Arthritis Flashcards
Seropositive arthritis
RA
SLE
Scleroderma
Vasculitis
Sjorgen’s syndrome
Seronegative arthritis
Psoriatic arthritis
Reactive arthritis
Enteric arthritis
Ankylosing spondylitis
OA commonly affects which joints
Hips
Knees
DIP
CMC
Lumbar spine
Cervical spine
RF for OA
Obesity
Age
Occupation
Trauma
Female
FHx
Presentation for OA
Joint pain
Stiffness
Worsens with activity and end of day
Bulky, bony enlargement of joint
Restricted ROM
Crepitus on movement
Effusions (fluid) around joint
Signs of OA in hands
Heberden’s nodes (DIP joints)
Bouchard’s noded (PIP)
Squaring at base of thumb (CMC)
Weak grip
Reduced ROM
XR changes in OA
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)
Diagnosis of OA
Without investigations IF >45 with typical pain associated with activity and has no morning stiffness (or <30m of stiffness)
Mx of OA
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
Presentation of RA
Pain
Stiffness (early morning >1h)
Swelling
Tenderness to joints
Fatigue
Weight loss
Flu-like illness
Muscle aches and weakness
Affected joints in RA
MCP
PIP
Wrist
MTP
Large joints: ankle, knee, hips and shoulders
Cervical spine (NOT lumbar)
Hand signs in RA
Z-shaped deformity to thumb
Swan neck deformity (hyperextended DIP and flexed PIP)
Boutonniere deformity
Ulnar deviation of fingers at MCP joints
Extra-articular manifestations in RA
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)
Eye manifestations of RA
Dry eye syndrome
Episcleritis
Scleritis
Keratitis
Cataracts (secondary to steroids)
Retinopathy (secondary to hydroxychloroquine)
Investigations for RA
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
Mx of RA
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
Classification of Psoriatic arthritis
Oligoarthritis
Symmetrical polyarthritis
DIP predominant
Spondyloarthritis
Arthritis mutilans
Oligoarthritis classification of Psoriatic arthritis
<5 joints
Tends to be asymmetrical
Most common presentation
Symmetrical polyarthritis presentation in Psoriatic arthritis
“rheumatoid pattern”
DIPS affected not MCPs
Common
DIP predominant psoriatic arthritis
Seen more often in men
Less common, <20% patients
Spondyloarthritis in psoriatic arthritis
Spondylitis +/- sacroiliitis
Presents with inflammatory back pain
Arthritis mutilans
Rarest form of psoriatic arthritis causing severe deformity of hands
Destruction of terminal phalanx - “telescopic” appearance of fingers
Investigations for psoriatic arthritis
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
Mx for psoriatic arthritis
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
What is reactive arthritis?
Aseptic arthritis arising 1-6w following GI (salmonella, shigella, campylobacter) or urogenital pathogens (chlamydia)
Seronegative spondyloarthropathy
CAN’T SEE, PEE, or CLIMB A TREE
Features of reactive arthritis
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
Skin changes in reactive arthritis
keratoderma blenorrhagicum - hyperkeratotic lesions on soles predominantly
Circinate balantis - eryhtematous plaques on glans penis
Investigations for reactive arthritis
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
Management of reactive arthritis
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
Presentation of ankylosing spondylitis
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
Ankylosing spondylitis associations (5As)
Anterior uveitis
aortic regurg
AV block
Apical lung fibrosis (upper lobes)
Anaemia of chronic disease
Schober’s test for ankylosing spondylitis
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
Investigations for ankylosing spondylitis
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
Management of ankylosing spondylitis
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
RF for septic arthritis
Pre-existing joint disease e.g RA
DM
Immunosuppression
Chronic renal failure
recent joint surgery
prosthetic joints
IVDU
age >80
Presentation for septic arthritis
fever
erythematous, not, swollen and painful joint
restricted movement
unable to walk if weight bearing joint
pain on active and passive movement
monoarticular
Investigations for septic arthritis
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)
Diagnosis for septic arthritis
Kocher criteria:
- fever >38.5
- non-weight bearing
- raised ESR
- raised WCC
Management for septic arthritis
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
Enteropathic arthritis
associated with IBD, GI bypass, coeliac disease and Whipple’s disease
Usually improve with treatment of bowel sx
Use DMARDs for resistant enteropathic arthritis
RF for gout
Male
FHx
Obesity
High purine diet
Alcohol
Diuretics
CVD
Kidney disease
Presentation for gout
single, acute, hot, swollen, painful joint
MTP (base of big toe)
CMC (base of thumb)
Wrist
Also knee and ankles
Investigations
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)
Management of gout
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
Presentation for pseudogout
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
Investigations for pseudogout
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)
Mx of pseudogout
symptom management - usually spontaneously resolves over weeks
1st = NSAIDs (naproxen + PPI)
Colchicine
IA steroid injections (exclude septic arthritis first)
Oral steroids
