Arthritides/Rheum Flashcards
1
Q
What is septic arthritis?
A
Infection of one or more joints caused by pathogenic bacteria
2
Q
What is the aetiology of septic arthritis?
A
Caused by current infection (haematogenous spread or direct inoculation)
- Staph aureus (>30yrs)
- Group B strep (<3 months)
- Neisseria gonorrhoea (<30yrs)
History usually <2 weeks duration
3
Q
What are the risk factors of septic arthritis?
A
Pre-existing joint disease (RA)
Immunosuppression (DM, iatrogenic)
Prosthetic joints
IVDU
4
Q
What are the signs and symptoms of septic arthritis?
A
Acutely inflamed tender swollen joint
Decreased range of motion
Systemically unwell
Knee most commonly affected
5
Q
What are the investigations for septic arthritis?
A
Urgent joint aspiration
- Gram stain and culture
- WCC
Bloods
- ESR/CRP, WCC, cultures
Imaging
- XR, MRI
6
Q
What is the management for septic arthritis?
A
IV ABx after aspiration
Analgesia
Consider joint washout under GA
7
Q
What is gout?
A
Acute monoarthropathy with severe joint inflammation, secondary to deposition of monosodium urate crystals
8
Q
What is the aetiology of gout?
A
Monosodium urate- hyperuricaemia Increased intake (high purine diet, alcohol) Increased production (malignancy- tumour lysis) Decreased excretion (diuretics)
9
Q
What are the risk factors of gout?
A
Male Obesity High cell turnover rate (tumour lysis syndrome, lymphoma, psoriasis) Drugs (diuretics, aspirin, cytotoxics) Alcohol excess Purine rich diet (meat, seafood) Renal impairment
10
Q
What are the symptoms of gout?
A
Rapid-onset severe pain- worst ever
Decreased range of motion
Most commonly affects joints in feet
First metatarsaophalangeal joint (podagra)
11
Q
What are the signs of gout?
A
Acute swollen joint
Tophi over extensor joint surfaces (elbow/knee), ear helix
Can present with uric acid stones:
- renal tract obstruction
- interstitial nephritis
- radiolucent on imaging
12
Q
What are the investigations of gout?
A
Blood
-serum uric acid (may be normal in acute attack)
Synovial fluid
- polarised light microscopy
- negatively birefringent needle-shaped crystals
XR
- soft tissue swelling and joint effusion (early)
- juxta-articular ‘punched-out’ erosions
13
Q
What is the management for gout?
A
Acute: NSAIDs, colchicine
Chronic: Conservative and allopurinol
14
Q
Why should you not give allopurinol in an acute attack of gout?
A
Can prolong/precipitate the attack
15
Q
What is pseudogout?
A
Inflammation of a joint, secondary to deposition of calcium pyrophosphate crystals
16
Q
What are the risk factors for pseudogout?
A
Elderly Female Hyperparathyroidism Haemochromatosis Osteoarthritis Hypomagnesia Wilson’s Acromegaly
17
Q
What are the symptoms and signs of pseudogout?
A
Very similar to gout- but affect more joints (polyarticular)
Commonly large joints (knee/wrist)
18
Q
What are the investigations for pseudogout?
A
Synovial fluid aspirate
XR of joints
Bloods- neutrophilia, raised CRP
19
Q
What is reactive arthritis?
A
A STERILE seronegativejoint inflammation that develops in response toan extra-articularinfection
20
Q
What is the aetiology of reactive arthritis?- state some common causative organisms
A
Post-infectious joint inflammation- typically affecting the lower limb 1-4 weeks after UTI/diarrhoea
- Chlamydia
- Salmonella
- Campylobacter
- Shigella
- Yersinia
- Gonorrhoea
21
Q
What are the risk factors for reactive arthritis?
A
Male 9:1
HLA-B27 serotype
Preceding gastrointestinal/genitourinary infections-
- Chlamydia
- Salmonella
- Shigella
- Yersinia
- Campylobacter.
22
Q
What are the symptoms of reactive arthritis?
A
ASYMMETRICAL OLIGOARTHRITIS
Worse in the morning
Knee most commonly affected (lower>upper affected)
23
Q
What are the signs of reactive arthritis?
A
Enthesitis (Achille's tendonitis) Conjunctivitis Mouth ulcers Circinate balanitis (ring shaped dermatitis of glans penis) Keratoderma blenorragica
24
Q
What is Reiter’s syndrome?
A
Triad of:
- Arthritis
- Urethritis
- Conjunctivitis
(Can’t see, pee, or climb a tree)
Initialactivation ofimmunesystem bymicrobial antigen –>autoimmunereactionaffectingskin, eyes&joints
25
What are the investigations for reactive arthritis?
- Joint aspiration
- Gram stain, culture & sensitivities
Exclude septic joint, crystal arthropathies- diagnosed by process of elimination:
- e.g. CRP, ESR, ANA, urogenital/stool culture, arthrocentesis
26
What are the risk factors for osteoarthritis?
```
Age >50
Female
Obese
Physical/manual occupation
FHx of OA
```
27
Which joints are affected in osteoarthritis?
```
DIP
PIP
Thumb CMC
Knees
Hips
```
28
What are the symptoms of osteoarthritis?
Pain worse on movement
Worse at the end of the day
Stiff, esp after rest
Reduced range of movement
29
What is rheumatoid arthritis?
Autoimmune condition causing chronic (>6 weeks) inflammation of synovial lining, tendon sheaths & bursa.
Characterised by symmetrical polyarthritis (>4) + extraarticular manifestations
30
What is the cause of rheumatoid arthritis?
Autoimmune destruction of joints
31
What are the risk factors for rheumatoid arthritis?
Smoker
FHx
History of rheumatoid arthritis
HLA-DR4 (often) or HLA-DR1 (sometimes)
32
Which joints are affected in rheumatoid arthritis?
MCPs
PIPs
MTP
No DIP involvement
33
What are the early signs of rheumatoid arthritis?
Joint inflammation
| MCP/PIP/wrist/MTP affected
34
What are the late signs of rheumatoid arthritis?
Swan neck deformity (affects more distal phalanges)
Boutonniere deformity (affects more thumb)
Z thumb
Ulnar deviation of fingers (at MCP)
Radial deviation at wrist
Trigger finger
35
What are the extra-articular signs of rheumatoid arthritis?
INFLAMMATION
- Scleritis/episcleritis
- Pulmonary fibrosis/pleuritis
- Bronchiolitis obliterans
- Tenosynovitis, bursitis
- Pericarditis
SECONDARY
- Anaemia CD
- Lymphadenopathy
- Rheumatoid nodules
SYNDROMES/DISEASES
- Felty's syndrome- RA, neutropenia & splenomegaly
- Amyloidosis
- Sjoren's syndrome
- Carpal tunnel syndrome
36
What are the investigations for rheumatoid arthritis?
BEDSIDE
- bloods- raised CRP and ESR
- anaemia, hypoalbuminaemia
SEROLOGY
- RF Ab (70% patients) = IgM Ab which targets Fc portion of IgG
- anti-CCP Ab = ++ sensitive and specific
IMAGING
- X-ray: soft tissue swelling, osteoporosis
- Ultrasound of the joint- to confirm synovitis
37
What is amyloidosis?
A group of disorders characterised by deposition of amyloid fibrils
38
What are the two types of amyloidosis?
```
AL amyloidosis (primary)
AA amyloidosis (secondary)
```
39
What is the aetiology of AL amyloidosis?
Proliferation of plasma cell clones
Monoclonal immunoglobulin formation
Fibrillar protein deposition
40
What are the risk factors for AL amyloidosis?
Monoclonal gammopathy of undetermined significance (MGUS)
Multiple myeloma
Lymphoma
41
What is MGUS?
A pre-multiple myeloma state, with raised paraprotein but no myeloma
42
What are the complications of AL amyloidosis?
Restrictive cardiomyopathy
Peripheral neuropathy
Depends on the organ affected, lots of overlap with AA amyloidosis
43
What is the aetiology of AA amyloidosis?
Chronic inflammation
Elevation of serum amyloid A
Fibrillar protein deposision
44
What are the risk factors for AA amyloidosis?
