14. Arthritis Flashcards

1
Q

What is Arthritis?

A

Defined as “inflammation of a joint”, though often “arthritis” describes a disease or group of diseases associated with single or multi joint inflammation.

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2
Q

A 25 year old female presents to A&E with a 2 day history of pain in right knee. She is an intravenous drug user, with no other significant past medical history.
On examination: Red, hot and swollen right knee with a reduced range of movement. The patient is febrile (38.5 ͦ C).
Blood tests have been sent and the patient is stable.

What is the next most appropriate course of action?
A. Request review by orthopaedic surgeon
B. MRI knee
C. X-ray of the knee
D. Start broad-spectrum IV antibiotics
E. Aspirate the joint effusion

A

E. Aspirate the joint effusion

Important to aspirate the joint before giving antibiotics in septic arthritis if patient stable to improve ability to grow and thus detect causative pathogen.
Ortho r/v should occur prior to aspiration in a patient with a prosthetic joint, as arthrocentesis should not occur outside of sterile environment.
MRI may show associated osteomyelitis, but not appropriate at this stage.

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3
Q

Joint aspirate colours and meaning

A

Green/yellow pus – white blood cells (predominantly neutrophils and will contain causative bacteria)

Sterile - Reactive Arthritis

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4
Q

Septic arthritis Definition, Aetiology and RF

A

Definition: Infection of one or more joints caused by pathogenic bacteria.

Aetiology:
Direct bacterial inoculation
Haematogenous spread
- Staphylococcus aureus (60%) - Neisseria gonorrhoea (in young sexually active)

Risk factors:

  • Pre-existing joint disease (e.g. RA)
  • Immunosuppression (e.g. DM, iatrogenic)
  • Prosthetic joints
  • IVDU
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5
Q

Symptoms & signs of Septic arthritis

A
  • Acutely inflamed tender, swollen joint
  • ↓Range of movement
  • Systemically unwell (e.g. fever)
  • Knee most commonly affected

History usually <2 weeks duration.

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6
Q

Septic arthritis Investigations

A

Urgent joint aspiration:

  • Gram stain & culture
  • White blood cell count

Bloods:
- ESR/CRP, WCC, Blood cultures

Imaging to identify underlying pathology (e.g. osteomyelitis, chondrocalcinosis)
- X-ray, MRI

Ortho to do aspiration in theatre for joint prothesis.

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7
Q

Septic arthritis Mx

A
IV antibiotics (after aspiration)
Analgesia
Consider joint washout under GA
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8
Q

A 54 year old man presents to A&E with severe pain in his left foot. The pain started suddenly 45 minutes ago. He denies any trauma, and has only recently been discharged following treatment for pneumonia.

On examination: Red, hot and swollen metatarsophalangeal joint. His basic observations are normal.
Bloods: ↑WCC, ↑CRP, uric acid normal
Joint aspiration: Needle-shaped negatively birefringent crystals

What is the most likely diagnosis?

  • Gout
  • Pseudogout
  • Septic arthritis
  • Reactive arthritis
  • Osteomyelitis
A

Gout
“Worst pain I’ve ever had doctor”
Most likely to be gout, given the severity & rapid-onset of the pain, and the joint involvement pattern (MTP). Dehydration often predisposes to gout – in this case the recent pneumonia likely contributed to this.

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9
Q

Gout Definition, Aetiology, RF

A

Definition: Acute monoarthropathy with severe joint inflammation, secondary to deposition of monosodium urate crystals.

Aetiology:
↑Uric acid (Purine metabolite)
- Under excretion
- Over-production

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10
Q

Gout Risk factors:

A

Male gender

  • High cell turnover state (e.g. tumour lysis syndrome, lymphoma, psoriasis) = high endogenous purine metabolism
  • Drugs (e.g. diuretics, aspirin, cytotoxics)
  • Alcohol excess
  • Purine rich diet (e.g. meat, seafood)
  • Renal impairment (decreased excretion)
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11
Q

Gout Symptoms

A

Symptoms:
- Rapid-onset severe pain – “worst pain ever”
↓Range of movement
- Most commonly affects joints in feet
- First metatarsophalangeal joint (podagra)

Symptoms:
- Acutely – swollen joint

Long term:

