Block 9: gout, osteoarthritits, osteoporosis, PMR, Psoriasis Flashcards
1
Q
Crystals in gout and CPPD
A
- Gout: negatively birefringent, needle shaped, monosodium urate
- Pseudogout: Positively birefringent, Rhomboidal, Calcium pyrophosphate
2
Q
Clinical diagnosis of gout
A
- Mono-articular involvement of a foot/ankle joint
- Previous episodes of a similar nature
- Rapid onset
- Erythema
- Male
3
Q
Treatment of gout
A
- Acute flare: NSAID (first line), Colchicine (caution in renal impairement, causes diarrhoea)
- Steroids (oral or injection): if NSAID’s and colchine are contraindicated can have intra-articular steroid injections, IL1 inhibitors
4
Q
Treatment of gout: prevention
A
- Prevention and management: lifestyle modification, change diet, reduce alcohol, weight loss, Allopurinal or febuxostat. Probenecid
- Allopurinol is first like prophylaxis form of urate lowering therapy (ULT) and is started when inflammation has settled. If refractory use urate oxidase or pegloticase
- Increase vitamin C
- Use losartan if co-existent hypertension
5
Q
Gout complications
A
- Tophi
- Bone complications: degenerative arthritis due to bone erosion and weakening of joints
- Osteoporosis
- Kidney disease
- Mental health: depression
6
Q
Crystal arthropathy management
A
- Acute: NSAIDs + PPI, Colchine, Corticosteroids oral/IA, Interleukin 1B inhibitor if refractors
- Chronic: attain normal BMI, stop alcohol, stay hydrated. After an acute attack Allopurinol. Febuostat, Probenecid, Rasburicase (severe/refractors)
- Chronic CPPD: identify and treat and underlying metabolic abnormalities. NSAIDs and PPI, Colchine, Corticosteroids, Methotrexate, Hydroxylchloroquine
7
Q
x ray of a joint affected by gout shows
A
- Maintained joint space(no loss of joint space)
- Lytic lesionsin the bone
- Punched out erosions
- Erosions can havesclerotic borderswithoverhanding edges
8
Q
Fibromyalgia
A
- Commonest cause of widespread MSK pain in women 20-55
- No abnormalities in blood tests or imaging
- Normal examination findings except tenderness
- Possible disorder of pain regulation: overlap with MH issues
- Difficult to treat
- Chronic- major cause of disability
- Poor prognosis: no cure and long course
9
Q
Fibromyalgia symptoms
A
- Widespread pain in muscles, tendons and ligaments (but not joints)
- Fatigue
- Morning stiffness <1 hour
- Pins and needles in hands and feet
- Unrefreshing sleep, insomnia
- Low mood: could do PHQ9
- Cognitive symptoms: brain fog
- Can co-exist with other MSK conditions: may be primary or secondary to it
10
Q
Diagnosis of fibromyalgia
A
- Widespread pain for >3 months
- Fatigue, sleep disturbance
- Cognitive disturbance
- Headaches, IBS symptoms
- Tenderness but no swelling/inflammation on examination: diagnosis more likely id tender in at least 11 out of 18 points on the body
- Non specific- can fulfil criteria even if you have different condition
11
Q
Management of fibromyalgia
A
- Difficult
- Drugs: Analgesics mainly ineffective, Tricyclic anti-depressants may have some effect, Pregabalin, duloxetine, amitriptyline
- CBT, “talking therapies”
- Graded exercise
- Explanation of disorder
- Local heat application
12
Q
Investigations fibromyalgia
A
Do bloods to exclude other disorders for example,hypothyroidism, inflammatory disorders, andhepatitis C. Example Blood tests iclude:U+Es, FBC, TFTs,LFTs, CRP / ESR, Rheumatoid factor,Ca2+, ANA, immunoglobulins.
