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Year 1 - BRS > 5.6 - Introduction to Rheumatology > Flashcards

5.6 - Introduction to Rheumatology Flashcards

1
Q

What is rheumatology?

A

The medical specialty dealing with diseases of the musculoskeletal system

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2
Q

What is a joint?

A

Where two bones meet

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3
Q

What is a tendon?

A

Cords of strong fibrous collagen tissue attaching muscle to bone

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4
Q

What are ligaments?

A

Flexible fibrous connective tissue which connect two bones

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5
Q

What questions are asked when it comes to the basic clinical approach to MSK history-taking and examination?

A
  • pain? swelling? stiffness? restricted range of movement?
  • speed of onset: acute, subacute, chronic
  • history of prolonged morning/inactivity stiffness (>30 mins)

Pattern of joint involvement:

  • number: 1 = monoarthritis, 2-4 = oligoarthritis, 5+ = polyarthritis
  • size - large (e.g. knee) or small (e.g. finger)
  • symmetrical vs asymmetrical
  • peripheral joints or spine
  • systemic features (fever, weight loss, malaise)
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6
Q

What does arthritis refer to?

A

Diseases of the joints

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7
Q

What are the two major divisions of arthritis?

A
  • degenerative joint disease - osteoarthritis
  • inflammatory joint disease - around 200 subtypes, inflammatory arthritis (main type of rheumatoid arthritis)
  • different presentation and treatments
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8
Q

What is inflammation?

A
  • a physiological response to deal with injury/infection
  • however, excessive/inappropriate inflammatory reactions can damage the host tissues
  • manifests clinically as redness (rubor), pain (dolor), heat (calor), swelling (tumor) and loss of function
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9
Q

What are physiological, cellular and molecular changes associated with inflammation?

A
  • increased blood flow
  • migration of white blood cells (leukocytes) into tissues
  • activation/differentiation of leukocytes
  • cytokine production e.g. TNF-alpha, IL1, IL6, IL17
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10
Q

What are the causes of joint inflammation?

A
  1. infection e.g. septic arthritis, tuberculosis - non-sterile inflammation
  2. crystal arthritis e.g. gout, pseudogout
  3. immune-mediated (autoimmune) e.g. rheumatoid arthritis (main form), psoriatic arthritis, reactive arthritis, systemic lupus erythematosus (SLE)
  • 1+2 = secondary inflammation in response to a noxious insult
  • 3 = primary inflammation
  • 2+3 = sterile inflammation
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11
Q

What causes septic arthritis?

A

Bacterial infection of a joint (usually caused by spread from the blood)

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12
Q

What are the risk factors for septic arthritis?

A
  • immunosuppressed
  • pre-existing joint damage
  • intravenous drug use (IVDU)
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13
Q

Why is septic arthritis a medical emergency?

A

If untreated, it can rapidly destroy a joint

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14
Q

How is septic arthritis presented clinically?

A
  • acute red, hot, painful, swollen joint
  • usually only one joint affected (monoarthritis) - gonococcal septic arthritis is an exception which often affects multiple joints (polyarthritis) and is less likely to cause joint destruction
  • typically fever + patient often systemically unwell
  • consider septic arthritis in any patient with an acute painful, red, hot, swelling of a joint, especially if there is a fever
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15
Q

How is septic arthritis diagnosed?

A

Joint aspiration - send sample for urgent gram stain and culture

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16
Q

What organisms commonly cause septic arthritis?

A
  • Staphylococcus aureus
  • Streptococci
  • Gonococcus
17
Q

How is septic arthritis treated?

A

Surgical washout (lavage) and intravenous antibiotics

18
Q

Crystal arthritis - What is gout caused by?

A
  • syndrome caused by deposition of monosodium urate (MSU aka uric acid) crystals in/around joints –> inflammation
  • high uric acid levels (hyperuricaemia) is a risk factor for gout
19
Q

What are the causes of hyperuricaemia?

A
  • genetic tendency
  • increased intake of purine rich foods that is broken down into urate
  • reduced excretion (kidney failure)
20
Q

What does tissue deposition of monosodium urate (MSU) crystals lead to?

A
  • gouty arthritis
  • tophi (aggregated deposits of MSU in tissue) - often develop around hands, feet, elbows and ears
21
Q

What are the clinical features of gout? (Crystal arthritis)

A
  • abrupt onset, acute
  • usually monoarthritis
  • big toe 1st metatarsophalangeal joint (MTPJ) most commonly affected (podagra)
  • can also affect other joints - most frequently in foot, ankle, knee, wrist, finger and elbow
  • tophi may develop around hands, feet, elbows and ears
22
Q

What do blood test results show for gout? (Crystal arthritis)

A
  • increased C-reactive protein (CRP) - marker of inflammation
  • increased serum urate
23
Q

What do X-rays show for gout? (Crystal arthritis)

A
  • usually normal initially
  • if recurrent/long-standing/chronic gout, juxta-articular erosions can develop
  • joint aspiration and synovial fluid analysis for definitive diagnosis
24
Q

Crystal arthritis - What is pseudogout caused by?

