following conditions:
- Rheumatoid Arthritis (RA): The most common cause; pannus is responsible for the characteristic joint destruction seen in RA.
- Psoriatic Arthritis: Inflammatory joint involvement associated with psoriasis.
- Tuberculous Arthritis: Pannus can also arise in infectious (e.g., tuberculosis-related) synovitis.
- Trachoma (Eye): In trachoma, a bacterial eye infection, pannus refers to the growth of blood vessels into the cornea, which can lead to vision impairment.
Symptoms
The symptoms caused by pannus depend on the affected organ. In joint disease, typical manifestations include:
- Joint pain, especially pronounced in the morning (morning stiffness)
- Swelling and warmth of affected joints
- Restricted range of motion
- Over time: joint deformities and permanent structural damage
In cases of ocular pannus, patients may experience visual disturbances or, in severe cases, loss of vision.
Diagnosis
Pannus tissue is identified using several diagnostic methods:
- MRI (Magnetic Resonance Imaging): The most sensitive imaging method for early detection of pannus in joints.
- X-ray: Reveals later-stage joint damage such as erosions and joint space narrowing.
- Ultrasound: Can visualize synovial hypertrophy and pannus tissue.
- Biopsy: Histological examination of tissue provides definitive confirmation.
- Laboratory tests: Elevated inflammatory markers (CRP, ESR), rheumatoid factor, and anti-CCP antibodies support the diagnosis of the underlying disease.
Treatment
Treatment targets the underlying disease with the goal of suppressing inflammation and halting pannus progression:
Pharmacological Treatment
- DMARDs (Disease-Modifying Antirheumatic Drugs): Foundational medications such as methotrexate that slow the course of rheumatoid arthritis.
- Biologics: Targeted therapies such as TNF-α inhibitors (e.g., adalimumab, etanercept) or IL-6 inhibitors (e.g., tocilizumab) that block specific inflammatory mediators.
- JAK Inhibitors: Newer oral agents that inhibit intracellular inflammatory signaling pathways.
- Corticosteroids: Used for short-term anti-inflammatory relief, e.g., prednisolone.
- NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): For symptomatic pain and inflammation relief.
Non-Pharmacological Treatment
- Physiotherapy to maintain joint function and mobility
- Occupational therapy to support daily living activities
- Surgical intervention (e.g., synovectomy -- surgical removal of the inflamed synovial membrane) in severe or refractory cases
References
- Firestein GS, et al. - Kelley & Firestein's Textbook of Rheumatology, 10th Edition. Elsevier, 2017.
- Smolen JS, et al. - Rheumatoid arthritis. Nature Reviews Disease Primers. 2018;4:18001. doi:10.1038/nrdp.2018.1.
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) - Rheumatoid Arthritis. Available at: www.niams.nih.gov
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