Arthritides

Question 1

Septic arthritis summary card

Answer 1

Direct bacteria inoculation or haematogenous spread in joint caused by Staph aureus > 30yo and Neisseria gonorrohoea < 30yo
= RFs: pre-existing joint disesae, IVDU, alcoholism, immunosuppression, prosthetic joints
= acutely inflammed tender, swollen joint, decreased range of movement, systemically unwell (fever), knee most commonly affected
= urgent joint aspiration (green/yellow, WBCC), bloods (blood cultures, WCC, ESR/CRP), imaging (X-ray, MRI)
= IV antibiotics after aspiration, analgesia, consider joint washout with GA

Question 2

Gout summary card

Answer 2

Uric acid crystals forming due to alcohol excess, being male, increased cell turnover rate (lymphoma), purine rich diet (meat, seafood), renal impairement, drugs (aspiring, diuretics, cytotoxics)
= rapid onset, severe pain, decreased range of movements, toph deposit over extensor joint surfaces (elbows/knees)
= bloods, x-ray (rat-bite erosions in late, soft tissue swelling and joint effusion in early), synovial fluid has -ve birefringent needle shaped crystals
= acute mx: NSAIDs/colchicine
= chronic mx: conservative + allopurinol

Question 3

Pseudogout summary card

Answer 3

Inflammation secondary to calcium pyrophosphate dihydrate crystals forming
= osteoarthritis, haemochromatosis, hyperPTH, DM, joint damage, elderly women
= similar to gout, affects wrists/kness
= synovial fluid has +ve birefringent rhomboid-shaped crystals, x-ray (chondrocalcinosis, erosions)
= conservative mx, treat underlying cause

Question 4

Reactive arthritis summary card

Answer 4

Sterile arthritis affecting lower limb 3-30 days after urethritis/dysentery
= Chlymadia (urogenital), Salmonella, Campylobacter, Shigella, Yersinia (GI)
= males (9:1), HLA-B27, precedes infection
= asymmetrical oligoarthritis, worse in mornings, knee mainly, mouth ulcers
= enthesitis (achilles), keratoderma blenorrhagia (brown raised plaques on soles and palms), urcinate balanitis (painless and plaque-like lesion on shaft/glans of penis), conjuctivitis

Question 5

Reactive arthritis triad

Answer 5

‘Reiter’s’
Arthritis, urethritis, conjunctivitis
- can’t see, can’t pee, can’t climb a tree

Question 6

Osteoarthritis summary card

Answer 6

Degradation of cartilage and underlying bone resulting in inflammation and osteophyte formation
= FHx of OA, physical/manual occupation, obesity, female, age > 50
= DIPs, PIPs, thumb CMC, knees, hips affected
= gradual onset, pain worse at end of day, worse w/ movement, relieved by resting
= Bouchard’s (PIP), Herberden’s (DIP), fixed flexion deformities, crepitus, thumb squaring, antalgic gait

Question 7

What does an X-ray show if pt has osteoarthritis?

Answer 7

L oss of joint space
O steophytes
S ubchondral sclerosis
S ubchondral cysts

Question 8

Rheumatoid arthritis presentation

Answer 8

Chronic systemic inflammatory disease characterised by symmetrical, deforming, peripheral polyarthritis
= early joint inflammation of MCPs, PIPs, wrist, MTPs (+ve squeeze test)
= late joint damage and deformity; Z-thumb, swan-neck, Boutonniere, ulnar deviation of fingers at MCP
= rheumatoid nodules over bony prominences, amyloidosis, anaemia, scleritis

Question 9

Rheumatoid arthritis ix

Answer 9

Bloods
- increased CRP/ESR (in active disease)
- rheumatoid factor (+ve 70% cases)
- anti-cyclic citrullinated peptide antibodies (anti-CCP; most sensitive)
Imaging
- X-ray
- US + MRI can identify synovitis more accurately