A
  • syndrome caused by deposition of calcium pyrophosphate dihydrate (CPPD) crystals –> inflammation

Risk factors:

  • background osteoarthritis
  • elderly patients
  • intercurrent infection
25
Q

How is crystal arthritis diagnosed usually?

A
  • joint aspiration and synovial fluid analysis - key investigation for any acute monoarthritis
  • needle inserted into joint and fluid aspirated, and examined under microscope using polarised light
  • sample sent to lab for microbiology (gram stain, culture, sensitivities) and polarising light microscopy to detect crystals
  • gout - needle shaped urate crystals with negative birefringence
  • pseudogout - rhomboid/brick-shaped CPPD crystals with positive birefringence
26
Q

How do we treat acute and chronic gout?

A
  • acute attack - reduce inflammation - non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, colchicine, steroids
  • chronic - reduce uric acid levels - lifestyle (avoid purine-rich food, beer) and pharmacological (allopurinol, febuxostat - xanthine oxidase inhibitors)
27
Q

What is rheumatoid arthritis?

A
  • chronic autoimmune disease characterised by pain, stiffness and symmetrical synovitis (inflammation of synovial membrane) of synovial (diarthrodial) joints
  • immune-mediated inflammatory joint disease - most common form is RA
28
Q

What is the primary site of pathology of rheumatoid arthritis?

A

In the synovium which includes:

  • synovial joints - e.g. proximal inter-phalangeal (PIP) joint synovitis
  • tenosynovium surrounding tendons - e.g. extensor tenosynovitis - patient cannot fully extend little and ring fingers
  • bursa - fluid filled sacs that provide lubrication for easy movement e.g. olecranon bursitis
29
Q

What are the key features of rheumatoid arthritis?

A
  • chronic arthritis
  • polyarthritis
  • symmetrical
  • early morning stiffness in and around joints (around 30 mins)
  • may lead to joint damage and destruction - ‘joint erosions’ on radiographs
  • extra-articular disease can occur e.g. rheumatoid nodules, other organs (vasculitis, episcleritis)
  • rheumatoid ‘factor’ may be detected in blood - autoantibody against IgG
  • ulnar deviation
30
Q

What is the pattern of joint involvement in rheumatoid arthritis?

A
  • symmetrical
  • affects multiple joints (polyarthritis)
  • affects small and large joints but particularly hands, wrists and feet
31
Q

What joints does rheumatoid arthritis most commonly affect?

A
  • metacarpophalangeal joints (MCP)
  • proximal interphalangeal joints (PIP)
  • wrists
  • knees
  • ankles
  • metatarsophalangeal joints (MTP)
  • tends to spare DIP joints in contrast to osteoarthritis
32
Q

What is osteoarthritis?

A
  • degenerative joint disease
  • pathological changes: cartilage worn out, bony remodelling
  • gradual onset, slowly progressive disorder
33
Q

What is the epidemiology of osteoarthritis?

A
  • more prevalent as age increases
  • previous joint trauma (e.g. footballer’s knees)
  • jobs involving heavy manual labour
34
Q

What are the symptoms and signs of osteoarthritis?

A
  • joint pain - worse with activity, better with rest
  • joint crepitus - creaking, cracking grinding sound on moving affected joint
  • joint enlargement e.g. Heberden’s nodes
  • limitation of range of motion
35
Q

Which joints are usually affected in osteoarthritis?

A
  • joints of the hand - distal interphalangeal joints (DIP), proximal interphalangeal joints (PIP), first carpometacarpal joint (CMC)
  • spine
  • weight-bearing joints of lower limbs especially knees and hips - first metatarsophalangeal joint (MTP)
36
Q

What are radiographic features of osteoarthritis?

A
  • joint space narrowing - indicates loss of articular cartilage leading to ‘bone on bone’ contact
  • subchondral bony sclerosis (increased whiteness on X-ray)
  • osteophytes (bone spurs/tiny outgrowths)
  • subchondral cysts
37
Q

What are radiographic features of rheumatoid arthritis?

A
  • joint space narrowing - secondary damage due to synovitis
  • osteopenia - juxta-articular osteopenia is common early radiographic sign in inflammatory arthritis of any cause
  • bony erosions - occur initially at margins of joint where the synovium is in direct contact with bone
38
Q

RA vs OA

A
  • age of onset: 30-50 vs >50
  • speed of onset: rapid vs slow
  • joint pattern: bilateral, symmetric vs asymmetric
  • movement: often better vs often worse
  • AM stiffness: >1h vs uncommon
  • hand joints: PIP, MCP vs DIP, thumb CMC
  • wrist, ankle, elbow: common vs uncommon
  • systemic symptoms: common vs not present
  • joint swelling: effusion, red, warm vs bony
  • ESR/CRP: elevated vs normal
  • serology: positive (RF) vs negative

Year 1 - BRS (73 decks)

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