  • Tophi can deposit over extensor joint surfaces (particularly elbows and knees) and may be evident in helix of ears.
  • Uric acid stones can cause renal tract obstruction & interstitial nephritis.
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12
Q

Give examples of radiodense (opaque), intermediate lucency and radiolucent stones

A
  • Radiodense (radiopaque) stones: Calcium Oxalate & Struvite
  • Intermediate lucency: Cystine
  • Radiolucent stones: Uric Acid
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13
Q

Gout Investigations:

A

Blood:
- Serum uric acid (can be normal in acute attack, can be falsely low or normal during); NB: can also be normal or low serum acid

Synovial fluid:

  • Polarised light microscopy
  • Negatively birefringent needle-shaped crystals

X-ray:

  • Early – soft tissue swelling and joint effusion
  • Late – juxta-articular ‘punched-out’ erosions (also called rat-bite erosions)
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14
Q

Gout Management

A
  • Acute: NSAIDs/colchicine

- Chronic: Conservative & allopurinol

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15
Q

Pseudogout definition, EF and Symptom/Signs

A
  • Definition: Inflammation of a joint, secondary to deposition of calcium pyrophosphate crystals
- Risk factors:
Elderly
Hyperparathyroidism 
Hemochromatosis
Osteoarthritis
  • Symptoms & signs:
    Very similar to gout
    Commonly wrist or knee
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16
Q

Pseudogout Invx and Mx

A
Synovial fluid (Polarized light microscopy)
- Positively birefringent rhomboid-shaped crystals

X-ray:
- Chondrocalcinosis (e.g. ca deposition in knee cartilage)

Mx: same as gout

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17
Q

DDx Septic Arthritis, Gout and Pseudogout

A

Septic arthritis

  • Bacterial infection
  • White cells and bacterial growth

Gout

  • Monosodium urate
  • NeGative birefringence

Pseudogout
- Calcium pyrophosphate
Positive birefringence

Joint aspiration is essential in the assessment of an acutely inflamed joint.

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18
Q

A 21 year old man presents with a 3 week history of a painful, hot, swollen right knee. He denies trauma or fever. He also complains of pain in his left heel. He was treated for a chlamydia infection 6 weeks ago.

What is the most likely diagnosis?

A. Gout
B. Pseudogout
C. Septic arthritis 
D. Reactive arthritis
E. Rheumatoid arthritis
A

D. Reactive arthritis

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19
Q

Reactive arthritis definition, aetiology, RF

A

Definition:
- A sterile arthritis (one of HLA-B27 associated seronegative spondyloarthropathies), typically affecting the lower limb ~1-4 weeks after urethritis or dysentery.

Aetiology:
- Post-infection joint inflammation
(Chlamydia,Salmonella,Campylobacter,Shigella, Yersinia)

Risk factors:

  • Male gender (9:1) for chlamydia-induced reactive arthritis
  • HLA-B27 genotype (30-50%)
  • Preceding infection
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20
Q

Symptoms of Reactive Arthritis

A
  • Asymmetrical oligoarthritis
    (Worse in morning)
  • Knee most commonly affected

Around 25% of patients have recurrent episodes whilst 10% of patients develop chronic disease

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21
Q

Reactive arthritis Signs

A
  • Enthesitis (e.g. Achilles’ tendonitis)
  • Keratoderma blenorrhagica (Brown raised plaques on soles and palms)
  • Mouth ulcers
  • Conjunctivitis
  • Circinate balanitis (Painless and plaque-like lesion on the shaft or glans of the penis)
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22
Q

What syndrome is RA associated with?

A

Reiter’s syndrome - ‘Can’t see, pee or climb a tree’

  • Arthritis
  • Urethritis
  • Conjunctivitis
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23
Q

A 56 year old woman presents with pain and stiffness of her hands. This pain is particularly bad at the end of the day. She has occasionally dropped things, and thinks her grip has become worse. She is taking regular over the counter analgesia. Heberden’s (Distal interphalangeal joints) and Bouchard’s nodes (proximal interphalangeal joints).

What is the most likely
diagnosis?

Rheumatoid arthritis
Osteoarthritis
Reactive arthritis
Psoriatic arthritis
Systemic sclerosis
A

Osteoarthritis

History of pain and stiffness in hands at the end of the day is classic for OA.

