Block 9: RA, SLE Flashcards
1
Q
RA diagnostic criteria
A
- Two or more swollen joints
- Morning stiffness
- Rheumatoid Factor
2
Q
Investigations in RA
A
- Blood Tests: FBC (neutropenia, normocytic anaemia), ESR, CRP, Rheumatoid Factor (not specific), Anti-CCP, ANA
- Plain X-ray
3
Q
RA synovium joint
A
Immune mediated destruction, causes thickening of synovium and joint diffusion. Destruction of articular cartilage and erosion of the subchondral bone resulting in cysts. Starts to affect the ligaments causing joint instability.
4
Q
RA: x-ray
A
- Narrowing joint space
- Marginal erosions: due to destruction of subchondral bone
- Periarticular osteopenia: due to disease and side effect of steroids
- Irregular joint surface
- Deformity / subluxation (patrial disarticulation of joint) / dislocation
- Soft tissue swelling
- Secondary Osteoarthritis: can affect hips and knees
- LESS
5
Q
RA: surgery
A
- Early and intensive pharmacological treatment in the critical first few months of disease - ‘window of opportunity’
- Overall reduced rates of surgical intervention on patients with RA
- Main indications for surgery - pain relief / improvement in function
- Correcting deformities; stabilising joints; decreasing disability
- Types of surgery: Arthroscopy and synovectomy; tendon transfer; resection arthroplasty; arthrodesis; total joint replacement
6
Q
Nerve conduction study/Electromyography
A
- NCS: test function of peripheral nerves by the speed of electric current conduction
- EMG: tests electrical activity produced by skeletal muscles
- Helps diagnose peripheral neuropathy like in carpal and cubital tunnel syndrome
7
Q
Types of surgery for RA
A
- Tendon transfer: when there is tendon rupture, move a tendon from a functional unit to a compromised one. Tend to be in hand
- Arthrodesis: fusion of joint, causes reduction of pain but loss of function as the joint can no longer move. Ankylosis is when the disease causes fusion of the joint- causes pain.
- Excision arthroplasty: the metatarsal heads are excised allowing freer movement at the joints. Metal wires are then inserted to stabilise the joint, removed a few weeks after the surgery. Helps with pain relief can cause instability
- Arthroscopic synovectomy: removal of inflamed synovium
8
Q
Indications for total joint replacement
A
- Painful synovitis / swelling
- Reduction in range of movement (lack of full extension)
- Ulnar nerve neuropathy (compression by inflamed synovium): cubital tunnel syndrome
- Laxity of soft tissues (ligaments) > instability
- Destruction of articular surfaces (joint erosion / cyst formation / bone loss)
9
Q
RA steroid injections
A
Relieve symptoms and reduce need for joint replacement. Aseptic technique, given every 4 months, repeated injections can weaken ligaments. Don’t do injection within 6 months of joint replacement
10
Q
SLE
A
- Peak incidence 20-35
- Strong genetic component: HLA-DRB1
- Common in afro-caribbeans
- Potential triggers: EBV, family history
- Drug induced lupus: Hydralazine, Isoniazid, Chlorpromazine, Minocycline, TNF inhibitor
- Photosensitive rash: often in butterfly distribution but not always, avoids eyelids
- Fatigue
- Arthritis: symmetrical polyarthropathy similar to RA though non deforming i.e. can still make fist and no x-ray changes
11
Q
Other SLE symptoms
A
- Alopoecia: patches of baldness
- Headaches
- Sicca symptoms: dryness of eyes and mouth
- Mouth ulcers: large, painful
- Pleuritic chest pain
- Raynaud’s phenomenon: colour change in the cold- white → blue/purple, when rewarming go red
- Recurrent miscarriages
- Can affect other systems: renal, Neurological/psychiatric (personality change, psychosis), haematological, can mimic other conditions
