Arthritides/Rheum Flashcards
What is septic arthritis?
Infection of one or more joints caused by pathogenic bacteria
What is the aetiology of septic arthritis?
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
What are the risk factors of septic arthritis?
Pre-existing joint disease (RA)
Immunosuppression (DM, iatrogenic)
Prosthetic joints
IVDU
What are the signs and symptoms of septic arthritis?
Acutely inflamed tender swollen joint
Decreased range of motion
Systemically unwell
Knee most commonly affected
What are the investigations for septic arthritis?
Urgent joint aspiration
- Gram stain and culture
- WCC
Bloods
- ESR/CRP, WCC, cultures
Imaging
- XR, MRI
What is the management for septic arthritis?
IV ABx after aspiration
Analgesia
Consider joint washout under GA
What is gout?
Acute monoarthropathy with severe joint inflammation, secondary to deposition of monosodium urate crystals
What is the aetiology of gout?
Monosodium urate- hyperuricaemia Increased intake (high purine diet, alcohol) Increased production (malignancy- tumour lysis) Decreased excretion (diuretics)
What are the risk factors of gout?
Male Obesity High cell turnover rate (tumour lysis syndrome, lymphoma, psoriasis) Drugs (diuretics, aspirin, cytotoxics) Alcohol excess Purine rich diet (meat, seafood) Renal impairment
What are the symptoms of gout?
Rapid-onset severe pain- worst ever
Decreased range of motion
Most commonly affects joints in feet
First metatarsaophalangeal joint (podagra)
What are the signs of gout?
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
What are the investigations of gout?
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
What is the management for gout?
Acute: NSAIDs, colchicine
Chronic: Conservative and allopurinol
Why should you not give allopurinol in an acute attack of gout?
Can prolong/precipitate the attack
What is pseudogout?
Inflammation of a joint, secondary to deposition of calcium pyrophosphate crystals
What are the risk factors for pseudogout?
Elderly Female Hyperparathyroidism Haemochromatosis Osteoarthritis Hypomagnesia Wilson’s Acromegaly
What are the symptoms and signs of pseudogout?
Very similar to gout- but affect more joints (polyarticular)
Commonly large joints (knee/wrist)
What are the investigations for pseudogout?
Synovial fluid aspirate
XR of joints
Bloods- neutrophilia, raised CRP
What is reactive arthritis?
A STERILE seronegativejoint inflammation that develops in response toan extra-articularinfection
What is the aetiology of reactive arthritis?- state some common causative organisms
Post-infectious joint inflammation- typically affecting the lower limb 1-4 weeks after UTI/diarrhoea
- Chlamydia
- Salmonella
- Campylobacter
- Shigella
- Yersinia
- Gonorrhoea
What are the risk factors for reactive arthritis?
Male 9:1
HLA-B27 serotype
Preceding gastrointestinal/genitourinary infections-
- Chlamydia
- Salmonella
- Shigella
- Yersinia
- Campylobacter.
What are the symptoms of reactive arthritis?
ASYMMETRICAL OLIGOARTHRITIS
Worse in the morning
Knee most commonly affected (lower>upper affected)
What are the signs of reactive arthritis?
Enthesitis (Achille's tendonitis) Conjunctivitis Mouth ulcers Circinate balanitis (ring shaped dermatitis of glans penis) Keratoderma blenorragica
What is Reiter’s syndrome?
Triad of:
- Arthritis
- Urethritis
- Conjunctivitis
(Can’t see, pee, or climb a tree)
Initialactivation ofimmunesystem bymicrobial antigen –>autoimmunereactionaffectingskin, eyes&joints
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
What are the risk factors for osteoarthritis?
Age >50 Female Obese Physical/manual occupation FHx of OA
Which joints are affected in osteoarthritis?
DIP PIP Thumb CMC Knees Hips
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
What is rheumatoid arthritis?
Autoimmune condition causing chronic (>6 weeks) inflammation of synovial lining, tendon sheaths & bursa.
Characterised by symmetrical polyarthritis (>4) + extraarticular manifestations
What is the cause of rheumatoid arthritis?
Autoimmune destruction of joints
What are the risk factors for rheumatoid arthritis?
Smoker
FHx
History of rheumatoid arthritis
HLA-DR4 (often) or HLA-DR1 (sometimes)
Which joints are affected in rheumatoid arthritis?
MCPs
PIPs
MTP
No DIP involvement
What are the early signs of rheumatoid arthritis?
Joint inflammation
MCP/PIP/wrist/MTP affected
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
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
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
What is amyloidosis?
A group of disorders characterised by deposition of amyloid fibrils
What are the two types of amyloidosis?
AL amyloidosis (primary) AA amyloidosis (secondary)
What is the aetiology of AL amyloidosis?
Proliferation of plasma cell clones
Monoclonal immunoglobulin formation
Fibrillar protein deposition
What are the risk factors for AL amyloidosis?
Monoclonal gammopathy of undetermined significance (MGUS)
Multiple myeloma
Lymphoma
What is MGUS?
