Arthritis Flashcards
Rheumatoid arthritis is an…
Inflammatory symmetrical, polyarticular arthritis of the small joints.
Risk factors for R. arthritis
Family history
Female > Male (3:1)
Other autoimmune disorders:
Rheumatoid arthritis is associated with HLA ______
DR1 and DR4
Pathophysiology of rheumatoid arthritis involves the chronic inflamamtion of…
Synovial lining of the joints, tendon sheaths and bursa
Symptoms of rheumatoid arthritis
Morning stiffness (45 mins)
- Relieved after movement
Swollen, tender joints
Constitutional features: fatigue, myalgia, mild fever, weight loss
Signs of rheumatoid arthritis
Hand deformities
- Swan neck
- Boutonnière
- Ulnar deviation of MCPJ
- Z thumb
Atlantoaxial subluxation
Extra-articular features of rheumatoid arthritis
Pulmonary
- Pulmonary fibrosis/ nodules
- Bronchiolitis obliterans (small airway obstruction)
Secondary Sjogren’s
Episcleritis/ Scleritis
Swan neck deformity describes the…
Hyperextension of the PIP and flexion of the DIP
Boutonnière deformity describes the…
Flexion of the PIP and hyperextension of the DIPs.
Rheumatoid factor (RF) is a _________ that binds to _________
IgM autoantibody that binds to the Fc region of IgG
Initial investigations for rheumatoid arthritis
FBC
- Anaemia of chronic disease
CRP, ESR
- May be raised
RF
- Raised in majority
Anti-CCP
- Most specific
X-ray hands
Early X-ray findings of rheumatoid arthritis
Periarticular osteopenia
Loss of joint space
Soft tissue swelling
Late X-ray findings of rheumatoid arthritis
Periarticular erosions
Subluxation
The DAS28 score describes ________ for ________
Disease activity score for rheumatoid arthritis.
Features of DAS28 score
28 joints:
- Number of swollen joints
- Number of tender joints
- ESR/ CRP level
- Patient’s global assessment of health (0-10, higher being worse)
The DAS28 score is used to…
Establish a baseline and assess the effectiveness of therapy used in Rheumatoid arthritis.
The DAS28 score is used to…
Establish a baseline and assess the effectiveness of therapy used in Rheumatoid arthritis.
Non-pharmacological management of RA
Physiotherapy
Occupational therapy
Podiatry
Good diet
Acute flares in Rheumatoid arthritis are controlled by…
NSAIDs
Corticosteroids (Prednisolone)
The first-line long-term pharamacological management of RA is…
DMARD monotherapy
- Methotrexate
- Leflunomide
- Sulfasalazine
Mild disease= hydroxychloroquine
Second-line long term pharmacological management of RA is…
Combination of DMARDs
- Methotrexate
- Sulfasalazine
- Leflunomide
Biologics are used to treat RA when…
A trial of at least 2 DMARDs fail to show substantial improvement.
RA has a worse prognosis for…
Younger, males
When a higher number of joints are affected
When there are erosions on an X-ray
What co-morbidities need to be screened for in RA
Osteoporosis/ osteopenia (FRAX)
Hypertension
Cardiovascular disease (QRISK)
Mood disorder
What vaccinations are encouraged for RA
Pneumococcal and influenza
What blood tests need to be carried out before starting DMARD
FBC, LFTs
- Especially for methotrexate (myelosuppression, hepatotoxicity)
Gout is caused by intra-articular deposits of ________
Monosodium urate crystals (due to high uric acid levels)
Risk factors of gout
Male
Metabolic syndrome
Alcohol syndrome
Diuretics
High purine diet (seafood, meat)
What joint is most commonly affected in gout
1st metatarsal phalangeal joint
What joints are commonly affected in gout
Wrists
1st carpometacarpal joint
Presentation of gout
Acute, hot, swollen joint pain (oligo/polyarthritis)
Severe pain
Gouty tophi (common in DIPJ)
Investigations for gout
Bloods
- CRP
Joint aspirate and microscopy
X-ray
Joint aspirate findings for gout
Needle-shaped crystals
Negative birefringent of polarised light
X-ray findings for gout
Maintained joint space
Lytic bone/ punched out lesions
Non-pharmacological management of gout
Keep affected joint elevated, rest, avoid excessive use
Lifestyle
- Low alcohol
- Low purine diet
- Weight loss
- Good hydration
First line management of acute gout
NSAID (naproxen)
Second line management of acute gout
Colchicine
First line agent for chronic gout
Allopurinol
Second line agent for chronic gout
Febuxostat
Pseudogout is caused by intra-articular deposits of ________ crystals
Calcium pyrophosphate
Joints most commonly affected in pseudogout are…
Knees most common
Shoulder, wrist, hip
Joint aspirate investigation in pseudogout will show…
Rhomboid shaped crystals with positive birefringent of polarised light
X-ray showing chondrocalcinosis is associated with…
Pseudogout
X-ray findings of pseudogout
Chondrocalcinosis
LOSS:
- Loss of joint space
- Osteophytes
- Subchondral cysts
- Subarticular sclerosis
Ankylosing spondylitis is associated with what genetic polymorphism.
HLA B27
Joints mainly affected in ankylosing spondylitis are…
Vertebral column
Sacroliac joint
Ankylosing spondylitis mainly affects what population?
