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Rheum > Arthropathies > Flashcards

Arthropathies Flashcards

1
Q

Arthritis patterns of presentation

A

Monoarthritis (one joint)
Oligoarthritis (<6 joints)
Polyarthritis (>5 joints)

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2
Q

Monoarthritis types

A

Septic
Crystal
OA
Trauma

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3
Q

Oligoarthritis types

A 
Crystal
Psoriatic
Reactive
Ankylosing spondylitis
OA
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4
Q

Symmetrical polyarthritis types

A

RA
OA
Viral
Systemic conditions

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5
Q

Asymmetric polyarthritis types

A

Reactive

Psoriatic

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6
Q

OA presentation

A

Pain + crepitus on movement with background ache at rest, worse with prolonged activity
Joint instability
Possible tenderness + deformity of joints e.g. Heberden’s at DIP + Bouchard’s at PIP

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7
Q

OA tests

A

XR shows: LOSS (loss of joint space, osteophyte formation, subchondral sclerosis + subchondral cysts)
CRP may be slightly elevated as there is some inflammatory component with cartilage damage

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8
Q

OA management

A

Weight loss, physio
Regular paracetamol ± topical NSAID + PPI if regular
Topical capsaicin may help
Intra-articular steroid injection temporary relief in severe
Arthroplasty if not significant risk of revision needed at older age

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9
Q

Septic arthritis risk factors

A 
Pre-existing joint disease (especially RA)
Diabetes mellitus
Immunosuppression
Chronic renal failure
Prosthetic joint/recent joint surgery
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10
Q

Septic arthritis presentation

A

Monoarthritis with hot joint + systemic symptoms
Knee affected in >50% of cases
Look for point of infection e.g. open wound, IV lines, pneumonia etc

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11
Q

Septic arthritis investigations

A

Joint aspiration for synovial fluid microscopy + culture

Blood cultures prior to antibiotics

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12
Q

Septic arthritis treatment

A

Empirical IV antibiotics e.g. tazobactam/piperacillin until bacterial sensitivities known, then appropriate Abx for organism
Approx 2 wks IV then 2-4 wks PO
Consider ortho review for arthrocentesis, washout + debridement + always refer pts with prosthesis

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13
Q

RA presentation

A

Typically symmetrical swollen, painful + stiff small joints of hands + feet, worse in morning
Can be widespread/systematic/recurrent soft tissue problems

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14
Q

RA signs

A

Early: swollen MCP/PIP/MTP/wrist joints, look for tenosynovitis/bursitis
Late: Ulnar deviation, subluxation of wrist + fingers, Boutonnière + swan neck deformities of fingers, z-deformity of thumbs

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15
Q

RA extra-articular manifestations

A

Nodules (elbow/lungs/cardiac/CNS)
Lungs (pleural disease/interstitial fibrosis -> bronchiolitis)
Cardiac (pericarditis/IHD)
Eye (Scleritis)

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16
Q

RA investigations

A

Rheumatoid factor + in ~70%, linked to severity
Anticyclic citrullinated peptide Ab (anti-ccp) highly specific to RA
XR shows loss of joint space, soft tissue swelling, juxta-articular osteoporosis, bony erosions
MRI shows synovitis + better for bone erosion than XR

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17
Q

RA diagnostic criteria

A 
1 or more swollen joint + score >5 from criteria:
Joint involvement
Serology
Acute phase reactants
Duration of symptoms
18
Q

RA management

A

DAS28 score used to monitor disease
DMARDs first line (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide)
Biologics if 2 DMARDs ineffective: Infliximab/adalimumab (TNF-a), rituximab (B-cell depletion), tocilizumab (il-1+6, monitor for hypercholesterolaemia), abatacept (t-cell costimulation)
Steroids for acute exacerbations
NSAIDs for symptomatic relief but no effect on disease

19
Q

Spondyloarthropathies clinical features

A

Asymmetric large joint pathology
HLA-B27 associated
Seronegative for rheumatoid factor
Extra-articular manifestations

20
Q

Gout presentation

A

Usually acute monoarthropathy with severe inflammation, >50% at first MTP (podagra)
Caused by sodium urate crystal deposition