A pre-multiple myeloma state, with raised paraprotein but no myeloma
What are the complications of AL amyloidosis?
Restrictive cardiomyopathy
Peripheral neuropathy
Depends on the organ affected, lots of overlap with AA amyloidosis
What is the aetiology of AA amyloidosis?
Chronic inflammation
Elevation of serum amyloid A
Fibrillar protein deposision
What are the risk factors for AA amyloidosis?
Rheumatoid arthritis
IBD
Chronic infection (TB, bronchiectasis, osteomyelitis)
What are the complications of AA amyloidosis?
Nephrotic syndrome
Splenomegaly
Hepatomegaly
Depends on the organ affected, lots of overlap with AA amyloidosis
What is the investigation for amyloidosis?
Histological biopsy of affected organ
What are spondyloarthritides?
Group of inflammatory arthritides affecting the spine and peripheral joints without production of RhF, and associated with the HLA-B27 allele
What are some common immunological features of the spondyloarthritides?
RhF negative
HLA B27 association
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
What are the 4 spondyloarthritides?
Ankylosing spondylitis
Psoriatic arthritis
Reactivie arthritis
Enteropathic arthropathy
What are the 3 joint patterns seen in psoriatic arthritis?
Symmetrical polyarthritis
Asymmetrical pauciarthritis
Spondylitic
DIP predominant
What is the characteristic of symmetrical polyarthritis?
Rheumatoid-like
What is the characteristic of assymetrical pauciarthritis?
Affects mostly digits and small bones of feet
oligoarthritis (only a few joints affected)
What is the characteristic of DIP predominant?
High incidence of nail changes:
Pitting
Onycholysis
Subungal hyperkeratosis
What is the characteristic of spondylitis?
Spine and sacroiliac involvement
What is the characteristic of arthritis multilans?
Severe deformity
Telescoping fingers
What are the common nail changes seen in psoriatic arthritis?
Pitting
Onycholysis
Subungal hyperkeratosis
What is ankylosing spondylitis?
Chronic progressive inflammatory arthropathy, mainly of the spine and sacroiliac joints (axial skeleton)
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
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
What are the signs of ankylosing spondylitis?
Progressive loss of spinal movement
EARLY = pain + stiffness
LATE = spinal fusion, kyphosis/loss of lordosis, neck extension
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
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
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.
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.
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
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.
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
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.
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.
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.
Define osteoarthritis
Asymmetrical degenerative synovial joint disease where cartilage destruction exceeds repair, causing pain & instability
epidemiology osteoarthritis
very very common
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
RFs primary osteoarthritis
Obesity age female occupation (lots of use of joints) ‘hereditary predisposition’ ?Post-menopause
Which pre-existing conditions can increase risk of developing osteoarthritis?
Inflammatory - RA or septic arthritis
Congenital – DDH
Metabolic – Wilson’s, acromegaly, haemochromatosis
Trauma
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.
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
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)
How can you divide up the arthritides?
DEGENERATIVE - osteoarthritis INFLAMMATORY - rheumatoid arthritis - Seronegative Spondyloarthropathies - Crystal Arthropathies
INFECTIOUS
- septic arthritis
- osteomyelitis
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)
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
Conservative management of osteoarthritis
- lifestyle - weight loss to reduce stress,
- physiotherapy- build stability & support in joints
- occupational therapy- maximize function & improve accessibility
Medical management of osteoarthritis
- stepwise analgesia
- intra-articular steroids (temporary Sx relief)
- joint replacement
Describe the stepwise analgesia used in OA management
- Oral paracetamol +/- topical NSAID / topical Capsaicin
- Oral NSAID + PPI
- Opiates – use with caution! - not good for chronic pain (dependence, adaptation)
Epidemiology RA
- Females
- 50-55yrs
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)
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.
Which antibody can predict disease development in RA?
anti-CCP antibodies
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
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)
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
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
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)
Methotrexate side effects
Mouth ulcers & mucositis Liver toxicity Pulmonary fibrosis Bone marrow suppression and leukopenia Teratogenic - avoid prior to conception (male & female)
Sulfasalazine side effects
Temporary male infertility (reduced sperm count)
Bone marrow suppression
Hydroxychloroquine side effects
Nightmares
Reduced visual acuity (macular toxicity)
Liver toxicity
Skin pigmentation
anti-TNF side effects
Increased infection risk
Reactivation of latent TB and chronic Hepatitis B
Rituximab side effects
Increased infection risk Night sweats Thrombocytopenia Peripheral neuropathy Liver and lung toxicity
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).
List the most common seronegative spondylarthropathies (PEAR)
Psoriatic arthritis
Enterohepatic arthritis
Ankylosing spondylitis
Reactive arthritis
Describe the Schober’s test
Mark 2 points: 10cm above L5, 5cm below
Patients bends forward
Point-point distance increases <5cm –> AS
What would you see in a X-ray of a patient with ankylosing spondylitis?
