Athropathies Flashcards
Osteoarthritis Xray
LOSS
- Loss of join space (narrowing)
- Osteophytic bony overgrowth on DIP (Heberden’s nodes)
- Subchondral sclerosis (white/density under cartilage- thickening of bone)
- Subchondral cyst: fluid-filled sac / holes which forms within a joint space
Rheumatoid Arthritis on Xray
LESS
Loss of joint space (narrowing) Erosions and joint desturction at MCP joints and carpal bones Soft tissue swelling Soft bones (osteopenia)
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
RA hand signs
- Z shaped deformity to the thumb
- Swan neck deformity (hyperextended PIP with flexed DIP)
- Boutonnieres deformity (hyperextended DIP with flexed PIP)
- Ulnar deviation of the fingers at the knuckle (MCP joints)
?
- ulnar drift - 3rd, 4th, 5th fingers: swelling of the MCPJ causes the fingers to become displaced and tend toward the little finger
- trigger thumb: pain, stiffness/locking/catching when you bend/straighten the finger
- swan neck of right finger: DIP is permanently flexed and PIP in hyperextension
- multiple hand deformities
What is osteoarthritis?
wear and tear of synovial joints as a result of genetic factors, overuse and injury
RF: obesity, age, occupation, trauma, female, fhx
the imbalance between cartilage worn down and chondrocytes repairing it
osteoarthritis clinical features
pain and stiffness in joints worse with activity (inflammatory activity improves with symptoms) deformity instability reduced function in the joint
Hips Knees Sacro-iliac joints Distal-interphalangeal joints in the hands (DIPs) The MCP joint at the base of the thumb Wrist Cervical spine
osteoarthritis signs in hands
Haberdens nodes (in the DIP joints) Bouchards nodes (in the PIP joints) Squaring at the base of the thumb at the carpo-metacarpal joint Weak grip Reduced range of motion
osteoarthritis diagnosis
can be made witthout investigation if over 45, typical activity related to pain and morining stiffness <30 min
osteoarthritis management:
- patient education
- weight loss
- physiotherapy, OT, orthotics
4. analgesia: paracetamol, NSAIDs, capsaicin add oral NSAIDS and PPE opiates, codeine/morphine IA steroids joint replacement
what is rheumatoid arthritis?
autoimmune condition causing chronic inflammation of the synvoial lining of the joints, tendon sheaths and bursa (synovitis)
RA clinical features
symmetrical
affects multiple joints
symmetrical polyarthritis
‘symmetrical distal polyarthropathy’
- pain
- swelling
- stiffness
- stiffness in small joint of hands feet, wrist, ankle, MCP and PIP
- large joints: knees, shoulders, elbows
systemic symptoms: fatige weight loss flu like illness muscle aches adn weakness
*worse with rest, improves with activity
RA genetic association and antibodies
genetic:
HLA DR4
HLA DR1
auto antibodies
RF rheumatoid factor targets the Fc portion of the IgG antibodies
anti-CCP autoantibodies are more sensitive and specific to RA than RF. can pre-date the development and give indication fo development.
Proximal Interphalangeal Joints (PIP) joints
Metacarpophalangeal (MCP) joints
Wrist and ankle
Metatarsophalangeal joints
Cervical spine
Large joints can also be affected such as the knee, hips and shoulders
*DIP almost never affected- likely to be herbenden’s nodes in osteoarthritis
what is palindromic rheumatism?
This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days and then completely resolve. Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full rheumatoid arthritis.
investigations of RA
clinical features Check rheumatoid factor If RF negative, check anti-CCP antibodies Inflammatory markers such as CRP and ESR X-ray of hands and feet US to evaluate and confirm synovitis
RA- diagnosis
- Diagnostic criteria come from the American College of Rheumatology (ACR) / European League Against Rheumatism (ELAR) from 2010:
Patients are scored based on:
The joints that are involved (more and smaller joints score higher)
Serology (rheumatoid factor and anti-CCP)
Inflammatory markers (ESR and CRP)
Duration of symptoms (more or less than 6 weeks)
Scores are added up and a score greater than or equal to 6 indicates a diagnosis of rheumatoid arthritis.
- DAS28 Score
The DAS28 is the Disease Activity Score. It is based on the assessment for 28 joints and points are given for:
Swollen joints
Tender joints
ESR/CRP result
It is useful in monitoring disease activity and response to treatment.
RA management
steroids for flare ups
NSAIDS, COX-2 inhibitors (PPI)
monitor CRP and DAS28 for success of treatment
DMARDS methotrexate, leflunomide, sulfasalazine hydroxychloroquine (mildest) 2nd line- ^ combination 3rd line: methotrexate plus biological therapy- TNF inhibiotr 4th line: methotrexate plus rituximab
RA biological terapies
Biological Therapies
Anti-TNF (adalimumab, infliximab, etanercept, golimumab and certolizumab pegol)
Anti-CD20 (rituximab)
Anti-IL6 (sarilumab)
Anti-IL6 receptor (tocilizumab)
JAK inhibitors (tofacitinib and baricitinib)
*all lead to immunosuppression
! infections
! reactivation of dormant infections like TB and hep B
methotrexate MOA and side effects
interferes with the metabolism of folate and suppresses certain components of the immune system
injection/tablet once per week
*folic acid 5mg is gvien
Mouth ulcers and mucositis
Liver toxicity
Pulmonary fibrosis
Bone marrow suppression and leukopenia (low white blood cells)
It is teratogenic (harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers
leflunomaide MOA and side effects
immuosupressant - interferes with pyrimidine prodction (RNA and DNA)
Mouth ulcers and mucositis
Increased blood pressure
Rashes
Peripheral neuropathy
Liver toxicity
Bone marrow suppression and leukopenia (low white blood cells)
It is teratogenic (harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers
sulfasalazine MOA and side effects
immunosuppressive and anti inflammatory, folate metabolism. safe in pregnancy but need folic acid supplementation
Temporary male infertility (reduced sperm count)
Bone marrow suppression
Hydroxychloroquine
traditionally anti-malarial
immunosuppressive- works on toll-like receptors by disrupting antigen-presenting and increasing pH in the lysosomes of the immune cells.