12
Q
SLE investigations
A
- FBC: normochromic, normocytic anaemia with leukopenia and thrombocytopenia
- renal function (urinalysis, urineprotein:creatinine ration, renal biopsy), ESR, CRP, others depending on symptoms/signs
- ANA positive in 95%
- Anti-smith antibodies: most specific but present in less than half of cases. Antibodies are diagnostic
- dsDNA, complement C3 and C4 – useful as disease activity markers. With disease activity dsDNA rises and complement falls
- Lupus anticoagulant (causes clotting), antiphospholipid antibodies
- BP and urinalysis
13
Q
SLE organ specific symptoms
A
- Renal disease: often asymptomatic till late stage, lupus nephritis
- Pregnancy loss, obstetric complications: lupus tends to get worse during pregnancy
- Respiratory: pleuritis, pneumonitis, pulmonary emboli
- Thrombotic risk
- Cardiovascular: Pericarditis, Raynaud’s, endocarditis, Atherosclerosis
- Neuropsychiatric: Headache or migraine, seizures, psychosis
- Complications of treatment
14
Q
SLE treatment
A
- Education and advice
- NSAIDs
- Sun block: for the rash but also sun increases disease activity generally
- Nutrition: healthy diet
- Smoking cessation
- Steroids for flares of arthritis
- DMARDs: Hydroxychloroquine (first line)
- Moderate to severe: Methotrexate, Azathioprine, Mycophenolate, Cyclophosphamide (fertility risk if male or female). DMARD’s
- Biologic drugs: Rituximab, Belimumab for more severe SLE
- Psychological support: CBT, support groups
15
Q
Skin manifestations of SLE
A
- photosensitive ‘butterfly’ rash
- discoid lupus: discoid raised patches with scaling and follicular plugging
- alopecia
- livedo reticularis: net-like rash. Mottled skin rash with purple discolouration
16
Q
Lupus criteria
A
- Uses 11 criteria of which 4 or more are required for diagnosis
- Malar rash.2 clinical and 2 laboratory
- Discoid lupus
- Photosensitivity
- Non-erosive arthritis involving 2+ peripheral joints
- Oral or nasopharyngeal ulcers
- Pleuritis or pericarditis
- Renal involvement
- Seizures or psychosis
- Haematological disorder: Haemolytic anaemia, Leukopenia, Lymphopenia, Thrombocytopenia.
- Immunological disorder: Anti-DNA antibody, Anti-Sm, Antiphospholipid antibodies.
- Positiveanti-nuclear antibody
17
Q
SLE complications
A
- Infection: made worse by treatment
- Lupus nephritis: more closely associated with positive anti-dsDNA SLE. Typical nephritic picture of peripheral oedema and haematuria
- Atherosclerosis: particularly bad if antiphospholipid syndrome as well
- Osteoporosis: often due to early menopause, reduced sun exposure and glucocorticoids
- Malignancy: particularly haematological, cervical or lung
18
Q
Diffuse pleural thickening (DPT)
A
- Asbestos related lung disease
- Diffuse pleural thickening in a similar pattern to empyema or haemothorax, occurs after BAPE in 40% of cases.
- Can be uni or bilateral and involves both the visceral and parietal pleura.
- On X-ray it appears as a smooth, conglomerate opacity along the pleura. On CT the pleura must be > 3mm thick.
- Causes pain and breathlessness from lung restriction.
- VC and TLCO will be low
19
Q
Gonadotropin adenoma
A
Women:
- If hypogonadism: Hot flushes, vaginal dryness
- If hypergonadism: Irregular menstruation, ovarian hyperstimulation syndrome
Male:
- If hypogonadism: Mood swings, decreased libido
- If hypergonadism: Enlarged testicles, deeper voice, balding on temples
20
Q
Somatotroph adenomas
A
Secrete growth hormone
- Cause acromegaly
- Enlarged hands, feet, head size, rounded face, macroglossia, frontal bossing
- O/E: Hypertension, T2DM, hypertrophic heart, carpal tunnel syndrome