- Sacroiliitis (early)
- Syndesmophytes
- Bamboo spine (late)
- Vertebral body sparing
Management of ankylosing spondylitis
NSAIDs
Steroids during flares – oral, IM or intraarticular
Anti-TNF
Secukinumab – IL17 mAb
Physiotherapty + smoking cessation + bisphosphonates for osteoporosis
-?Surgery
Management reactive arthritis
Abx until septic arthritis excluded NSAIDs Intra-articular steroids Systemic steroids (if multiple joints) DMARDs or anti-TNF if recurrent
Psoriatic arthritis affects how many psoriasis patients?
Affects 10-20% psoriasis patients
Middle age
State some extra-articular manifestations of psoriatic arthritis
Psoriasis plaques Oncholysis & pitting of nails Dactylitis, Enthesitis Conjunctivitis, anterior uveitis Aortitis Amyloidosis
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
Investigations for psoriatic arthritis
X-ray:
- periostitis
- ankylosis
- osteolysis
- dactylitis
- PENCIL IN CUP APPEARANCE
what is ankylosis?
joint stiffening due to bones joining together
what is periostitis?
inflammation ofperiosteumcausing irregular, thick bone outline
Pencil-in-cupappearance
Central erosion of bone next to the joint causes hollowed out cup appearance (whilst adjacent bone is narrow & “sits” inside the cup)
Management of psoriatic arthritis
NSAIDs
DMARDs
Anti-TNFs
Last line = Ustekinumab (IL-12/23 mAb)
+ Derm treatment e.g., UV therapy, coal tar, emollients
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
classic X-ray finding in enterohepatic arthritis?
marginal syndesmophytes
Management of enterohepatic arthritis?
NSAIDs
DMARDs
Anti-TNFs
+ IBD treatment
Keratoderma blenorrhagicum is typical of which arthritis?
Reactive arthritis
Skin lesions commonly found on the palms and soles
Gottron’s papule are associated with which condition?
dermatomyositis
What are the different crystals formed in gout versus pseudo gout?
GOUT- monosodium urate
PSEUDOGOUT- calcium pyrophosphate
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
How is septic arthritis managed?
- Empirical IV Abx (vancomycin covers gram +tive strep/staff)
- IV Abx 2 weeks (MC+S directed)
- Oral Abx 4 weeks
STOP any biological therapies eg TNF-a inhibitors
How is an acute attack of gout managed?
NSAIDs+/- PPI
Colchicine(anti-mitotic, stops WBC migration)
Corticosteroids
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.
How is pseudogout managed?
Mono/oligoarticular disease:
- Intra-articular corticosteroids
- +/-paracetamol
Polyarticular disease:
- NSAIDs or colchicine
- +/- paracetamol
- systemic corticosteroids if 1stline fails/contraindicated
Chronic/recurrent: joint replacement
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
Define osteomyelitis
Infection of the bone leading to inflammation, necrosis and new boneformation
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
How can osteomyelitis be categorised?
Acute, subacute or chronic (>6 weeks) subtype
most common causative organism for osteomyelitis?
S. aureus (+ group A strep).
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).
Symptoms of osteomyelitis
Nonspecificpain in affectedarea Fever Malaise Rigors Preceding skin lesion,sorethroat, trauma oroperation
Signs of osteomyelitis
Localisederythema,swelling& warmth
Reduced ROM of affected joint
Discharge from associatedwound/ulcer
Investigations for osteomyelitis- what would they show?
BLOODS- raised CRP, WCC
XR/MRI- NAD first 2 weeks, then darkening in infectedareas, periostealthickening
BONE CULTURE (+blood culture/wound swabs)
Management of osteomyelitis
SUPPORTIVE: immobilisation, analgesia
MEDICAL: high dose IV Abx (empirical then adapt to culture)
SURGICAL: debridement- indicated if necrosis/biofilm
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).
most common causative organisms of Osteomyelitis in the elderly
Gram negative bacilli
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
What age is most commonly affected in Rheumatic fever?
peak age = 5-15years
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
Erythema marginatum can be caused by which disease>
Rheumatic fever
Jones’ Major Criteria for Rheumatic fever (CASES)
Carditis Arthritis Sydenham’s chorea Erythema marginatum Subcutaneous nodules
When do symptoms present in rheumatic fever?
2-4 weeks after strep throat infection
Minor criteria for Rheumatic fever
Fever Raised ESR or CRP Migratory arthralgia Prolonged PR interval Previous rheumatic fever Malaise Tachycardia
Commonest cause of Rheumatic fever?
GROUP A STREP
How is diagnosis of Rheumatic fever made?
Group A strep infection + 2 major criteria
OR
1 major + 2 minor criteria
Which valve is commonly affected by Rheumatic fever?
mitral
Tests for Strep infection
Raised or rising streptococci antibodies
Positive throat swab
Positive rapid group A streptococcal antigen test
Histology of Rheamatic fever
Beady fibrous vegetations (verrucae) Aschoff bodies (small giant-cell granulomas) Anitschkov myocytes (regenerating myocytes)
