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
What are some signs and symptoms of hypermobility spectrum disorder?
- Pain around joints is worse after activity
- Fatigue
How is hypermobility spectrum disorder treated?
NO CURE
Non-Pharmacological
- Physiotherapy to strengthen and reduce subluxation
- Splinting
Pharmacological
- Paracetamol
- Specialst pain management
What are the different types of arthritis?
- Inflammatory: seronegative, seropositive (RA and lupus), septic/infectious, crystal induced
- Non-inflammatory: OA
Also think if mono or polyarthritis
What is the pathophysiology of the most common type of arthritis, OA?
Progressive loss of articular cartilage accompanied by new bone formation and capsular fibrosis
What are some risk factors for OA?
- Age
- Female
- Obesity
- Trauma
- Joint malalignment
What are some signs and symptoms of OA?
- Monoarticular joint pain
- Crepitus
- Reduced ROM
- Early morning stiffness <30mins
- Inacitivity gelling in knee
- Feeling that joint is going to ‘give way’
How is OA diagnosed and what will this show?
X-RAY
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral bone cysts
How is OA managed conservatively, medically and surgically?
Conservatively: physiotherapy for strengthening, weight loss to decrease joint loadning, walking stick
Medically: regular paracetamol, oral or topical NSAIDs, topical capsaicin, intrarticular corticosteroid injections
Surgically: joint replacements
What is nodal OA?
OA affecting the PIPJs (Bouchard’s), DIPJs (Herbeden’s), thumb CMCs and knees
More common in post menopausal women
What is fibromyalgia? (diagnosis of exclusion)
- Chronic (>3months) widespread pain in all 4 quadrants of the body involving left and right side, above and below the waist and the axial skelton
- Fatigue and unrefreshing sleep
- Can also be low mood, stiffness and disturbe sleep
What is the possible pathogenesis of fibromyalgia?
- Deliberate sleep deprivation
- Reduced REM and delta-wave sleep so hyperactivatin in response to noxious stimulation and neural activation of pain perception sensors in response to non-painful stimuli
What are some of the symptoms of fibromyalgia?
- Joint/muscle stiffness
- Fatigue
- Unrefreshed sleep
- Headaches
- IBS
- Depression and anxiety
- Poor concentration
- Widespread tender points
What are some risk factors for fibromyalgia?
- Female
- Middle aged 40-50
- Low household income
- Low educational status
- Trigger e.g emotional or physical
How is fibromyalgia diagnosed?
- Clinical diagnosis
- Clinical tests rule out other diagnoses
- No MSK or neurological abnormalities on examination
- Tender points on palpation of muscles
How is fibromyalgia treated?
- Patient education (pacing, exercise, relaxation, physio)
- CBT
- Low dose amitriptylline can help pain and improve sleep
- Pregabalin can be used if amitriptylline not useful
- Duloxetine or SSRIs for concurrent depression
- DO NOT GIVE STEROIDS, NSAIDS OR OPIATES
What blood tests are recommended in fibromyalgia to rule out other pathology?
- ESR/CRP
- FBC
- U+Es
- LFTs
- Ca
- CK
- TFT
What is osteoporosis?
Low bone mass that leads to compromised bone strength and increased risk of fracture
Cortical bone affected then long bone fractures, if trabeculae ten cresh fractures
What are some risk factors for osteoporosis?
Modifiable and Non-modifiable
SHATTERED
Steroids
Hyperthyroidism, hyperparathyroidism, hypercalcuria
Alcohol
Thin
Testosterone low
Early menopause
Renal or liver failure
Erosive/Inflammatory bone disease
Diet low in Ca
What are some secondary causes of osteoporosis?
- Celiac
- Eating disorders
- Hyperparathyroidism
- Hyperthyroidism
- Multiple myeloma
How is a diagnosis of osteoporosis made?
Gold standard: DEXA of lumbar spine and hip. See image for numbers
Other investigations: X-ray, Ca, PO4
What is a Z-Score for osteoporosis?
Comparison of the patients BMD with other people of the same age and gender
If <2 then consider secondary osteoporosis
What fractures should make you suspect osteoporosis?
- Non trauma vertebral compression fracture
- Non-trauma rib fracture
How is osteopenia treated? (T of -1 to -2.5)
RISK MODIFICATION
- Weight bearing exercise
- Vitamin D3 supplements
- Limit alcohol
- Smoking cessation
- Diet advice (increase Ca and Vit D)
What is the pharmacological treatment for osteoporosis?
Lifestyle changes, Vitamin D and Ca supplementation PLUS
1st line: oral bisphosphonates (e.g alendronic acid) but can give IV if oral not tolerated
2nd Line: Denosumab or Teriparatide
Can give HRT to prevent osteoporosis and testosterone to hypergonadal men
What instructions should you give to patients on how to take alendronic acid?
- Take on empty stomach
- Take with full glass of water
- Remain upright for 30 minutes after taking
- Wait 30 minutes before eating or taking other drugs
What are some side effects of oral bisphosphonates such as alendronic acid?
- Photosensitivity
- GI upset
- Oesophageal ulcers
- Jaw osteonecrosis
What are some indications for a DEXA scan?
- Low trauma fracture
- Women >65 with one or more risk factors for osteoprosis
- Before giving long term steroids
Do not need pretreatment for women >75 years
What is gout?
Deposition of monosodium urate crystals in joints (usually first MTJ) leading to inflammatory mono-arthritis. Due to hyperuricaemia
Long term can get urate deposits (tophi) and renal disease
What are some things that can trigger a gout attack?
