Arthritis Flashcards
4 major CT diseases:
Autoinflammatory or autoimmune disease:
In autoimmune diseases it is predominantly polymorphisms in adaptive immune system
Anti-nuclear antibodies
This patients have AB binding to nucleus which then bind to marker
Targets of an anti-nuclear antibody:
-Anti double stranded DNA binding ones-SLE commonly
SLE genetic predisposition:
- Increase in cell debris and lots of nuclei around
- High level of active B cells
- Promotes loss of tolerance so get antibodies to double stranded DNA
- ABs bind to antigens forming immune complexes and they get stuck in small blood vessels and activate and use up complement
Immune complexes
SLE symptoms:
- Skin-malar rash
- Kidneys-glomerulonephritis leading to acute renal failure
- Pleurisy with pleural effusion
- Pericarditis and pericardial effusion
- Joints-arthritis
- Autoimmune cytopenias
Immunological investigations
High levels of ds DNA antibodies
High ESR-due to high inflammation, CRP is often normal in lupus
C4 complement is low as complexes are using up complement
Management
ANA pos and ds DNA pos, high ESR, low C4
Hydroxychloroquine-most patients
Commonly mycophenolate
Immunosuppression targets B cells
Compromise drug toxicity and disease activity
Primary Sjogren’s syndrome:
Primary Sjogrens syndrome investigations:
Unlike Lupus, don’t tend to be dsDNA positive
Ro and La positive
Not usually necessary to do lip gland biopsy
Management isn’t to immunopsuppress but is tear replacement because damage has already been done to glands and immunosuppressive drugs are very toxic
INCREASED RISK OF LYMPHOMA!
Idiopathic inflammatory myositis-What are the 2 types? Both affect muscles but dermatomyositis affects skin mainly
Especially proximal muscles. Typically around the thighs and sometimes upper arms
Dermatomyosis-heliotrop rash over eyes
Gottron’s papules
Shawl sign over chest
IIM: management and investigations
Manage with immunosuppression otherwise patients will become increasingly weak.
Steroid and then add in methotrexate
Systemic Sclerosis (scleroderma):
No ds-DNA positive
- Inflammation
- But also get activation of fibroblasts and fibrosis which underpins tightening of skin
- Activation of eosinophils-vascular disease
Scleroderma symptoms
Tightening of skin around fingers and particularly around the mouth
2 forms of systemic sclerosis:
Limited-skin tightening is limited to hands, feet and calves
ANA positive and tend to stain in centromere
Diffuse-skin features extend to chest, often have lung and kidney disease. Can present with hypotensive renal failure.
4 Connective tissue disease:
Sjogren’s syndrome-affect exocrine glands-dry eyes, dry mouth
Systemic sclerosis-CREST features
Systemic vasculitis-what is it?
Autoimmune:
These diseases occur without infection or trauma ie genetic factors drive them with some environmental factors which drive these
Primary systemic Vascultitis:
Inflammation of arteries and veins-bechets
Large vessels-takayasu
Can see in angiogram she has lost right subclavian so would get claudication of upper limb
If affects carotid get CNS disease
Common in women from japan
Giant cell arteritis
- Inflammation of temporal arteries, can get ischaemia and ulceration of scalp because of it
- Ischaemic optic neuropathy is real worry with this disease
Giant cell arteritis investigation and management:
Key thing to remember is prednisolone
- Got cramp on chewing (distinguish from TMJ)
- IV methylprednisolone for rapid treatment
Response and follow up:
What is GCA related to?
Involves bursitis and synovitis
Polymyalgia rheumatica
Moderate dose of prednisolone
Always ask-headaches, jaw claudication and visual symptoms to check about GCA
Moderate dose of prednisolone
Think about gastric protection and bone protection when giving steroids
Polyarteritis Nodosa:
Small vessel vasculitis-ANCA associated vaculitis:
GPA symptoms:
Haemoptysis-due to upper airway nodules which can bleed
Immunosuppress with high doses of steroids and steroid sparing agents
Immune complex vasculitis eg IgA disease:
Henoch scholein purpura-get gut involvement and gut pain
IgA disease:
Rash on buttock and legs
Biopsy skin or kidney to show inflammation in vessels and IgA depostion
Differential diagnosis of a systemically unwell patient:
Check ANA-points to CT disease
ANCA-points to one of the small vessel disease
LUPUS, GCA and polymyalgia rheumatica learn only these
=SLE
inflammatory myositis-muscle pain and high CK
sjrogrens-tends to be older women and dry eyes but would have high antibodies
=Giant cell arteritis with features of polymyalgia rheumatica
- Larger vessels going to head and masseter
- Treat with high doses of prednisolone
Summary slide:
