Arthritis (s) Flashcards
Define osteoarthritis
Degenerative condition affecting articular cartilage. Loss of cartilage with bone remodelling and inflammation
Epidemiology of osteoarthritis
- More common in women
- More common with increasing age
- Most common arthritis
Causes of osteoarthritis
- Age - cumulative trauma
- Gender - female, increased prevalence after menopause
- Genetic predisposition - less common in afro-caribbean
- Occupation - manual labour, sports, farming
- Obesity - low grade inflammatory state
- Other: local trauma, RA, abnormal joints - hypermobility, congenital hip dysplasia
Pathology of osteoarthritis
- Destruction of articular cartilage (reduction of articular space)
- Exposed subchondral bone becomes sclerotic, increased vascularity, subchondral cyst formation
- Repair causes cartilaginous growth formation which become calcified (osteophytes)
Signs and symptoms of osteoarthritis
- Joint involvement: early morning stiffness <30min, pain after exercise/end of day, reduced joint function
- Most often hips, knees, spine, small joints of the hand (asymmetrical)
- Hard swelling, crepitus
- Heberden’s nodes (DIPJ), Bouchard’s nodes (PIPJ)
- Alteration in gait
Investigations for osteoarthritis
- XR LOSS - loss of articular space, osteophytes, subchondral cysts, subchondral sclerosis
- CRP slightly raised, no autoantibodies
Management of osteoarthritis (non-medical)
- Lose weight + exercise
- OT, PT
- Walking aids
Management of osteoarthritis (pharmacological)
- Analgesics - NSAIDs, paracetamol, opioids, capsaicin
- Transdermal analgesic patches - buprenorphine, lignocaine
- Intra-articular corticosteroid injections
Management of osteoarthritis (surgical)
- Joint replacement
- Arthroplasty - surgical replacement or reconstruction of a joint
- Arthroscopy - keyhole surgery for loose bodies
- Osteotomy - cutting the bone for realignment
Define rheumatoid arthritis
Chronic systemic autoimmune inflammatory disease characterised by symmetrical, deforming, peripheral polyarthritis
Epidemiology of RA
- Young - 30-40 onset
- 3x more common in women
- Familial association
- HLA-DR4 association
- More common in smokers
Pathology of RA
Infiltration of synovium by inflammatory cells -> angiogenic cytokines form new synovial blood vessels -> synovium proliferates and grows over cartilage producing a pannus -> destroys subchondral bone and cartilage -> bony lesions
Signs and symptoms (intra-articular) of RA
- Joints - early morning stiffness >30min, ease with use
- Symmetrical red, swollen, tender, warm joints
- Usually wrists and feet
- Ulnar deviation
- Swan neck deformity
- Boutonnière deformity
- Rheumatoid nodules (check elbows)
- Z thumb
Signs and symptoms (extra-articular) of RA
- Cardiac disease : IHD, pericarditis
- Vascular disease : accelerated atherosclerosis, vasculitis
- Haematological disease: anaemia, splenomegaly
- Lung disease: pleuritis, pulmonary fibrosis
- Skin: rheumatoid nodules, erythema nodosum
- Neurological: Peripheral neuropathy, stroke
- Eyes: episcleritis, scleritis, sjogren’s
- Kidneys : amyloidosis
Investigations of RA
- RF - positive in 70-80%
- Anti-CCP - highly specific
- FBC, ESR, CPR
- Xray: LESS
- Loss of joint space
- Erosion
- Soft tissue swelling
- Soft bones (osteopenia)
Management of RA
- DMARDs - Methotrexate, sulfasalazine 1st line
- TNF-a inhibitor - infliximab, rituximab 2nd line
- Analgesia - NSAIDs, intra-articular steroid injection
- PT, OT
- Surgery
Types of seronegative spondyloarthropathies
- Ankylosing spondyloarthritis
- Psoriatic arthritis
- Enteropathic arthritis
- Reactive arthritis
Define seronegative spondyloarthropathies
A group of inflammatory joint conditions affecting mainly the spinal column and peripheral joints and enthesitis
What allele is associated with seronegative spondyloarthropathies
HLA B27
