11 - joint pain and swelling

Question 1

What is uric acid formed from?
Which foods have high levels?
Other causes?

Answer 1

purines

Red meat, oilly fish, shellfish, beer

tumour necrosis, enzyme deficiencies, diuretics, renal failure.

Question 2

What causes the pain in gout?

Answer 2

Recurrent inflammatory arthritis and possible stone disease due to urate crystal formation.

Question 3

Mx of gout

Answer 3

Acute: NSAIDs and colchine

Chronic: lifestyle and allopurinol

Question 4

What is pseudogout

Answer 4

is calcium pyrophosphate. Usually affects knees.

Usually product of systemic disease which needs to be investigated.

Question 5

Egs of Sero+ve / -ve arthiritis

Answer 5

Seropositive: RA, SLE, Systemic sclerosis, PBC, sarcoid, sjogren’s

Seronegative: OA, AS, psoriatic, reactive,

Question 6

2 Rfs of Osteoarthritis?

Answer 6

Obesity, industry

Question 7

Mx of OA?

Answer 7

Physio, lifestyle, NSAIDs, arthroplasty

Question 8

Are the joints in RA usually affected symmetrically? Other features of the joints?

Answer 8

Yes

Hot, swollen, pain, stiff worst in morning, deformity ….

Question 9

2 Antibody blood tests for RA?

Answer 9

RF

Anti cyclic citrullinated peptide

Question 10

Mx of RA ?

1st line?

Answer 10

nsaids, corticosteroids, DMARDS, biologics

DMARD + short term steroids ->titrate down
Steroids work rapid, and takes a time for DMARDs to kick in

Question 11

3 associations with psoriatic arthritis

Answer 11

(Seronegative inflammatory)

HLA-B27, psoriasis, enteropathic arthropathy (IBD)

Question 12

Which arthritis does psoriatic mimic? How to differentiate ?

Answer 12

RA (often red hot joints)

RF negative - Anti-CCP negative
usually asymmetric
Skin and nail beds often affected

Question 13

1st line for psoriatic A ?

Answer 13

NSAIDS (before DMARDs)

Question 14

What is HLA-B27 ?
Associations?
Postive association?
Commonly from which countires?

Answer 14

Major histocompatibility complex antigen which presents antigen peptides from both self and non-self.

anklylosing spondylitis, psoriasis, IBD and reactive arthritis. (seronegatives)

provides resistance to HIV infection.

More common in Northern Europe

Question 15

Usual cause of joint infections?> Rf?

Answer 15

Bacteial
StaphA, strep, gonorrhoea

joint replacement

Question 16

Ix for infected joints?

Answer 16

arthrocentesis, aspiration with staining and culture, inflammatory markers

Question 17

Mx for infected joint ? Which is allergic to usual drug ?

Answer 17

Washout and Abx

Usually favours Fluclox (clindamycin if allergic) unless there are factors suggestive of atypical organisms: age, UTI, frail, recent surgery, MRSA, IVDU

Question 18

What is reactive arthritis also called?

Cause?

Answer 18

Reiters disease
Cross-reactive seronegative illness based on infection in another part of the body

Usually STI/enteric infection: food poisoning, gastroenteritis, chlamydia, Yersinia, salmonella.

Question 19

Reactive Sx mnemonic?

Answer 19

Can’t see (uveitis), can’t pee (urethritis/cervicitis), can’t climb a tree (arthritis).

Question 20

Mx of reactive Arthritis?

Answer 20

Treat underlying infection, NSAIDs then steroids and DMARDs for symptoms.

Question 21

DDx of joint pain in kids

Answer 21

JIA+Still’s, 
Osgood-Schlatter, 
Perthe’s,
ALL,
Hip dysplasia,
Transient synovitis,
Growing pains,

Question 22

What is JIA?
Sx?
Mx?

Answer 22

Non-infection, autoimmune inflammatory joint disease lasting 6/52 in children 16 or below.

Largely RF –ve.

Symptoms: lethargy, limping, reduced appetite, flu like illness with swelling of the joint. Pain. Deformity. Uveitis.

4 or fewer is oligo. More is poly.

Refer to specialists. Treat with PT and other usual rheum Mx.

Question 23

What is firbromyalgia? Sx?
Associations?
diagnosis?

Answer 23

Probably a psychological problem akin to functional illness and conversion disorders.
Occurs most commonly in women world over.
Symptoms include: heightened response to pain (both muscular and enteric), weakness, spasms, insomnia, tiredness, paraesthesiae

anxiety, PTSD, personality disorder and depression

On an axis/collective with similar disorders such as restless leg syndrome, complex regional pain syndrome, non-coeliac gluten sensitivity, CFS and IBS.

Diagnosis of exclusion

Question 24

Mx of fibromyalgia ?

Answer 24

As pain is psychogenic, do not use opioids.

GABAs are also discouraged due to addictive potential and poor benefit for majority. Best evidence is currently for duloxetine and psychotherapy.

TCAs also effective.
Patient lobby a bit ‘unusual;’.

Medically unexplained symptoms is a poor term/misnomer.

These patients are ‘heartsinks’. The disease needs to be explained to them, also that best results come from CBT and exercise NOT medication.