Question 10

Amyloidosis summary card

Answer 10

Disorder characterised by protein deposition in abnormal fibrillar formation, resistant to degradation
- pt hx: years of paraproteinaemiea/chronic inflammatory disease, non-specific sx, nephrotic syndrome

AL amyloid (primary)
= lymphoma, multiple myeloma, NGUS
= restrictive cardiomyopathy, peripheral neuropathy
= proliferation of plasma cell clone; monoclonal immunoglobulins, forming fibrillar protein deposits

AA amyloid (secondary)
= RA, IBD, chronic infection (TB), bronchiectasis, osteomyelitis
= splenomegaly, nephrotic syndrome, hepatomegaly
= chronic inflammation elevated serum amyloid A, forming fibrillar protein deposits

Question 11

What ix are found in amyloidosis?

Answer 11

Histological diagnosis from biospy from affected tissue
=> +ve congo-red staining w/ red-green birefringence under polarised high powered light microscopy

Question 12

Men are PEAR HEADS

Answer 12

P soriatic arthritis
E nteropathic arthritis
A nkylosing spondylitis
R eactive arthritis

H LA B27
E nthesitis
A symmetrical oligoarthritis w/ axial involvement and extraarticular involvement
D actylitis
S eronegative

*more common in men

Question 13

Extraarticular features of spondyloarthritides

Answer 13

IBD, aortic regurgitation, anterior uveitis, psoriaform rashes, oral ulcers

Question 14

Psoriatic arthritis summary card

Answer 14

Asymmetrical oligoarthritis (hands and feet), distal interphalangeal predominant, spondylitis, arthritis mutilans, symmetrical polyarthritis (rhumatoid-like)
= nail changes (80%): pitting, oncholysis, suburyral hyperkeratosis
= x-ray: ‘pencil-in-cup’ deformity

Question 15

Ankylosing spondylitis summary card

Answer 15

Presents with back pain, worse in morning, improves w/ exercise, midline, insidious onset (> 3 months duration)
= progressive loss of spinal movement, sacroiliac tenderness
= RFs: FHx, age < 30, HLA-B27, male
= MRI most sensitive to detect early disease, eplvic x-ray but shows late signs

Question 16

What would pelvic x-ray of AS show?

Answer 16

Syndesmophytes
Vertebral body squaring
Sacroilitis
Bamboo spine; rare late sign

Question 17

What’s Schober’s test?

Answer 17

Decreased distance between two points drawn on back showing restriction in lumbar flexion due to ankylosing spondylitis
= should be > 5 cm

Question 18

A 50yr old woman presents to her GP with pain in her joints. She complains that for the past 2 months she has had a lot of difficulty getting dressed in the morning because her hands are always stiff and painful, but this improves as the day goes on. Which investigation is most specific for the most likely diagnosis?

A X-ray
B Anti-CCP antibodies
C Rheumatoid factor
D MRI
E c-ANCA antibodies

Answer 18

B Anti-CCP antibodies

Question 19

A 50yr old woman presents to her GP with pain in her joints. She complains that for the past 2 months she has had a lot of difficulty getting dressed in the morning because her hands are always stiff and painful, but this improves as the day goes on. What would you be most likely to see on an X-ray of the hand?

A Joint space narrowing and brown tumours
B Juxta-articular osteopenia and osteophytes
C Joint space narrowing and Heberden’s nodes
D Joint space narrowing and subchondral sclerosis
E Joint space narrowing and joint erosions

Answer 19

E Joint space narrowing and joint erosions

Question 20

What would you seen in an x-ray for RA?

Answer 20

Uniform joint space narrowing
Juxta-articular osteopenia
Joint erosions at join margins
Joint deformity and destructions

Question 21

A 28yr old man presents with a 1 month history of lower back pain. When questioned, he mentions it is very difficult for him to get out of bed in the morning, and he struggles to keep his back straight, although this improves over the course of the day. On examination, you note tenderness over the lumbosacral spine and SI joints. Which of the following complications is this man most at risk of?