- Trauma
- Surgery
- Starvation
- Infection
- Diuretics
What are some risk factors and differentials for gout?
Need to rule out septic arthritis!!!
DD: haemarthrosis, reactive arthritis
What investigations are done to diagnose gout and what do they show?
- Serum urate: raised
- Xray of joint: soft tissue swelling, punched out erosions
- Joint aspiration of synovial fluid: negatively birefringent needle shaped crystals under polarised light microscopy
What are the general management principles of gout?
- Treat acute attack
- Prevent recurrences by lowering serum urate with medication and lifestlye
- Lower CVD risk as gout associated with CVD
How do we treat and acute attack of gout?
- RICE
- NSAIDs or Colchicine
- IM or oral steroids
How is chronic gout treated?
Lifestyle changes:
- Lose weight
- Regular exercise
- Purine rich foods
- Reduce alcohol consumption
- Increase fluid intake
Pharmacology (ULT if >1 attack in a year)
- Allopurinol or Febuxostat
- Cover allopurinol with NSAID as can cause acute attack
- Can use benzbromarone and sulfinpyrazone as renal excretion of uric acid but more side effects
What is pseudogout?
Deposition of calcium pyrophosphate crystals in a joint causing inflammatory arthritis. Usually in knees or wrist
What are some risk factors of pseudogout?
- Old age
- OA
- Hyperparathyroidism
- Haemochromotosis
What are some investigations for pseudogout and what do they show?
- X-ray: calcium deposition (chondrocalcinosis)
- Synovial fluid analysis: positively birefringent rhomboid shaped crystals
How is pseudogout treated?
Acute: RICE, NSAIDs, intraarticular steroid injections
Prevention: possible colchicine
What is the pathophysiology of rheumatoid arthritis?
Autoimmune disease causing symmetrical polyarthritis and increased CVD risk
Antibodies to Fc portion of IgG RF and anti-CCP. Made due to cirullination of self antigens that are then recognised by B and T cells so produce antibodies RF and anti-CCP.
Stimulated macrophages release TNFa and stimulate osteoclast differentiation so bone damage. Inflammatory cascade leads to proliferation of synviocytes that grow over cartilage and restrict nutrients to cartilage
What is the typical history of RA?
- Woman aged 30-5
- Progressive symmetrical polyarthritis
- Affects MCPs, PIPs, MTPs and spares DIPJs
- Can affect hips, knees, shoulders, C-spine
- >6 weeks
- Morning stiffness >30 minutes
- Malaise
- Low grade fever
What signs can you see on examination with RA?
- Early: soft tissue swelling and tenderness
- Hands: ulnar deviation and subluxation of fingers, swan-neck and Boutonniere deformity, Z-deformity of thumbs
- Rheumatoid nodules: elbow
- Median nerve: may be compressed at carpal tunnel
What are some extra-articular manifestations of ra?
- Fatigue, fever weight loss
- Nodules: elbows, lung, cardiac, lymphadenopathy
- Lungs: pleural disease, intersitial fibrosis
- Cardiac: IHD, pericarditis
- Osteoporosis
- Carpal tunnel syndrome
- Frozen shoulder
- De Quervian’s tenosynovitis
What is a pneumonic to remember the extra-articular manifestations of RA?
- 3 Cs
- 3 As
- 3 Ps
- 3 Ss
What are some investigations you should do if you suspect RA?
- FBC: anaemia of chronic disease
- RF and Anti-CCP: positive, high titres associated with severer disease and extra-articular manifestations
- Inflammatory markers: raised
- Xray: see image
- USS/MRI: early disease has greater sensitivity for synovitis
- HRCT: if lung disease
What is the criteria for diagnosing RA?
EULAR
- Joint involvement
- Serology
- Acute phase reactants
- Duration of symptoms
What is the management for RA?
Non-Pharmacological: OT, physio, psychotherapist
Pharmacological:
1st line us Methotrexate monotherapy helps improve long term outcomes.
- Consider combination with HCQ, leflunomide, sulfasalazine
- If disease still severe after combination DMARDs consider biologics (TNF-a inhibitors)
- Steroids for acute flares
- NSAIDs or symptoms relief with PPI cover
How should you start DMARDs for RA?
- Give methotrexate weekly with folic acid
- Give steroid cover for first 3 months
What tool can you use to measure if RA is improving or getting worse?
DAS28 helps to tell you the disease activity
Looks at how many swollen joints, how many tender joints, inflammatory markers and patient as a whole
If a patient is complaining of swelling in the small joints of the hand but you cannot see or palpate this on examination, what investigation should you order?
US to look for synovitis. MRI also
A DEXA scan produces a T-Score. Although this can determine bone mass, it cannot predict the risk of fractures. What can be used to predict the risk of fractures?
FRAX tool can calculate 10 year risk of hip fracture and osteoporotic fracture
What is the definition of an osteoporotic/fragility/low trauma fracture?
Fracture as a result of a fall from standing height or less, at walking speed or less
What test is needed next?
URINE DIPSTICK
What might a temportal artery biopsy show in GCA?
- Granulomas
- Necrotizing arteritis
- Nothing as skip lesions
What is seen on muscle biopsy with polymyositis and dermatomyositis?
What is the most common side effect of methotrexate and alendronic acid?
Methotrexate: nausea
Alendronic acid: indigestion/epigastric pain
What is the inheritance pattern of HLA-B27 gene?
Autosomal dominant
What are some of the complications of ankylosing spondylitis?
- Increased risk of CVD
- Osteoporosis
- IBS
- Anterior uveitis