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24
Q

A 67 year old woman presents with pain, swelling and stiffness of her left knee. This pain is particularly bad after walking the dog.
On examination there is swelling of the left knee and a reduced range of movement. She has an antalgic gait.

What is the most likely
diagnosis?

Rheumatoid arthritis
Osteoarthritis
Reactive arthritis
Psoriatic arthritis
Systemic sclerosis
A

Osteoarthritis

Antalgic gait develops as a way to avoid pain while walking (A shortened stance phase in painful limb)
Image is a weight bearing AP plain radiograph of knees. This shows a right-sided total knee replacement and features of osteoarthritis in the left knee.
These can be remembered as LOSS:
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

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25
Q

Osteoarthritis Definition and Aetiology and joint involvement

A

Definition: Degradation of cartilage and the underlying bone, leading to inflammation and osteophyte formation.

Aetiology:
Mechanical stress

Joint involvement:

  • Small: DIPs, PIPs, thumb CMC
  • Large: knees, hips
26
Q

OA Risk factors

A
Age > 50 
Female gender
Obesity
Physical/manual occupation
Family history of OA
27
Q

Osteoarthritis Symptoms:

A
(Gradual in onset)
Pain
Worse with movement, relieved by rest
Worse at end of day
Stiffness
Especially after rest
Reduced range of movement
28
Q

OA Signs

A

Bouchard’s (PIP) & Heberden’s (DIP) nodes. Thumb squaring ( 1st CMC).
Fixed flexion deformity
Crepitus
Antalgic gait

29
Q

Investigations for OA

A
X-Ray:
Loss of joint space
Osteophytes
Subchondral sclerosis 
Subchondral cysts
30
Q

Mx for OA

A

MDT approach (physio strengthening exercises, weight loss, supports/braces, insoles etc)
Analgesia
NSAIDs
Joint injection
Joint replacement - Most effective treatment for pain relief in OA

31
Q

A 55 year old woman presents with painful and swollen joints in her hands. Her hands are stiff for over an hour after waking every morning. She is taking regular over the counter analgesia.

On examination:
Boutonnieres and Swan Neck

What test is the most specific for
the likely diagnosis?

Erythrocyte sedimentation rate
C-reactive protein 
Rheumatoid factor
Anti-cyclic citrullinated peptide 
Anti-nuclear antibody

Systemic sclerosis

A

Anti-cyclic citrullinated peptide

Rheumatoid hands
Anti-CCP is most specific test for RA. RF is a useful test in RA, though is less specific than anti-CCP. ANA is commonly associated with systemic lupus erythematosus. ESR and CRP are general markers of inflammation.

32
Q

Definition of RhA, aetiology and joint involvement

A

Chronic systemic inflammatory disease characterised by a symmetrical, deforming, peripheral polyarthritis.

Aetiology:
Autoimmune joint destruction

Joint involvement:
MCPs, PIPs
No DIP joint involvement

33
Q

Epidemiology and Risk factors of RhA

A

1% of population - common
HLA-DR4 = increased disease severity

Age 50-60 years
Female gender (>2:1)
Smokers
Family history of RA (HLA-DR4/DR1 linked)

34
Q

Rheumatoid arthritis Symptoms

A

(Duration >6 weeks)
- Bilateral and symmetrical joint pain (MCPs, PIPs, wrist, MTP)

Stiffness worse in the morning lasting >1 hour (inflam) relieved by use

Movement and grip likely to be restricted due to pain, swelling and stiffness.

35
Q

Articular Signs of RhA

A

Early – Joint inflammation (Tender swollen joints)

  • Positive ‘squeeze test’
  • MCPs, PIPs, wrist, MTPs

Late – Joint damage & deformity

  • Swan-neck: rupture of lateral slips → PIPJ hyper-extension
  • Boutonnière: rupture of central slip of extensor expansion → PIPJ prolapse through “button-hole” created by the two lateral slips.
  • Z-thumb
  • Ulnar deviation of fingers at MCPs
36
Q

Extra-articular Signs of RhA (Most important)

