Arthritis

Question 1

Seropositive arthritis

Answer 1

RA
SLE
Scleroderma
Vasculitis
Sjorgen’s syndrome

Question 2

Seronegative arthritis

Answer 2

Psoriatic arthritis
Reactive arthritis
Enteric arthritis
Ankylosing spondylitis

Question 3

OA commonly affects which joints

Answer 3

Hips
Knees
DIP
CMC
Lumbar spine
Cervical spine

Question 4

RF for OA

Answer 4

Obesity
Age
Occupation
Trauma
Female
FHx

Question 5

Presentation for OA

Answer 5

Joint pain
Stiffness
Worsens with activity and end of day
Bulky, bony enlargement of joint
Restricted ROM
Crepitus on movement
Effusions (fluid) around joint

Question 6

Signs of OA in hands

Answer 6

Heberden’s nodes (DIP joints)
Bouchard’s noded (PIP)
Squaring at base of thumb (CMC)
Weak grip
Reduced ROM

Question 7

XR changes in OA

Answer 7

L - loss of joint space
O - osteophytes (bony spurs)
S - subarticular sclerosis (increased density of bone along joint line)
S - subchondral cysts (fluid-filled holes in bone)

Question 8

Diagnosis of OA

Answer 8

Without investigations IF >45 with typical pain associated with activity and has no morning stiffness (or <30m of stiffness)

Question 9

Mx of OA

Answer 9

Non-pharm: therapeutic exercise to improve strength and function and reduce pain, weight loss and OT
1st line = Topical NSAIDs
Oral NSAIDs (with a PPI)
Weak opiates and paracetamol are only recommended for short-term, infrequent use
IA steroids injection temporarily improve sx
Joint replacement

Question 10

Presentation of RA

Answer 10

Pain
Stiffness (early morning >1h)
Swelling
Tenderness to joints
Fatigue
Weight loss
Flu-like illness
Muscle aches and weakness

Question 11

Affected joints in RA

Answer 11

MCP
PIP
Wrist
MTP
Large joints: ankle, knee, hips and shoulders
Cervical spine (NOT lumbar)

Question 12

Hand signs in RA

Answer 12

Z-shaped deformity to thumb
Swan neck deformity (hyperextended DIP and flexed PIP)
Boutonniere deformity
Ulnar deviation of fingers at MCP joints

Question 13

Extra-articular manifestations in RA

Answer 13

pulmonary fibrosis
Felty’s syndrome (RA, neutropenia and splenomegaly)
Sjorgens syndrome (with dry eyes and dry mouth)
Anaemia
CVD
Rheumatoid nodules (firm, painless lumps under skin, typically on elbows and fingers)
Lymphadenopathy
Carpal tunnel syndrome
Amyloidosis
Bronchiolitis obliterans (small airway destruction and airway obstruction in lungs)
Caplan syndrome (pulmonary nodules in RA patients exposed to coal, silica or asbestos)

Question 14

Eye manifestations of RA

Answer 14

Dry eye syndrome
Episcleritis
Scleritis
Keratitis
Cataracts (secondary to steroids)
Retinopathy (secondary to hydroxychloroquine)

Question 15

Investigations for RA

Answer 15

RF positive
anti-CCP (RF negative should test for anti-CCP)
Early XR: loss of joint space, juxta-articular osteoporosis, soft-tissue swelling
Late XR: periarticular erosions, subluxation

Question 16

Mx of RA

Answer 16

DMARD monotherapy: 1st line = oral methotrexate, alternatives leflunomide or sulfalazine
+ short course of prednisolone whilst waiting for DMARD to take effect (2-3m)
Additional DMARDs may be offered in combination
If doesn’t respond, biologics offered with methotrexate or without if C/I
TNF-inhbitors if no response to 2/+ DMARDs - entanercept, infliximab, adalimumab
Rituximab - antiCD20 monoclonal antibody

Question 17

Classification of Psoriatic arthritis

Answer 17

Oligoarthritis
Symmetrical polyarthritis
DIP predominant
Spondyloarthritis
Arthritis mutilans