Rheumatoid arthritis
IBD
Chronic infection (TB, bronchiectasis, osteomyelitis)
45
What are the complications of AA amyloidosis?
Nephrotic syndrome
Splenomegaly
Hepatomegaly
Depends on the organ affected, lots of overlap with AA amyloidosis
46
What is the investigation for amyloidosis?
Histological biopsy of affected organ
47
What are spondyloarthritides?
Group of inflammatory arthritides affecting the spine and peripheral joints without production of RhF, and associated with the HLA-B27 allele
48
What are some common immunological features of the spondyloarthritides?
RhF negative
| HLA B27 association
49
What are some common clinical features of the spondyloarthritides?
```
Axial arthritis (spine/sacroiliac involvement)
Enthesitis (Achilles tendonitis/plantar fasciitis/costochondritis)
Dactylitis
Anterior uveitis
Psoriaform rashes
Oral ulcers
Aortic regurgitation
IBD
```
50
What are the 4 spondyloarthritides?
Ankylosing spondylitis
Psoriatic arthritis
Reactivie arthritis
Enteropathic arthropathy
51
What are the 3 joint patterns seen in psoriatic arthritis?
Symmetrical polyarthritis
Asymmetrical pauciarthritis
Spondylitic
DIP predominant
52
What is the characteristic of symmetrical polyarthritis?
Rheumatoid-like
53
What is the characteristic of assymetrical pauciarthritis?
Affects mostly digits and small bones of feet
| oligoarthritis (only a few joints affected)
54
What is the characteristic of DIP predominant?
High incidence of nail changes:
Pitting
Onycholysis
Subungal hyperkeratosis
55
What is the characteristic of spondylitis?
Spine and sacroiliac involvement
56
What is the characteristic of arthritis multilans?
Severe deformity
| Telescoping fingers
57
What are the common nail changes seen in psoriatic arthritis?
Pitting
Onycholysis
Subungal hyperkeratosis
58
What is ankylosing spondylitis?
Chronic progressive inflammatory arthropathy, mainly of the spine and sacroiliac joints (axial skeleton)
59
What are the risk factors for ankylosing spondylitis?
```
Male 2.5:1 (men present earlier)
Age <30yrs (younger = poorer outcome)
VERY STRONG FHx
HLA-B27 +ve
MS, myasthenia, LEMS, MND, PD, dementia
```
60
What are the symptoms of ankylosing spondylitis?
```
Insidious onset >3 months of:
INFLAMMATORY back pain
Midline, sacroiliac joints + axial spine
Worse in the morning
Better with exercise
```
61
What are the signs of ankylosing spondylitis?
Progressive loss of spinal movement
EARLY = pain + stiffness
LATE = spinal fusion, kyphosis/loss of lordosis, neck extension
62
What test can you do to identify ankylosing spondylitis?
Schober's test
Mark two points on the spine
The distance between the two should be >5cm upon leaning forwards
63
What are the investigations for ankylosing spondylitis?
Bloods
- Raised ESR/CRP, ACD, Rh negative
Genetic test
- HLA B27 +ve 90-95%
- XR-
MRI
- Bone marrow oedema (early)
Lung function tests
-impairment from kyphosis
Schober's test
-lumbar motility
Pelvic XR
64
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
```
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.
65
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
```
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.
66
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
```
D. Reactive arthritis
67
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 you find Bouchard's and Heberden's nodes.
What is the most likely diagnosis?
```
A. Rheumatoid arthritis
B. Osteoarthritis
C. Reactive arthritis
D. Psoriatic arthritis
E. Systemic sclerosis
```
B. Osteoarthritis
Osteoarthritic hands – Heberden’s (Distal interphalangeal joints) and Bouchard’s nodes (proximal interphalangeal joints).
History of pain and stiffness in hands at the end of the day is classic for OA.
68
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
```
B. 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
69
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 you note a swan neck deformity and Boutonniere deformity.
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
```
D. Anti-cyclic citrullinated peptide
Rheumatoid hands. Swan neck deformity of index finger. Boutonniere deformity of middle finger.
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.
