10 - Joint Rheumatology Flashcards
What is giant cell arteritis and what is the typical aetiology?
- Chronic vasculitis of large and medium vessels in the scalp, neck and arms.
- Occurs in people over 50 and associated with polymyalgia rheumatica
- Usually inflammation of arteries originating from arch of aorta
What are some risk factors for GCA?
- >50 years old (1 in 500)
- Caucasian
- Female
- Polymyalgia rheumatica
- Genetic Predisposition with HLA-DR4
What are the symptoms of GCA?
- Headache
- Scalp tenderness especially over temporal artery
- Jaw/tongue claudication on mastication
- Amaurosis fugax
- Blindness, diplopia, blurring
- Constitutional symptoms e.g malaise, weight loss
When is GCA an emergency?
- Any visual symptoms as there is a risk of irreversible bilateral vision loss
- Visual symptoms can present weeks-months after onset of other symptoms
What tests should you order if you suspect GCA?
- ESR/CRP: raised
- Platelets: raised
- Hb: lower
- Temporal artery biopsy: do not wait for this to start steroids, also may be negative biopsy due to skip lesions
How is GCA diagnosed?
How is GCA treated?
If acute visual symptoms
- Immediate IV methylprednisolone for 1-3 days
If just GCA
- Prednisolone PO 60-100mg for at least 2 weeks then consider tapering
- Low dose aspirin to reduce thrombotic risk
- PPI, Adcal and Bisphosphonate if long term steroids
What is polymyalgia rheumatica?
Syndrome characterised by pain and stiffness of shoulder, hip girdles and neck
What is the aetiology of polymyalgia rheumatica?
- Usually affects people >50 with peak incidence at 70-80
- Associated with GCA
How does polymyalgia rheumatica present?
- New sudden onset bilateral aching, tenderness and morning stiffness in shoulders, hips and neck of an elderly patient
- Difficulty rising from chair or combing hair due to proximal limb involvement
- Night time pain
- Systemic symptoms e.g fatigue, weight loss, low grade-fever
What might you find on examination of a patient with polymyalgia rheumatica?
- Decreased ROM of shoulders, neck, hips
- Muscle strength normal just limited by pain
- Muscle tenderness
What investigations should you do if you suspect polymyalgia rheumatica?
- CRP and ESR: raised
- CK: normal, helps distinguish ffrom myopathies
How can you diagnose polymyalgia rheumatica?
History and exam with raised inflammatory markers to support (need ESR and CRP)
Consider temporal artery biopsy if GCA symptoms
How is polymyalgia rheumatica treated?
- Prednisolone PO daily then taper. Should have rapid response in week, if not then reconsider diagnosis.
- Bone protection for steroids
- Methotrexate if patient relapsing/prolonged therapy for steroid sparing treatment
What are some differential diagnoses for polymyalgia rheumatica?
- Recent onset RA
- Malignancy
- Hypothyroidism
- Polymyositis
- OA
- Spinal stenosis
What are spondylarthropathies?
Group of inflammatory conditions that tend to affect the axial skeleton. They all share clinical features of:
- Seronegative (RF -ve)
- HLA-B27 association
- Axial arthritis in spine and SI joints
- Asymmetrical large joint oligoarthritis or monoarthritis
- Enthesitis
- Dactylitis
- Extraarticular features
What conditions are included in spondylarthropathies?
- Ankylosing spondylitis
- Psoriatic arthritis
- Enteropathic arthritis
- Reactive arthritis
What features suggest inflammatory back pain?
IPAIN
What is ankylosing spondylitis and who does it mainly affect?
Chronic inflammatory disease involving the spine and SI joints
Usually affects young men (15-30)
HLA-B27 association
What are the presenting symptoms of ankylosing spondylitis?
- Gradual onset lower back pain that is worse in the night. Early morning stiffness
- Pain relieved with exercise/improves throughout the day
- Pain radiates from SI joints to bilateral buttock
- May have thoracic or chest pain
What might you find on examination of a patient with ankylosing spondylitis?