Question 18

Oligoarthritis classification of Psoriatic arthritis

Answer 18

<5 joints
Tends to be asymmetrical
Most common presentation

Question 19

Symmetrical polyarthritis presentation in Psoriatic arthritis

Answer 19

“rheumatoid pattern”
DIPS affected not MCPs
Common

Question 20

DIP predominant psoriatic arthritis

Answer 20

Seen more often in men
Less common, <20% patients

Question 21

Spondyloarthritis in psoriatic arthritis

Answer 21

Spondylitis +/- sacroiliitis
Presents with inflammatory back pain

Question 22

Arthritis mutilans

Answer 22

Rarest form of psoriatic arthritis causing severe deformity of hands
Destruction of terminal phalanx - “telescopic” appearance of fingers

Question 23

Investigations for psoriatic arthritis

Answer 23

Raised ESR/CRP - if normal doesn’t exclude
RF - non-specific can be positive, negative may help differentiate from RA
anti-CCP - negative can help differentiate from RA, may be positive
HLA-B27: increases probability of spondyloarthritis, not excluded if negative
Plain XR: hands and feet is symptomatic, changes may be absent in early disease, DIP joint erosion and periarticular new-bone formation, osteolysis and pencil in-cup deformity in advanced disease
USS - absence of XR changes, tendon swelling, increased blood flow and erosions - inflammation
Consider MRI of joints

Question 24

Mx for psoriatic arthritis

Answer 24

MDT approach
Conserative: PT, OT, podiatry, hand therapy
NSAIDs: relief of pain, used alone in initial management of limited disease
IA steroid injections - alone or with oral meds
DMARDs: failure to respond to NSAIDs or severe disease
1st line: methotrexate (alternatives leflunomide, sulfalazine)
2nd line: biologics (entanercept, infliximab, apremilast)
DMARDs can be combined
Short courses or oral steroids may be needed while initiating DMARDs

Question 25

What is reactive arthritis?

Answer 25

Aseptic arthritis arising 1-6w following GI (salmonella, shigella, campylobacter) or urogenital pathogens (chlamydia) Seronegative spondyloarthropathy CAN'T SEE, PEE, or CLIMB A TREE

Question 26

Features of reactive arthritis

Answer 26

Triad: arthritis, urethritis and conjunctivitis <4w post GI/GU infection Hx of abdo pain, diarrhoea, urethral discharge, dysuria or GU sx Lower extremities joints: knees, ankles and feet Pain, swelling and limitation of movement Conjunctivitis Anterior uveitis Fever, weight loss, fatigue

Question 27

Skin changes in reactive arthritis

Answer 27

keratoderma blenorrhagicum - hyperkeratotic lesions on soles predominantly Circinate balantis - eryhtematous plaques on glans penis

Question 28

Investigations for reactive arthritis

Answer 28

Clinical diagnosis Elevated ESR and CRP RF and ANA: rule out other conditions that cause similar sx HLA-B27 testing: useful as a prognostic marker, not diagnostic Urinalysis: increased leucocytes, haematuria and mild proteinuria NAAT: Chlamydia Trachomatis Stool test: salmonella, shigella, campylobacter - may be negative by onset of arthritis Radiography: no specific abnormalities, soft tissue swelling MRI: assess enthesitis and involvement of sacroiliac joints

Question 28

Management of reactive arthritis

Answer 28

1st line = NSAIDs for acute phase Corticosteroids - acute flare or unresponsive to NSAIDs DMARDs: 2nd line when NSAIDs and steroids fail Sulfasalazine - peripheral disease Methotrexate - spinal disease, acute and chronic anti-TNF if other treatments fail PT Treat chlamydia with abx: doxycycline or azithromycin, both with rifampin for 6m Topical steroids for skin Ophthalmology - anterior uveitis

Question 29

Presentation of ankylosing spondylitis

Answer 29

young adult male in 20s Sx develop gradually over >3m pain and stiffness in lower back sacroiliac pain worse with rest and improves with movements worsens in night and morning, may wake them stiffness >30m in morning Chest pain: costovertebral and sternocostal joints Enthesitis Dactylitis Vertebral fractues SOB

Question 30

Ankylosing spondylitis associations (5As)

Answer 30

Anterior uveitis aortic regurg AV block Apical lung fibrosis (upper lobes) Anaemia of chronic disease

Question 31

Schober's test for ankylosing spondylitis

Answer 31

assesses spinal mobility patient stands straight, locate L5 vertebrae point marked 10cm above and 5cm below (15cm apart) patient bends forward as far as possible distance between points is measured <20cm indicated a restriction in lumbar movement - helps support diagnosis