13
Q
Kellgren-Lawence grading scale for knee arthritis
A
- Normal: no features of OA
- Doubtful: minute osteophytes, doubtful significance
- Mild: definite osteophytes, normal joint space
- Moderate: moderate joint space reduction
- Severe: joint space is greatly reduced, subchondral sclerosis
14
Q
OA hands changes
A
- Herberden’s nodes- distal interphalangeal joint
- Bouchard nodes- proximal interphalangeal joint
15
Q
Non inflammatory arthritis i.e. Osteoarthritis
A
- 4 cardinal symptoms: pain, stiffness, swelling, loss of function/ difficulty in activities of daily living
- Pain: worse during or after activity
- Stiffness: can be in the mornings (tend to be less than 30 minutes) and on or after activity
- Bony swelling
- Difficulty in ADL
16
Q
Joint involvement in osteoarthritis
A
spine (spondylosis), carpometocarpal joint, distal interphalangeal joint, knees, in the big toe the metatarsal pharyngeal joint
17
Q
Joint involvement in RA
A
wrists, metacarpal pharyngeal joints, PIP, ankles and metatarsal pharyngeal joints
18
Q
Inflammatory arthritis (RA)
A
- 4 cardinal symptoms: Pain, stiffness, swelling, loss of function/difficulty in activities of daily living
- Pain: often worse in the mornings and on activity
- Stiffness: worse in the mornings (prolonged early morning stiffness >30 minutes) and on inactivity
- Swelling in joints
- Difficulty in ADL
19
Q
Bone remodelling
A
- Trabecular bone (spongy bone): replaced every 3-4 years
- Cortical bone (compact bone): replaced every 10 years
- Bone breakdown: osteoclasts
- Bone formation: osteoblasts
20
Q
Pathology of osteoporosis
A
- Thinning of cortical bone
- Fewer trabecular
- Bone cells are normal with normal mineralisation
- There is more bone breakdown with osteoclasts then bone formation with osteoblasts
21
Q
Risk factors for osteoporosis
A
- Age
- Low oestrogen: post menopause or early menopause
- Low serum calcium: after bones have been formed
- Smoking
- Alcohol
- No weight baring exercise
- Steroids
- Co-morbidities: Crushings, diabetes, hyperthyroidism
22
Q
Secondary causes of osteoporosis
A
- Endocrine: Hyperthyroidism, Hyperparathyroidism, Crushings disease, Diabetes mellitus, Hyperprolactinaemia, Early menopause
- Gastrointestinal: Coeliac disease, IBD, chronic liver disease
- Rheumatoid arthritis
- Metabolic: CKD
- Drug induced: steroids, antiepileptics
Complications of osteoporosis: Fractures
23
Q
DEXA scan
A
- Dual energy x-ray absorptiometry
- Analyses bone density to diagnose osteoporosis
- Hip, radius, back
24
Q
FRAX score
A
Evaluates fracture risk, gives a 10 year probability of a fracture. It considers:
- Age
- Sex
- Weight
- Height
- Previous fracture
- If the parent had a fractured hip
- Current smoking
- Corticosteroids
- Rheumatoid arthritis
- Secondary osteoporosis
- Alcohol 3 or more units/day
- Femoral neck BMD (g/cm)
25
Q
Osteoporosis treatment
A
- Conservative: quit smoking, reduced alcohol, regular exercise, Balanced diet
- Medical: Bisphosphonates (oral alendronic acid, IV zoledronate), Teripartide, Denosumab. Calcium and vitamin D replacement
- Surgical: bony fractures
26
Q
When to do a FRAX score
A
- Do FRAX score in women >65 and men >75
- OR
- In women <65 and men <75 with risk factors
27
Q
When to offer a DEXA scan
A
- Offer DEXA scan without initial FRAX score to anyone >50 with history of fragility fracture
- Consider starting treatment without DEXA scan in people with a vertebral fracture
- For patients with risk factors for osteoporosis do a FRAX score first. High risk patient should have DEXA
28
Q
Polymyalgia rheumatica (PMR)
A
- An inflammatory condition causing pain and stiffness in the shoulder and pelvic girdle
- More common in women >50 and caucasian
- Respond well to steroids, treatment tends to be over 2-3 months
- 15% develop GCA
29
Q
Clinical features of PMR
A
- Shoulder and/or pelvic girdle pain and morning stiffness lasting at least 45 minutes (may be initially unilateral but then becomes bilateral). Worse in the morning and after rest, interferes with sleep
- Improvement in symptoms one week after a trial of corticosteroids (usually prednisolone)
- Systemic features: low grade fever, fatigue, anorexia, weight loss and depression
- Peripheral oligoarticular arthritis (wrist, knee and metacarpophalangeal joint)
- Associated features: muscle tenderness, carpel tunnel syndrome, peripheral oedema
30
Q
Patients requiring referral to rheumatologists due to atypical features of PMR
A
- Have red flags of serious pathology (includingweight loss. night pain or neurological features) and don’t have a identifiable cause
- Younger than 60
- Do not have the core symptoms of PMR: Bilateral shoulder/pelvic girdle pain, >45 minutes of morning stiffness
- Have unusual features of PMR: Normal, or very high inflammatory markers, Chronic onset of symptoms, Limited response to steroids
31
Q
PMR investigations
A
- CRP/ESR: normally elevated. CRP is more sensitive but ESR is associated with higher risk of relapse
- Bloods: FBC, U&E, LFT, TSH, Calcium, Creatine kinase, Serum protein electrophoresis, RF, anti-CCP
- Urine dip
- Chest x-ray: before commencing methotrexate
- US: subacromial bursitis is associated with PMR
32
Q
Diagnosing PMR
A
- Age >50
- Acute or subacute bilateral pelvic and/or shoulder girdle aching, morning stiffness lasting >45 minutes
- A good response to corticosteroids
- Acute phase response: elevated CRP or ESR