70
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:you note DIP swelling in the right hand, alongside some onycholysis and pitting.
What is the most likely diagnosis?
```
A. Rheumatoid arthritis
B. Osteoarthritis
C. Reactive arthritis
D. Psoriatic arthritis
E. Systemic sclerosis
```
D. Psoriatic arthritis
Asymmetrical oligoarthropathy, with involvement of the distal interphalangeal joints. Nail changes are present (pitting & onycholysis). Around 10-20% percent of patients with skin lesions develop an arthropathy. Arthritis can present before skin changes.
71
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
```
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.
72
Define osteoarthritis
Asymmetrical degenerative synovial joint disease where cartilage destruction exceeds repair, causing pain & instability
73
epidemiology osteoarthritis
very very common
74
How can osteoarthritis be classified and sub-classfied?
PRIMARY
- further classified into localised (hands/knee/hip/foot only) and generalised (hands + another joint)
SECONDARY
- further damage resulting from pre-existing conditions that have caused altered joint stability and architecture
75
RFs primary osteoarthritis
```
Obesity
age
female
occupation (lots of use of joints)
‘hereditary predisposition’
?Post-menopause
```
76
Which pre-existing conditions can increase risk of developing osteoarthritis?
Inflammatory - RA or septic arthritis
Congenital – DDH
Metabolic – Wilson’s, acromegaly, haemochromatosis
Trauma
77
Briefly outline the pathophysiology of osteoarthritis
Due to imbalance of cartilage matrix synthesis & degradation (increased catabolism and/or reduced formation).
- ↑ matrix metalloproteinase enzymes (break down collagen & proteoglycan)
- Direct damage to chondrocytes & cartilage (mechanical stress)
All this + direct trauma --> cartilage loss --> altered joint structure and stability which exacerbates any mechanical stress --> eventual joint failure.
78
What are the symptoms of osteoarthritis?
```
Morning stiffness (<30 mins)
Joint pain – gradual onset, worse on activity, better with rest.
High-use or weight bearing joints – Hip, knee or DIP, PIP, 1st CMC, wrist
```
SEVERE DISEASE:
- night pain
- instability
- deformity
- loss of function
79
What are the symptoms of osteoarthritis O/E?
Enlargement of the:
- PIP = Bouchard's nodes
- DIP = Heberden's nodes
Reduced range of joint movement
Malalignment- varus/valgus knees
Crepitus- palpable/audible creaking of joints on movement
Effusion (with NO warmth/erythema)
80
How can you divide up the arthritides?
```
DEGENERATIVE
- osteoarthritis
INFLAMMATORY
- rheumatoid arthritis
- Seronegative Spondyloarthropathies
- Crystal Arthropathies
```
INFECTIOUS
- septic arthritis
- osteomyelitis
81
What x-ray findings may be present in OA? (LOSS)
```
Loss of joint space
Osteophytes
Subarticular sclerosis (= increased density of bone along joint line where bones are in contact)
Subchondral cysts (along joint line)
```
(NOTE- severity of symptoms do not correlate with x-ray findings)
82
What investigations would you do for OA?
DO NOT need Ix if the patient is over 45, has no morning stiffness (or <30 mins), typical activity related joint pain.
- X-ray- confirm and assess joint damage
- Joint aspiration- high viscosity, straw coloured aspirate
83
Conservative management of osteoarthritis
- lifestyle - weight loss to reduce stress,
- physiotherapy- build stability & support in joints
- occupational therapy- maximize function & improve accessibility
84
Medical management of osteoarthritis
- stepwise analgesia
- intra-articular steroids (temporary Sx relief)
- joint replacement
85
Describe the stepwise analgesia used in OA management
1. Oral paracetamol +/- topical NSAID / topical Capsaicin
2. Oral NSAID + PPI
3. Opiates – use with caution! - not good for chronic pain (dependence, adaptation)
86
Epidemiology RA
- Females
| - 50-55yrs
87
Symptoms of RA
6+ weeks of:
- Pain, swelling of joints- MCP, PTP, PIP
- Morning joint stiffness lasting >1hour
- Systemic upset – weight loss, fatigue, malaise
(may have pleuritis chest pain in severe RA causing pericarditis)
88
What is Boutonniere's deformity?