safe in pregnancy
Nightmares
Reduced visual acuity (macular toxicity)
Liver toxicity
Skin pigmentation
anti-TNF
tumour necrosis factor is a cytokine which stimulates inflammation.
Adalimumab Infliximab Golimumab Certolizumab pegol Etanercept
side effects:
vulnerable to severe infections (sepsis)
reactivation of TB/hep B
rituximab
monoclonal antibodies, targets the CD20 protein on the surface of B cells causing destruction.
Vulnerability to severe infections and sepsis Night sweats Thrombocytopenia (low platelets) Peripheral neuropathy Liver and lung toxicity
reactive arthritis
‘Reiters syndrome’
clinical features
synovitis in joints as a reaction to a recent infection trigger (GI, STI)
associations:
Bilateral conjunctivitis (non-infective)
Anterior uveitis
Circinate balanitis is dermatitis of the head of the penis
(can’t see, can’t pee, can’t climb a tree)
(acute monoarthritis- single joint)
warm and swollen painful joint
reactive arthritis investigations + management
rule out septic arthritis!
acute warm, swollen and painful joint
antibiotics until septic arthritis excluded
aspirate joint and send a sample for gram staining, culture and senstivity. crystal examination (gout, pseudogout)
NSAIDS steroid injections systemic steroids *most resolve in 6 months. recurrent- DMARDS, anti TNF meds
psoriatic arthritis
inflammatory arthritis with psoriasis
mild stiffness / soreness in joint
severe: arthritis mutilans (destruction of joint)
patterns of psoriatic arthritis
Symmetrical polyarthritis presents similarly to rheumatoid arthritis and is more common in women. The hands, wrists, ankles and DIP joints are affected. The MCP joints are less commonly affected (unlike rheumatoid).
Asymmetrical pauciarthritis affecting mainly the digits (fingers and toes) and feet. Pauciarthritis describes when the arthritis only affects a few joints.
Spondylitic pattern is more common in men. It presents with:
Back stiffness
Sacroiliitis
Atlanto-axial joint involvement
Other areas can be affected:
Spine
Achilles tendon
Plantar fascia
signs of psoriatic arthritis
Plaques of psoriasis on the skin
Pitting of the nails
Onycholysis (separation of the nail from the nail bed)
Dactylitis (inflammation of the full finger)
Enthesitis (inflammation of the entheses, which are the points of insertion of tendons into bone)
Psoriasis Epidemiological Screening Tool (PEST)
question tool
high score- refer to rheumatologists
xray changes psoriatic arthritis
Periostitis is inflammation of the periosteum causing a thickened and irregular outline of the bone
Ankylosis is where bones joining together causing joint stiffening
Osteolysis is destruction of bone
Dactylitis is inflammation of the whole digit and appears on the xray as soft tissue swelling
Pencil-in-cup appearance
‘pencil in cup apperance’
central erosion of the bone beside ithe joint
arthritis mutilans
This is the most severe form of psoriatic arthritis. This occurs in the phalanxes. There is osteolysis (destruction) of the bones around the joints in the digits. This leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a “telescopic finger”.
psoriatic arthritis mx
NSAIDs for pain
DMARDS (methotrexate, leflunomide or sulfasalazine)
Anti-TNF medications (etanercept, infliximab or adalimumab)
Ustekinumab is last line (after anti-TNF medications) and is a monoclonal antibody that targets interleukin 12 and 23
SLE
- autoimmune disease
- disease limited to the joints and skin, kidneys
- first line: hydroxychloroquine
ANA, antidsDNA
- malar butterfly rash (flat erythema)
- discoid rash
- photosenstiivtiy
- painless oral or nasopharyngeal ulceration
- non erosive arthritis
- serositis
- renal disorder
- CNS disorder
- haematological disorder
Pagets disease
osteitis deformans
Pagetic patients are predisposed to bone tumours.
malignant osteosarcomas constitue the majority of tumors, usually present with new pain in long standing pageitc lesiosn.
aching pelvis / femur hearing loss frontal bowing of skull angioid streaks elevated ALP, normal GGT
Polymyalgia rheumatica
ESR
CRP
prednisolone 15mg per day (pt can be on steroids for 2 years)
provide ca2+ and vit D supplements and a bisophosphonate.
Felty syndrome
splenomegaly
neutropenia
rheumatoid arthritis
skin changes*
50-70 y/o.
tx: treat underlying rheumatoid arthritis. splenomectaly in severe neutropenia.
aspiration of joint
aspirate with knee extended
needle inserted medialy and below the patella
*rule out septic arthritis
contraindications:
bacteraemia, haemoarthrosis, impending joint replacement surgery (scheduled in a few days) adjacent osteomyelitis, joint prosthesis, osteochondral fracture, periarticular cellulitis, uncontrolled bleeding disorder or coagulopathy.