- Normal
- Loss of lumbar lordosis
- Exaggerated thoracic kyphosis
- Reduced chest expansion
- Decreased lumbar flexion (Schober’s test <20cm)
What are some extraarticular features that ankylosing spondylitis is associated with?
- Enthesitis (achilles tendonitis, plantat fascitis)
- Anterior uveitis
- Aortic valve incompetence
- AV block
- Pulmonary apical fibrosis
- Amyloidosis
How is ankylosing spondylitis investigated and diagnosed?
Diagnosis is clinical with support from imaging
- MRI spine and SI joints(more sensitive than X-ray)
- X-Rays
- Raised CRP/ESR
- Normocytic anaemia
- HLA-B27 positive in 90% cases
What do MRI and X-ray’s show in ankylosing spondylitis?
MRI:
- Active inflammation with bone marrow oedema
- Destructive changes like erosions, sclerosis, ankylosis
X-Ray
- SI joint space narrowing due to fusion, sclerosis, ankylosis/fusion
- Vertebral syndesmophytes due to enthesitis between ligaments and vertebrae
- Bamboo spine due to calcification of ligaments
- Dagger spine
How is ankylosing spondylitis managed?
- Physiotherapy with intense exercise to maintain posture
- NSAIDs
- TNF-a inhibitors (adalimumab)
- IL-17 inhibitors
- Can have local steroid injections and hip replacements if severe
How does psoriatic arthritis present?
Occurs in 10% of psoriasis patients and can occur before skin changes. Often have nail changes, enesthesis and rashes with lots of patterns:
- Oligoarthritis with dactylitis in DIPJs
- Symmetrical
- Monoarthritis
- Psoriatic arthritis mutilans (rare severe deformity)
What radiological investigations are done for psoriatic arthritis and what are the findings?
- CRP raised
- X-Ray: central joint erosions with mouse ears and pencil in cup deformity
- MRI: central joint erosions
How is psoriatic arthritis managed?
- NSAIDs
- DMARDS (Sulfasalazine and Methotrexate)
- TNF-a inhibitors
- IL-17 inhibitors
What is the pathophysiology of reactive arthritis?
Condition where arthritis and other features occur as an autoimmune response to an infection elsewhere in the body, e.g GI or GU infection
- Post dysentry: Salmonella, Shigella, Campylobacter
- Post Urethritis: Chlamydia Trachomatis
How does reactive arthritis present?
- Up to 2 weeks after initial infection
- Acute monoarthritis of lower limb
- Reiter’s: urethritis, uveitis/conjunctivitis and arthritis
- Other features: uveitis, keratoderma blenorrhagica, circinate balanitis, mouth ulcers, enthesitis
What is Reiter’s syndrome?
Triad of:
- Arthritis
- Conjunctivitis
- Urethritis
Can’t see, Can’t pee, Can’t climb a tree!!!!
How is reactive arthritis investigated?
- Take joint aspirate to rule out septic arthritis/gout!!!!!!!!!!!!!!!
- Serology
- STI screening
- Stool culture if diarrhoea
- Raised CRP/ESR
How is reactive arthritis managed?
- Treat underlying infection (may not improve arthritis)
- NSAIDs or local steroid injections
- If not resolving in 6 months consider DMARDs (often HLA-B27+)
What is enteropathic arthritis?
Chronic inflammatory arthritis associated with IBD and Coeliac’s. 10% of IBD patients will get.
Can be peripheral arthritis (2/3) or axial arthritis (1/3)
What are the two different types of peripheral disease for enteropathic arthritis?
Type 1: oligoarticular, asymmetric, associated with IBD flares
Type 2: polyarticular, symmetrical, less correlation with IBD flares
How is enteropathic arthritis managed?
- Treat bowel symptoms and will improve arthritis
- Do not use NSAIDs as this can flare IBD
- Consider TNF-a inhibitors for bowel and arthritis symptoms
What is hypermobility spectrum disorder and who does it commonly affect?
Pain syndrome where joints move beyond normal limits due to laxity of ligaments, capsules and tendons
More common in women, Asian people, family history and presents in childhood