Tear in central tendon/slip extensor components of fingers
When patient attempts to straighten the digit, the lateral tendons (flexor digitorum superficialis) pull on distal phalanx which, unsupported by central structures
causes DIP extension, PIP flexion.
89
Which antibody can predict disease development in RA?
anti-CCP antibodies
90
What might you see on X-ray of a patient with RA?
Joint space narrowing
Joint destruction, deformity
Bony erosions at joint margins
Juxta/Periarticular osteopenia
Soft tissue swelling
91
Diagnostic criteria for RA
Joints involved (more & smaller joints score higher)
Serology – Rh factor, anti CCP
Inflammatory markers (ESR, CRP)
Duration of Sx (< or > 6 weeks)
92
State the NICE referral guidelines for suspected RA
Refer any adult with persistent synovitis (even if –ve Rh Factor, anti CCP and inflammatory markers).
Small joints of hands, feet, multiple joints OR Sx >3 months urgent referral
93
How is RA managed?
Induce remission & keep meds at “minimal effective dose” to control disease:
- STEROIDS- at initial pres + to control flare ups
- NSAIDs/COX-2 inhibitors (+PPI)
- DMARD-
- hydroxychloroquine (mild)
- methotrexate + infliximab/rituximab
94
List common types of drug used to induce remission in RA
DMARDS
- Methotrexate - 1st line
- (add leflunomide, sulfasalazine if Rx)
BIOLOGICS
- Anti-TNF (adalimumab, infliximab)
- Anti-CD20 (rituximab)
(add one to methotrexate if still Rx)
95
Methotrexate side effects
```
Mouth ulcers & mucositis
Liver toxicity
Pulmonary fibrosis
Bone marrow suppression and leukopenia
Teratogenic - avoid prior to conception (male & female)
```
96
Sulfasalazine side effects
Temporary male infertility (reduced sperm count)
| Bone marrow suppression
97
Hydroxychloroquine side effects
Nightmares
Reduced visual acuity (macular toxicity)
Liver toxicity
Skin pigmentation
98
anti-TNF side effects
Increased infection risk
| Reactivation of latent TB and chronic Hepatitis B
99
Rituximab side effects
```
Increased infection risk
Night sweats
Thrombocytopenia
Peripheral neuropathy
Liver and lung toxicity
```
100
A 62-year-old female presents to the GP with repeat sinus infections over the past year. On examination, she has mild symmetrical synovitis of the hand and wrist. Laboratory blood work reveals raised ESR, positive Rh factor and anti-CCP antibodies and borderline neutropenia.
What additional finding would help to confirm the likely diagnosis?
```
Rheumatoid nodules
Granular lymphocytes on bone marrow examination
HLA B27+ Genetic testing
Periosteal thickening on X-ray
Splenomegaly on abdominal USS
```
E – splenomegaly on abdominal USS.
This woman is likely experiencing Felty syndrome (a complication of rheumatoid arthritis) characterized by a triad of neutropenia, splenomegaly in addition to the Rh arthritis. It typically occurs in those with a strong family Hx of Rh A and with a personal Hx of 10-15 years of disease. The repeat sinus infections are a manifestation of her neutropenia (poor immune response).
101
List the most common seronegative spondylarthropathies (PEAR)
Psoriatic arthritis
Enterohepatic arthritis
Ankylosing spondylitis
Reactive arthritis
102
Describe the Schober's test
Mark 2 points: 10cm above L5, 5cm below
Patients bends forward
Point-point distance increases <5cm --> AS
103
What would you see in a X-ray of a patient with ankylosing spondylitis?
- Sacroiliitis (early)
- Syndesmophytes
- Bamboo spine (late)
- Vertebral body sparing
104
Management of ankylosing spondylitis
NSAIDs
Steroids during flares – oral, IM or intraarticular
Anti-TNF
Secukinumab – IL17 mAb
Physiotherapty + smoking cessation + bisphosphonates for osteoporosis
-?Surgery
105
Management reactive arthritis
```
Abx until septic arthritis excluded
NSAIDs
Intra-articular steroids
Systemic steroids (if multiple joints)
DMARDs or anti-TNF if recurrent
```
106
Psoriatic arthritis affects how many psoriasis patients?