Question 32

Investigations for ankylosing spondylitis

Answer 32

CRP and ESR elevated HLA B27 testing XR spine and sacrum - bamboo spine - fusion of sacroiliac and spinal joints - squaring of vertebral bones - subchondral sclerosis and erosions - syndesmophytes (areas of bone growth where ligaments insert into bone) Ossification of ligaments, discs and joints Fusion of facet, sacroiliac and costovertebral joints

Question 33

Management of ankylosing spondylitis

Answer 33

1st line - NSAIDs 2nd line - anti-TNF (adalimumab, entanercept or infliximab) 3rd line - secukinumab or ixekizumab (monoclonal antibodies against IL-17) OR Upadacitinib (JAK inhibitor) IA steroid injections Conservative - exercise and mobilisation, avoid smoking, Bisphosphonates Surgery if joint deformity PT

Question 34

RF for septic arthritis

Answer 34

Pre-existing joint disease e.g RA DM Immunosuppression Chronic renal failure recent joint surgery prosthetic joints IVDU age >80

Question 35

Presentation for septic arthritis

Answer 35

fever erythematous, not, swollen and painful joint restricted movement unable to walk if weight bearing joint pain on active and passive movement monoarticular

Question 36

Investigations for septic arthritis

Answer 36

joint aspiration for synovial fluid microscopy and culture = key investigation, fluid often yellow/green Blood cultures Bloods - FBC, CRP, U&Es, calcium, phosphate XR = usually normal, may show signs of chronic gout (punched out lesions in juxta-articular bone)

Question 37

Diagnosis for septic arthritis

Answer 37

Kocher criteria: - fever >38.5 - non-weight bearing - raised ESR - raised WCC

Question 38

Management for septic arthritis

Answer 38

rule out systemic bacteraemia - septic six protocol admit to hospital prosthetic joint - urgent referral to ortho - managed in theatre - surgical arthrocentesis and washout Native joint - aspiration and empirical abx - IV flucloxacillin before culture results, ceftriaxone if gonococcal arthritis suspected Continue abx for 2 weeks before switching to PO if patient improving

Question 39

Enteropathic arthritis

Answer 39

associated with IBD, GI bypass, coeliac disease and Whipple's disease Usually improve with treatment of bowel sx Use DMARDs for resistant enteropathic arthritis

Question 40

RF for gout

Answer 40

Male FHx Obesity High purine diet Alcohol Diuretics CVD Kidney disease

Question 41

Presentation for gout

Answer 41

single, acute, hot, swollen, painful joint MTP (base of big toe) CMC (base of thumb) Wrist Also knee and ankles

Question 42

Investigations

Answer 42

usually clinical diagnosis raised serum urate level exclude septic arthritis: synovial fluid aspiration - shows monosodium urate crystals, needle-shaped and negatively birefringent of polarised light XR: maintained joint space, lytic lesions in bone, punched out erosions (can have sclerotic borders and overhanging edges)

Question 43

Management of gout

Answer 43

Acute: 1st line = NSAIDs (naproxen + PPI), 2nd = Colchine, 3rd = oral steroids Prophylaxis (not started until weeks after acute attack resolves, continued during subsequent attacks) with allupurinol or febuxostat Lifestyle changes can reduce risk: weight loss, staying hydrated and minimising consumption of alcohol and purine based foods

Question 44

Presentation for pseudogout

Answer 44

many are asymptomatic picked up incidentally on XR Chronic pain and stiffness in multiple joints present acutely with rapid onset of sx typically >65 with rapid onset, swollen, stiff and painful knee common joints: shoulders, hips and wrists

Question 45

Investigations for pseudogout

Answer 45

must exclude septic arthritis joint aspiration - shows calcium pyrophosphate crystals - rhomboid-shaped and positively birefringent of polarised light XR: chondrocalcinosis - calcium deposits in joint cartilage, show as a thin white line in middle of joint space Other XR findings: similar to OA LOSS (loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts)

Question 46

Mx of pseudogout

Answer 46

symptom management - usually spontaneously resolves over weeks 1st = NSAIDs (naproxen + PPI) Colchicine IA steroid injections (exclude septic arthritis first) Oral steroids