A
  • Rheumatoid nodules: Usually subcutaneous lumps, particularly over bony prominences, though can occur in the lining of internal organs (classically the lungs)
  • Scleritis/episcleritis
  • Anaemia
  • Amyloidosis
37
Q

Extra-articular Signs of RhA (All)

A

General: Malaise, lethargy, low grade fever, weight loss
Cardiovascular: Increased of cardiovascular disease & pericarditis/pericardial effusion
Respiratory: Nodules, pleural effusion, pulmonary fibrosis, pneumoconiosis (Caplan’s syndrome)
Renal: Amyloidosis
Neurological: Peripheral neuropathy, carpal tunnel syndrome, mononeuritis multiplex, atlanto-axial subluxation
Opthalmological: Scleritis, episcleritis, keratoconjunctivitis sicca
Haematological: Anaemia (multifactorial – Anaemia of chronic disease, iron-deficiency anaemia secondary to NSAID-induced gastritis/ulcer, aplastic anaemia secondary to DMARD use, methotrexate-induced folate deficiency, pernicious anaemia)

38
Q

What is Felty’s syndrome?

A

↓WCC + splenomegaly + RA

39
Q

Rheumatoid arthritis investigations

A

Blood:

  • ↑CRP & ESR in ‘active’ disease
  • Rheumatoid factor (circulating IgM specific for self IgG Fc): Positive in ~70%, High titres are associated with disease severity and extra-articular manifestations
  • Anti-cyclic citrullinated peptide antibodies (Anti-CCP) - More specific marker for RA

Imaging:

  • X-ray
  • Ultrasound and MRI can identify synovitis more accurately
40
Q

Management for RhA

A

MDT approach
Medical therapy includes NSAIDs, analgesia, DMARDs (methotrexate, sulfasalzine & hydroxychloroquine), corticosteroid for acute flares and biologics (Anti-TNF agents – Infliximab, etanercept and Anti-CD20 - Rituximab)

41
Q

The American College of Rheumatology criteria can be used to diagnose what disease and what does it use?

A

The American College of Rheumatology criteria can be used to diagnose RA. This criteria uses pattern of joint involvement, serology, biochemistry and symptom duration to establish diagnosis.

42
Q

Amyloidosis Definition and 3 types

A

Definition: A group of disorders characterised by deposition of protein in an abnormal fibrillar form, resistant to degradation

AL Amyloid (primary)
AA Amyloid (secondary)
Familial Amyloidosis (AD mutation in transthyretin, transport protein produced by liver)
43
Q

AL Amyloid Aetiology, RF

A

Aetiology
- Proliferation of plasma cell clone → monoclonal immunoglobulins → fibrillar protein deposition

Risk factors
•MGUS (pre-MM state; paraprotein in serum but no myeloma)
•Multiple myeloma
•Lymphoma

44
Q

AA amyloid Aetiology, RF

A

Aetiology
- Chronic inflammation → chronically elevated serum amyloid A (acute phase protein) → fibrillar protein deposition

Risk factors

  • Rheumatoid arthritis
  • Inflammatory bowel disease
  • Chronic infection: TB, bronchiectasis, osteomyelitis

Inflammatory polyarthropathies (RhA, AS, Psoriatic, Juvenile arthritis) account for 60% of AA amyloid cases.

45
Q
AL Amyloid (primary) vs
AA Amyloid (secondary) - symptoms and joint involvement
A

Symptoms and signs will be dependant of organ involvement. Often non-specific (fatigue, weight loss etc). Large amount of crossover in presentation between AA and AL. Almost any organ can be affected.

AL Amyloid (primary):

  • Restrictive cardiomyopathy
  • Peripheral neuropathy

AA Amyloid (secondary)

  • Nephrotic syndrome
  • Hepatomegaly
  • Splenomegaly
46
Q

Invx findings for Amyloidosis

A

Histological diagnosis from biopsy of affected tissue

Positive Congo-red staining with red-green birefringence under polarised light microscopy.

47
Q

Amyloidosis Key hints for Year 3 SBAs

A
  • Many years history of paraproteinaemia or chronic inflammatory disease
  • Presents with non-specific symptoms or nephrotic syndrome
  • Periorbital purpura
  • Macroglossia
48
Q

A 60 year old woman presents with painful and swollen joints in her hands. Her hands are stiff in the mornings and after periods of rest. The stiffness eases with activity.