Affects 10-20% psoriasis patients
| Middle age
107
State some extra-articular manifestations of psoriatic arthritis
```
Psoriasis plaques
Oncholysis & pitting of nails
Dactylitis, Enthesitis
Conjunctivitis, anterior uveitis
Aortitis
Amyloidosis
```
108
Most severe form of psoriatic arthritis
Arthritis mutilans
Characterized by osteolysis at phalanxes --> progressive shortening of the digit
Coupled with skin folding, generates a ”telescopic finger” appearance
109
Investigations for psoriatic arthritis
X-ray:
- periostitis
- ankylosis
- osteolysis
- dactylitis
- PENCIL IN CUP APPEARANCE
110
what is ankylosis?
joint stiffening due to bones joining together
111
what is periostitis?
inflammation of periosteum causing irregular, thick bone outline
112
Pencil-in-cup appearance
Central erosion of bone next to the joint causes hollowed out cup appearance (whilst adjacent bone is narrow & “sits” inside the cup)
113
Management of psoriatic arthritis
NSAIDs
DMARDs
Anti-TNFs
Last line = Ustekinumab (IL-12/23 mAb)
+ Derm treatment e.g., UV therapy, coal tar, emollients
114
What are the characteristics of enteropathic Arthritis?
ASSOCIATED WITH IBD
- Assymetrical lower extremity arthritis
- Symmetrical sacroiliitis
- Enthesitis less common
- Uveitis occasionally
- May see erythema nodosum + pyoderma gangrenosum
115
classic X-ray finding in enterohepatic arthritis?
marginal syndesmophytes
116
Management of enterohepatic arthritis?
NSAIDs
DMARDs
Anti-TNFs
+ IBD treatment
117
Keratoderma blenorrhagicum is typical of which arthritis?
Reactive arthritis
| Skin lesions commonly found on the palms and soles
118
Gottron's papule are associated with which condition?
dermatomyositis
119
What are the different crystals formed in gout versus pseudo gout?
GOUT- monosodium urate
| PSEUDOGOUT- calcium pyrophosphate
120
compare and contrast gout and pseudo gout on aspiration
Both show turbid, yellow, low viscosity fluid with raised WCC.
However...
GOUT:
- needle shaped crystals
- negatively birefringent
PSEUDOGOUT:
- rhomboid shaped crystals
- positively birefringent
121
How is septic arthritis managed?
1. Empirical IV Abx (vancomycin covers gram +tive strep/staff)
2. IV Abx 2 weeks (MC+S directed)
3. Oral Abx 4 weeks
STOP any biological therapies eg TNF-a inhibitors
122
How is an acute attack of gout managed?
NSAIDs +/- PPI
Colchicine (anti-mitotic, stops WBC migration)
Corticosteroids
123
How is gout managed in the long term prophylactically?
Aim is to reduce uric acid levels
- allopurinol
- febuxostat
- probenecid
- adjust diet, alcohol
NOTE: wait at least two weeks after an acute attack of gout before starting allopurinol.
124
How is pseudogout managed?
Mono/oligoarticular disease:
- Intra-articular corticosteroids
- +/- paracetamol
Polyarticular disease:
- NSAIDs or colchicine
- +/- paracetamol
- systemic corticosteroids if 1st line fails/contraindicated
Chronic/recurrent: joint replacement
125
An 81-year-old female presents to her GP with sudden onset pain in her left knee. Examination reveals an erythematous and swollen joint. She is afebrile. 1 week previously, her carers reported a fall at her residential home.
Given the likely diagnosis, what electrolyte disturbance might be seen on blood tests?
hypophosphataemia
Low phosphate is one of the causes of pseudogout, along with: idiopathic, hyperPTH, hypoMg.
Clues it is pseudo gout include elderly & female plus the fall 1 week ago as pseudo gout is often precipitated by trauma or illness
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Define osteomyelitis
Infection of the bone leading to inflammation, necrosis and new bone formation
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What are the risk facotrs/aeitiology of osteomyelitis?