Females > Males (6:1)
Adolescents/ young adults
- Age 20-30
What inflammatory conditions are associated with HLA B27
Ankylosing spondylitis
Uveitis
IBD
Reactive arthritis
Symptoms of ankylosing spondylitis
Neck/ sarcoiliac stiffness
- Worse in morning, improves with activity
Lower back pain
Constitutional: fatigue, weight loss, myalgia
Chest pain:
- costovertebral/ costosternal pain
- Pulmonary fibrosis
Eye pain (anterior uveitis)
MSK signs of ankylosing spondylitis
Loss of lumbar and cervical lordosis
- Hyperextended spine
Reduced lumbar flexion (Schober’s test) and lateral cervical flexion
Enthesitis
- Plantar fasciitis
- Achiles tendonitis
Spinal tenderness
Dactylitis
Non articular features of ankylosing spondylitis
Cardiovascular
- AV Heart block
- Aortitis/ AR
Pulmonary
- Apical pulmonary fibrosis
Bowel
- IBD
Eye
- Anterior uveitis
Scober’s test will show a reduced lumbar movement of ________ in ankylosing spondylitis
<20cm
Investigations for ankylosing spondylitis
Bloods
- Raised ESR and CRP
- Anaemia
- Negative RF and anti-CCP
Genetic HLA B27 testing
Whole spine X-ray/ MRI spine
High resolution CT= apical pulmonary fibrosis
Echocardiogram= aortic regurgitation, aortitis
ECG= AV heart block
X-ray findings for ankylosing spondylitis
Joint fusion
- Sarcoliliac
- Vertebral facets
Vertebral syndesmophytes
Bamboo spine
Subchondral sclerosis/ erosions
Ossification of ligaments, discs and joints
Syndesmophytes describes ________ and is associated with ________
Describes bony growths within a ligament, associated with ankylosing spondylitis.
First line management of ankylosing spondylitis
NSAIDs + physio
Non-pharamcological management of ankylosing spond
Physiotherapy + exercise & mobilisation
Smoking cessation
Psoriatic arthritis occurs in _______ % of patients with psoriasis
10-20%
Patterns of psoriatic arthritis
Symmetrical polyarthritis
- DIPJ involvement
- Wrist, ankle
Axial pattern
- Back, sacroiliac, atlanto-axial
Asymmetrical
- Affects digits
__________ is a screening tool used to psoriasis patients to assess for psoriatic arthritis
PEST (psoriasis epidemiological screening tool)
X-ray findings in psoriatic arthritis
Inflamed perosteum
Joint fusion
Dactylitis
Pencil-in-cup appearance (central erosions)
Osteolysis
First line therapy for long-term management of psoriatic arthritis
DMARDs (methotrexate)
First line biologic for psoriatic arthritis
Anti-TNF
- Infliximab
- Adalimumab
- Etanercept
The joints most commonly affected in osteoarthritis are…
Knee
Hip
DIP
Shoulder
Joints most commonly affected in rheumatoid arthritis are…
MCPJ
PIPJ
MTPJ
Heberden’s and Bouchard’s nodes are associated with….
Osteoarthritis
Herbeden’s nodes appear on _______ whilst Bouchard’s nodes appear on ________
Herbeden’s= DIPJs
Bouchards= PIPJs
The surgical management of knee osteoarthritis with mechanical locking is…
Arthroscopic lavage & debridement
2nd line= knee replacement
Non pharmacological advise for OA
Weight loss
Exercise/ physio to strengthen muscle around the joint
Appropriate footwear/ bracing/ walking device
Infections that common cause reactive arthritis
GI
- Campylobacter
- E.coli O157
- Shigella, Salmonella
STI
- Chlamydia
- Gonorrhea
- HIV
Features of Reiter’s syndrome
Conjuctivitis (“can’t see”)
Urethritis (“can’t pee”)
Arthritis (“Can’t bend the knee”)
Complications of reactive arthritis
Cervicitis
Pericarditis
Reactive arthritis has what genetic association
HLA-B27
Kertoderma blenorrhagicum is associated with _______
Reactive arthritis
First-line investigations for reactive arthritis
Bloods
- FBC= raised WCC
- CRP= raised
- Blood culture
GI symptoms
- Stool culture
Urine dip, MC+S
Joint aspirate
Joint X-ray
STI screen, HIV test
Reactive arthritis usually resolves within…
6 months
Acute management of reactive arthritis
NSAIDs
Intra-articular steroid injection/ systemic steroids (if polyarthritis)
Felty’s syndrome describes a triad of…
Low WCC
Splenomegaly
RA
Acute management of symptomatic sarcoidosis
Oral corticosteroids
______% of sarcoidosis resolves within _____months
60% within 6 months
What are the indications for urate lowering therapy for gout
Multiple/ troublesome flares
CKD 3+
Diuretics use
Gouty tophi/ chronic gouty arthritis
How is urate lowering therapy started
Treat to target
- Start at low dose and aim for serum urate <360 umol/L or <300 (in severe/ resistant)
- Monitoring urate monthly until target is reached
Indications for specialist management of gout
Chronic kidney disease >3b
History of organ transplant
Uncertain diagnosis
Contraindicated/ ineffective treatment
What is rheumatoid factor?
Autoantibody that binds to the Fc region of IgG.
Primary IgM but can be any immunoglobulin isotype.
First line biologics used for ankylosing spondylitis?
Anti-TNFa
- Etanercept
- Infliximab
- Adalimumab
Second line biologics used for ankylosing spondylitis?
Secukinumab
- Anti IL-17