On examination: Asymmetrical oligoarthropathy, DIP involvement, nail pitting + onycholysis

What is the most likely diagnosis?

Rheumatoid arthritis
Osteoarthritis
Reactive arthritis
Psoriatic arthritis
Systemic sclerosis
A

Psoriatic arthritis

Around 10-20% percent of patients with skin lesions develop an arthropathy. Arthritis can present before skin changes.

49
Q

Spondyloarthritides Definition

A

Group of inflammatory arthritides affecting the spine and peripheral joints without production of rheumatoid factor and associated with the HLA-B27 allele. Seronegative (RF -ve)

50
Q

4 types of Spondyloarthritides

A

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthropathy

51
Q

Clinical features of Spondyloarthritides

A
  • ‘Axial arthritis’ – spine & sacroiliac joint involvement
  • Enthesitis (Inflammation of the site of insertion of tendon or ligament into bone) – Achilles tendonitis, plantar fasciitis, costochondritis
  • Dactylitis (Inflammation of an entire digit due to soft tissue oedema, and tenosynovial and joint inflammation)
52
Q

Extra-articular features of Spondyloarthritides

A

Extra-articular:

  • Anterior uveitis (iritis)
  • Psoriaform rashes
  • Oral ulcers
  • Aortic regurgitation
  • Inflammatory bowel disease
53
Q

5 Types of Psoriatic arthritis, in order of prevalence

A

Variable presentation of joint involvement, nail changes in 80%

  1. Symmetrical polyarthritis (RhA like)
  2. Asymmetrical oligoarthritis
    (typically hands and feet)
  3. DIP predominant (high incidence of nail changes)
  4. Spondylitis (Spine and sacroiliac involvment)
  5. Arthritis multilans (Severe deformity, telescoping fingers)
54
Q

Invx and Mx of Psoriatic arthritis

A

X-Ray: Pencil-in-cup deformity

Mx: Similiar to RhA

55
Q

A 29 year old man presents to the GP with lower back pain and stiffness for the last 3 months. His symptoms are worse in the morning and improve with exercise. He also complains of a painful Achilles tendon when walking. You note that he last attended the practice 1 month ago with a red eye.

What is the most likely diagnosis?

Spinal stenosis
Multiple myeloma
Ankylosing spondylitis
Reactive arthritis
Polymyalgia rheumatica
A

Ankylosing spondylitis

Most likely diagnosis is ankylosing spondylitis – Inflammatory sounding back pain (worse in morning eases on exercise) + Red eye = iritis, Achilles tendonitis = enthesitis
Spinal stenosis – Classically causes neurogenic claudication (Pain and weakness of calves and thighs when walking), may also have numbness or parasthesia
Multiple myeloma - Common cause of lower back pain in ELDERLY. Features are remembered as CRAB: Hypercalcaemia, Renal injury, Anaemia, Bone pain.

56
Q

Ankylosing spondylitis Definition and Risk factors

A

Chronic progressive inflammatory arthropathy of the spine and sacroiliac joints

Risk factors:
Male gender (2.5:1)
Age <30 years
Family history of ankylosing spondylitis 
HLA-B27 positivity (80%)
57
Q

AS Symptoms

A
Back pain
Midline
Worse in morning
Improvement with exercise
Insidious onset (>3 months duration)
58
Q

AS Signs

A

Sacroiliac tenderness
Progressive loss of spinal movement
- Schober’s test: two points are marked on the patient’s back (10 cm above and 5 cm below the posterior superior iliac spine). The distance between the two points should increase by more than 5 cm when the patient bends as far forward as possible. If the increase is smaller than 5cm, then this demonstrates a restriction in pumbar flexion and Schober’s test is positive

59
Q

AS Invx

A

Pelvic x-ray:

  • Sacroiliitis (Radiographically apparent sacroiliitis may take many years to develop; normal pelvic x-ray =/= exclude Dx)
  • Vertebral body squaring
  • Syndesmophytes (Ossification of outer fibers of annulus fibrosus)
  • ‘Bamboo spine’ (Rare late sign)
60
Q

AS Mx

A

Intense exercise regimens, NSAIDs, TNF alpha blockers.