HAEMATOGENOUS SPREAD
- IVDU
- Immunosuppression
- Diabetes
- Sickle cell (Ax with salmonella)
DIRECT INOCULATION
- Penetrating injury
- Ulcers
- Surgery
CONTIGUOUS SPREAD
- Cellulitis
- Localised infection
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How can osteomyelitis be categorised?
Acute, subacute or chronic (>6 weeks) subtype
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most common causative organism for osteomyelitis?
S. aureus (+ group A strep).
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How does the location of osteomyelitis vary with age?
Common in young children & affects the long bones.
In adults, much more common in the vertebrae e.g., Pott's disease (TB).
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Symptoms of osteomyelitis
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Nonspecific pain in affected area
Fever
Malaise
Rigors
Preceding skin lesion, sore throat, trauma or operation
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Signs of osteomyelitis
Localised erythema, swelling & warmth
Reduced ROM of affected joint
Discharge from associated wound/ulcer
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Investigations for osteomyelitis- what would they show?
BLOODS- raised CRP, WCC
XR/MRI- NAD first 2 weeks, then darkening in infected areas, periosteal thickening
BONE CULTURE (+blood culture/wound swabs)
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Management of osteomyelitis
SUPPORTIVE: immobilisation, analgesia
MEDICAL: high dose IV Abx (empirical then adapt to culture)
SURGICAL: debridement- indicated if necrosis/biofilm
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A 7-year-old boy with a history of sickle cell anaemia presents to A&E with fever and severe pain in his right leg. The father reports that he fell off his bicycle in the school playground 1 week ago.
Which organism is most likely to be found on blood culture?
Salmonella spp
Patient is most likely suffering from (septic arthritis or progression to) osteomyelitis. Due to his history of sickle cell, the most likely causative organism is Salmonella spp (along with Staph aureus which is a common cause in all age groups).
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most common causative organisms of Osteomyelitis in the elderly
Gram negative bacilli
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A 58-year-old gardener presents to the GP with joint pain, particularly at the base of her thumb. She has had to take the last week off work as the pain has become too severe to carry out her usual tasks. Examination reveals mild crepitus and stiffness over the right 1st carpometacarpal and 2nd proximal interphalangeal joint.
Given the most likely diagnosis, what might be seen on plain X-Ray of the hand?
This patient, whilst fairly young has an occupation that would expose her to lots of manual handling tasks & therefore increase her risk od “wear and tear” primary osteoarthritis.
The X-ray changes seen in OA include:
- Loss of joint space
- Osteophytes
- Subchondral/subarticular sclerosis
- Subchondral cysts
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What age is most commonly affected in Rheumatic fever?
peak age = 5-15years
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Which organs are affected in rheumatic fever? State common pathologies for each organ affected
Multisystem illness affecting:
Heart: pancarditis i.e. endocarditis, myocarditis, pericarditis
Joints: arthritis and synovitis;
Skin: Erythema marginatum, subcutaneous nodules
CNS: Encephalopathy, Sydenham’s chorea
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Erythema marginatum can be caused by which disease>
Rheumatic fever
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Jones’ Major Criteria for Rheumatic fever (CASES)
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Carditis
Arthritis
Sydenham’s chorea
Erythema marginatum
Subcutaneous nodules
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When do symptoms present in rheumatic fever?
2-4 weeks after strep throat infection
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Minor criteria for Rheumatic fever
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Fever
Raised ESR or CRP
Migratory arthralgia
Prolonged PR interval
Previous rheumatic fever
Malaise
Tachycardia
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Commonest cause of Rheumatic fever?
GROUP A STREP
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How is diagnosis of Rheumatic fever made?
Group A strep infection + 2 major criteria
OR
1 major + 2 minor criteria
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Which valve is commonly affected by Rheumatic fever?
mitral
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Tests for Strep infection
Raised or rising streptococci antibodies
Positive throat swab
Positive rapid group A streptococcal antigen test
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Histology of Rheamatic fever
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Beady fibrous vegetations (verrucae)
Aschoff bodies (small giant-cell granulomas)
Anitschkov myocytes (regenerating myocytes)
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