- Exclusion of other conditions that mimic PMR: infection, active cancer and GCA
33
Q
PMR management
A
- Oral corticosteroids and gradually weaned off with dose adjustments being every 4-8 weeks and reviews one week after each dose adjustment
- If symptoms begin again after dose reduction then dose may need to be increased. Don’t need routine bloods can rely on reported symptoms
34
Q
Complications of PMR
A
- Chronic relapsing course- symptoms exacerbate frequently when reducing the corticosteroid dose
- Risks of corticosteroids: osteoporosis, increased infection risk, T2D, hypertension, cataracts, glaucoma, skin changes (thinning or bruising)
- GCA
35
Q
PMR reducing regime of prednisolone
A
- 15mg until the symptoms are fully controlled, then
- 12.5mg for 3 weeks, then
- 10mg for 4-6 weeks, then
- Reducing by 1mg every 4-8 weeks
36
Q
PMR: addition measures for long term steroids ‘Dont Stop’
A
- Don’t–steroid dependenceoccurs after 3 weeks of treatment, and abruptly stopping risksadrenal crisis
- S–Sick day rules (steroid doses may need to be increased if the patient becomes unwell)
- T–Treatment card – patients should carry asteroid treatment cardto alert others that they are steroid-dependent
- O–Osteoporosis prevention may be required (e.g.,bisphosphonatesandcalcium and vitamin D)
- P–Proton pump inhibitors are considered forgastro-protection(e.g., omeprazole)
37
Q
Giant cell arteritis (temporal arteritis)
A
A type of systemic vasculitis affecting the medium and large arteries. Key complication is visual loss which can be irreversible
38
Q
GCA presentation
A
- Unilateral headache: severe and around the temple and forehead
- Temple artery is tender and thickened to palpation with reduced or absent pulsation
- Scalp tenderness (e.g., noticed when brushing the hair)
- Jaw claudication
- Blurred or double vision
- Loss of vision if untreated
39
Q
GCA diagnosis
A
- Clinical presentation
- Raised inflammatory markers, particularly ESR (usually more than50mm/hour)
- Temporal artery biopsy(showingmultinucleated giant cells)
- Duplex ultrasound(showing thehypoechoic“halo”signandstenosisof the temporal artery)
40
Q
GCA management
A
- Steroids: started immediately before confirming diagnosis. 40-60mg prednisolonedaily with no visual symptoms or jaw claudication. 500mg-1000mg methylprednisolonedaily with visual symptoms or jaw claudication
- Once condition is controlled steroid dose is weaned over 1-2 years
- Aspirin75mg daily decreases vision loss and strokes
- Proton pump inhibitor(e.g., omeprazole) for gastroprotection while on steroids
- Bisphosphonatesandcalcium and vitamin Dfor bone protection while on steroids
41
Q
GCA complications
A
- Steroid-related complications (e.g., weight gain, diabetes and osteoporosis)
- Visual loss
- Cerebrovascular accident (stroke)
42
Q
Chronic plaque psoriasis
A
- 85-90%
- Well defined patches of redness with a thick silver scale
- Typically on extensor surfaces like elbows and knees
- Increased itch
43
Q
Causes of psoriasis
A
- Intense proliferation and abnormal keratinocytes proliferation, triggered by an active cellular immune system
- Role for T cells, dendritic cells and cytokines
- Genetic factors: HLA-B13, -B17 and Cw6
- Type 1 psoriasis (young onset) most strongly associated with CW0602 (PSORS1)
- Environmental triggers i.e. trauma, infection, drugs, EtOH. Improved by sunlight
44
Q
Psoriasis histology
A
- Psoriatic epidermis contains scattered neutrophils
- Neutrophil microabcesses can form
- Psoriasis may be pustular
45
Q
Types of psoriasis
A
- Guttate psoriasis
- Erythrodermic psoriasis
- Scalp psoriasis
- Flexural psoriasis
Features of psoriasis: nail pitting, onycholysis
46
Q
Treatment for psoriasis
A
- First line treatment of Psoriasis: Calcipotriol, Tar, Dithranol (anthralin) for chronic plaque psoriasis, topical steroids
- Photo: PUVA, UVB
- Systemic: biologics, ciclosporin, methotrexate, retinoids
- The systemic treatment is more toxic then first line
47
Q
Features of chronic plaque psoriasis
A
- Erythematous plaque covered in silvery white scale
- Clear delineation between normal and affected skin
- Typically effects extensor surfaces like elbows and knees
- Plaques 1 to 10cm in size
- If the scale is removed, a red membrane with pinpoint bleeding points may be seen (Auspitz’s sign)
48
Q
Stepwise treatment for chronic plaque psoriasis
A
- Regular emollients to reduce scale loss and pruritis
- First line: potent corticosteroids once daily plus vitamin D analogue applied once daily for up to 4 weeks
- Second line: if no improvements after 8 weeks then a vitamin D analogue twice daily
- Third line: if no improvements after 8-12 weeks then either a potent corticosteroid twice daily up to 4 weeks or a coal tar preparation OD or BD. Short acting dithranol can be used.
49
Q
Psoriasis complications
A
- Psoriatic arthropathy
- Increased incidence of metabolic syndrome
- Increased incidence of cardiovascular disease
- Increased incidence of venous thromboembolism
- Psychological distress
50
Q
Guttate psoriasis
A
- More common in children and adolescents.
- May be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing.
- Tear drop papules on the trunk and limbs. Pink scaly patches or plaques of psoriasis
- Tends to be acute over days
- Tends to resolve spontaneously within 2-3 months. Use topical agents as per psoriasis, UVB phototherapy. Tonsillectomy might be necessary with recurrent episodes