21
Q

Gout risk factors

A

Reduced urate excretion (elderly, post-menopausal, anti-HT drugs, impaired renal function, aspirin)
Excess urate production (alcohol/red meat/seafood, psoriasis)

22
Q

Gout investigations

A

Polarised light microscopy of synovial fluid shows negatively birefringent needle like urate crystals
Radiograph shows punched-out erosions in juxta-articular bone in later stages

23
Q

Acute gout treatment

A

High dose NSAID
Colchicine 0.5mg twice daily if NSAID contraindicated
Steroid short term may be used, other 2 contraindicated in renal impairment

24
Q

Gout prevention

A

Lose weight, change diet, remove aspirin
Start prophylaxis if >1 gout per year/tophi

Allopurinol titrated up from 100mg/24h (starting and stopping may cause acute attacks, don’t stop taking even if acute attack develops)
Febuxostat 80mg/24h 2nd line prophylaxis
Uricosuric drugs inc urate excretion

25
Q

What is CPPD

A

Calcium pyrophosphate deposition, pseudogout
Usually monoarthropathy of larger joints in elderly
Chronic CPPD inflammatory RA-like symmetrical polyarthritis + synovitis

26
Q

CPPD investigations

A

Polarised light microscopy shows rhomboid positively birefringent calcium crystals
XR shows calcium deposition in soft tissues e.g. chondrocalcification

27
Q

CPPD management

A

In acute NSAIDs ± Colchicine 0.5-1mg/24h

In chronic CPP inflammatory arthritis Methotrexate + hydroxychloroquine may be used

28
Q

What is ankylosing spondylitis

A

Chronic inflammatory disease of spine + SI joints

29
Q

Ankylosing spondylitis presentation

A

Typically man <30yrs with gradual onset lower back pain worse at night
Morning spinal stiffness relieved with exercise
Pain radiates from SI joints to hips, improves at end of day

30
Q

Ankylosing spondylitis associations

A 
Amyloidosis
Achilles tendon problems (osteoporosis)
Acute iritis
Apical lung fibrosis
Aortic regurgitation/AV node block
31
Q

Ankylosing spondylitis investigations

A

Clinical diagnosis supported by imaging
MRI shows bone marrow oedema + destructive inflammatory changes
XR shows SI widening, sclerosis, erosions + joint space narrowing; bamboo spine in late disease

32
Q

Ankylosing spondylitis pathology

A

Vertebral syndesmophytes (bony growth in ligaments), fusion of growths with vertebral body above causing ankylosis

33
Q

Ankylosing spondylitis management

A

Exercise for backache (physio)
NSAIDs for symptoms, steroid injection temp relief
TNF-a blockers for severe (adalimumab, etanercept)
Hip replacement/spinal osteotomy if indicated

34
Q

Enteric arthropathy

A

Associated with IBD, coeliac, GI bypass

Arthropathy improves with bowel symptom treatment

35
Q

Psoriatic arthritis presentation

A

With 10-40% of psoriasis, can present before skin changes
Nail changes in 80%

Symmetrical polyarthritis/asymmetric oligoarthritis

DIP joints + spinal involvement

36
Q

Psoriatic arthritis imaging

A

Erosive changes, pencil in cup deformity if severe

37
Q

Psoriatic arthritis management

A

NSAIDs
Sulfasalazine
Methotrexate
Anti-TNF

38
Q

Reactive arthritis pathology

A

Autoimmune response to infection (typically GI/GU)

39
Q

Reactive arthritis presentation

A

Can’t see, can’t pee, can’t climb a tree

Triad of urethritis, arthritis, conjunctivitis is Reiter’s syndrome (former name for reactive arthritis)

40
Q

Reactive arthritis investigations

A

Raised ESR + CRP

Culture stools
Infectious serology
Sexual health review

XR may show enthesitis with periosteal reaction

41
Q

Reactive arthritis management

A

Splint acutely affected joints

NSAIDs/local steroid injection
Sulfasalazine/methotrexate if symptoms >6mths

Treating original infection may not make big difference to arthritis

42
Q

HLA B27 positive associations

A

Acute anterior uveitis

Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteric arthropathy

Rheum (4 decks)

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