Shared clinical features of seronegative spondyloarthropathies
- Seronegative - rheumatoid factor negative
- Strong association with HLA B27
- Axial arthritis
- Asymmetrical peripheral arthritis
- Enthesitis - inflammation at insertion of tendons/ligaments to the bone
- Dactylitis - inflammation of digit due to soft tissue oedema and tenosynovial and joint inflammation
- Extra articular: iritis, psoriaform rashes, oral ulcers, IBD
Signs of seronegative spondyloarthropathies (SPINEACHE)
Sausage digits (dactylitis) Psoriasis Inflammatory back/buttock pain NSAIDs responsive Enthesitis Arthritis Crohn's/colitis associated HLA B27 associated Eye problems (uveitis)
Define ankylosing spondylitis
Chronic inflammatory disease of the spine and sacroiliac joints. Unknown aetiology
Epidemiology of ankylosing spondylitis
- More common in young men (<30y)
2. Smokers
Pathology of ankylosing spondylitis
Inflammation forming syndesmophytes -> fusion of the vertebrae (bamboo spine)
Clinical presentation of ankylosing spondylitis (7)
- Gradual onset lower back pain that radiates to buttocks with morning stiffness that eases with exercise
- Waking in the second half of the night due to pain
- Loss of movement in low back
- Reduced lordosis and increased kyphosis
- Enthesitis
- Systemic features: fever, malaise, fatigue
- Extra articular involvement:achilles tendonitis, apical fibrosis, aortic regurgitation
Investigations for ankylosing spondylitis
- Diagnosis is clinical supported imaging
- Xray/MRI - erosion and sclerosis of margins of sacroiliac joints. Bamboo spine
- ESR, CRP, HLA B27 +ve (90%), RF -ve
Management of ankylosing spondylitis
- Intense exercise regimen to maintain mobility and posture
- NSAIDs followed by TNF-a inhibitors (infliximab)
- Surgery - hip/shoulder replacement, correct spinal deformities
Define psoriatic arthritis
Inflammatory arthritis associated with psoriasis. 10-40% with psoriasis will develop
Signs and symptoms of psoriatic arthritis
- Ranges mild synovitis to severe progressive erosive arthropathy
- Symmetrical polyarthritis
- DIPJ primarily affected
- Psoriatic arthritis mutilans (bone tissue disappears)
- Associated with nail changes, synovitis, acneiform rashes, palmo-plantar pustulosis
Investigations for psoriatic arthritis
- Radiology - erosive changes, ‘pencil in cup’ deformity in severe cases
Management of psoriatic arthritis
- NSAIDs followed by DMARDs (methotrexate, sulfasalazine), TNF-a inhibitors also work
- Surgery - can correct deformed joints
Enteroarthritis
- Occurs in up to 20% of patients with IBD
- Erythema nodosum, pyoderma gangrenosum (skin condition where pustules form and grow into ulcers)
- Management like reactive arthritis
Define reactive arthritis
Arthritis and other clinical manifestations occur as an autoimmune response to infection elsewhere in the body (usually GI or GU). Preceding infection may be resolved or asymptomatic by the time reactive arthritis presents
Epidemiology of reactive arthritis
Typically young men
Causative organisms of reactive arthritis
GI: campylobacter, salmonella, shigella
GU: chlamydia trachomatisor
Signs and symptoms of reactive arthritis
- Acute onset: malaise, fever, fatigue
- Lower back pain common (also stiffness/pain in knees, ankles, feet)
- Asymmetrical, oligoarthritis (no more than 6 joints)
- Enthesitis
- Keratoderma blenorrhagica (brown raised plaques on soles and palms)
- Reiter’s - conjunctivitis, urethritis, arthritis
Investigations for reactive arthritis
- Raised CRP, ESR
- Culture stool if diarrhoea
- Serum antibodies/infectious serology
- STI screening
- X-ray - enthesitis with periosteal reaction
Management of reactive arthritis
- Splint affected joints, PT, aspirate synovial effusions
- Drugs: NSAIDs/local steroid injection, methotrexate if >6 months
- Treating original infection may have very little affect