A Anterior uveitis
B Conjunctivitis
C Aortic aneurysm
D Urethritis
E Eczema

Answer 21

A Anterior uveitis

Question 22

A 32 yr old woman presents to A&E with severe pain in her right knee and an inability to weight bear. An examination of the knee joint reveals a red, tender and swollen knee. Which of the following investigations is most likely to reveal the diagnosis?

A Serum calcium
B Serum urate
C Blood culture
D Joint aspiration
E X-ray

Answer 22

D Joint aspiration

Question 23

A 25yr old man presents to his GP with a 3 day history of pain and stiffness in his right knee and ankle, and pain on passing urine. He has no significant past medical history, however he mentions that he suffered from a “stomach bug” approximately 2 weeks ago. His blood results show:
WCC: 14*109/L (Normal: 4-10)
CRP: 52 (Normal: <5)

What is the most likely diagnosis?
A Henoch-Schonlein purpura
B Rheumatoid arthritis
C Reactive arthritis
D Systemic lupus erythematosus (SLE)
E Microscopic polyangiitis

Answer 23

C Reactive arthritis

Question 24

A 51 yr old obese man presents to A&E with severe pain in his right toe. The pain came on over the course of an hour and he is now unable to weight bear. He is afebrile. The A&E consultant suspects that this man is suffering from gout, and requests a joint aspirate. Which of the following findings on joint aspiration would support the consultant’s diagnosis?

A Needle shaped, negatively birefringent crystals
B Needle shaped, positively birefringent crystals
C Rhomboid shaped, negatively birefringent crystals
D Rhomboid shaped, positively birefringent crystals
E Diamond shaped, negatively birefringent crystals

Answer 24

A Needle shaped, negatively birefringent crystals

Question 25

A 63 year old lawyer presents to her GP with a 3 month history of pain in her right thumb. She mentions that the pain is predominantly at the base of her thumb, and it is so severe that at the end of the day that she can no longer type or write with her right hand. Her observations and PMHx are otherwise unremarkable. Which of the following investigations would help to confirm the diagnosis?

A DEXA scan
B X-ray
C Anti-CCP antibodies
D Rheumatoid factor
E CT scan

Answer 25

B X-ray

Question 26

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

Answer 26

E Aspirate the joint effusion

Question 27

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?
A Gout
B Pseudogout
C Septic arthritis
D Reactive arthritis
E Osteomyelitis

Answer 27

A Gout

Question 28

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

Answer 28

D Reactive arthritis

Question 29

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.

On examination: nodes on DIPs and PIPs of both hands

What is the most likely
diagnosis?

A Rheumatoid arthritis
B Osteoarthritis
C Reactive arthritis
D Psoriatic arthritis
E Systemic sclerosis

Answer 29

B Osteoarthritis

DIP - Heberden’s
PIP - Bouchards

Question 30

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?

A Rheumatoid arthritis
B Osteoarthritis
C Reactive arthritis
D Psoriatic arthritis
E Systemic sclerosis

Answer 30

B Osteoarthritis

Question 31

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: swan neck deformity of index finger, Boutonniere deformity of middle finger

What test is the most specific for
the likely diagnosis?

A Erythrocyte sedimentation rate
B C-reactive protein
C Rheumatoid factor
D Anti-cyclic citrullinated peptide
E Anti-nuclear antibody

Answer 31

D Anti-cyclic citrullinated peptide

Question 32

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: asymettrical oligoarthropathy, involving DIPs, nail changes present (pitting and oncholysis)

What is the most likely diagnosis?

A Rheumatoid arthritis
B Osteoarthritis
C Reactive arthritis
D Psoriatic arthritis
E Systemic sclerosis

Answer 32

D Psoriatic arthritis

Question 33

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?

A Spinal stenosis
B Multiple myeloma
C Ankylosing spondylitis
D Reactive arthritis
E Polymyalgia rheumatica

Answer 33

C Ankylosing spondylitis