Connective tissue disease and vasculitis Flashcards
Rheumatology:
Joint History
Joint exam
LOOK, FEEL, MOVE!!!!
Boney-osteophytes
Boggy-synovitis
Arthritis
There are more than one type of osteoarthritis
Osteoarthritis
Do get synvovitis and joint effusion, so do get inflammatory component
Osteoarthritis clinical presentation
Boney swelling eg Heberdons and bouchards nodes
Osteoarthritis examiation
Varus deformity-coming in
Osteoarthritis radiographical
weight bearing scan
Treatment of osteoarthritis
No DMARD shown to be effective!
Paracetamol then ibuprofen and cocodamol.
But be ware of risk eg cocodamol can cause dependence
Arthritis summary
Gout-first MTP joint
Pseudogout-risk and knee
GOUT arthritis
Only a ⅓ comes from diet, most uric acid comes from breakdown metabolic products
Some people tend to have higher uric acid because they failure to excrete it effectively (underpins familial basis of gout-due to polymorphism), or high BMI or high diet purines
Tophi in soft tissues and arthritis in joints
GOUT arthritis presentation
Red, swollen joint-differential can be cellulitis
Only get tophi in gout, not pseudogout
Gout-examination
Gout investigations
- Blood test for urate (may be in reference range and still cause gout)
- Acute phase response is to excrete more urate (so at this point urate will be lower so when patient has recovered, go back to test this)
- Can have high neutrophil which is hard to differentiate from infection
- Rat bite periarticular erosion
Gout treatment
- Give colchicine for acute attacks as tackles neutrophils
- Chronic-want a xanthine oxidase inhibitor eg allopurinol
Gout lifestyle
- Reduce alcohol especially beer
- Reduce Game and rich fish
Calcium pyrophosphate crystals
Like depositing in floating cartilage eg wrists and knees
Rhomboid shape crystals
Older people, especially females
Subcutaneous swelling
Inflammed risk esp in older women, ddx is septic arthritis
There is no prophylactic medication-can’t try and dissolve crystals
Arthritis summary
RA aetiology
Autoinflammatory or autoimmune
Polymorphisms in RA
HLA-DR1 and HLA-DR4
Polymorphism involving genes affecting the adaptive immune response
Losing tolerance in RA
-RF are Around 60-70% sepecific and sensitive for Rheumatoid Arthritis
If lose tolerance and develop AB to citrullinated peptides then you are highly likely to get RA
This is the more helpful test!
What happens to the joint in RA?
Increase in synvoial fluid, loss of joint space and erosive change. In synvovium have activation of t, b cells and macrophages, fibroblast synoviocytes
Macrophages produce TNF alpha which stimulates the fibroblast like synoviocytes which produce IL-6 setting up cycle as this stimulates macrophages
RA-clinical presentation
RA-examination
Boggy joints due to inflammatory synovitus
RA-investigations
US and MRI scans (as looking for soft tissue swelling)
Black area is abnormal-thickened synovium and synovial fluid. Put doppler on to show blood supply and this shows increased blood supply as inflammed.
RA-management:
RA-management-drugs
Steroids aren’t long term-only used at start or for bridging treatments
START DMARDs to prevent inflammation and destruction. Remember methotrexate!
Biological dmards targeting cytokines and inflammatory molecules eg TNF alpha blocker
Targeted synthetic dmards-block signalling pathways eg Jakinibs
Poorly controlled RA
Poorly controlled RA features
Systemic issues of RA:
RA-what has changed?
Arthritis summary
Spondyloarthritis
No infection or crystals effecting this
Spondyloarthritis
Genes affect regulation of innate and adaptive immune response
Spondyloarthritis-4 conditions with common features
HLA-B27 positive!
Spondyloarthritis-genetic polymorphisms
HLA-B27-adaptive immune response whereas other ones affect innate response.
Spondyloarthritis enthetitis
Il-23
Spondyloarthritis-sacroilitis
Start with soft tissue imaging eg MRI and then progress to X-ray
Spondyloarthritis-synovitis is a features
Spondyloarthritis-dactylitis:
Axial Spondyloarthritis
Axial Spondyloarthritis
Get bamboo spine and shiny corners on spine due to enthetitis.
Axial Spa is term should be using used to think this is ankylosing spindylitis but this takes 7 years to get xray changes so delays treatment
Psoriatic arthritis
Can get arthritis mutilans form of psoriatic arthritis which causes very deformed joints
Reactive arthritis
Enteropathic arthritis
Spondyloarthritis investigations
Rarely ask for xray as MRI is better as it shows synovitis. Look for shiny corners on spine
Spondyloarthritis management
Spondyloarthritis management-drug treatment
DMARDs-conventitional dmards like methotrexate only works for peripheral arthritis not central so go straight to biologics eg TNF alpha blocker
Summary
