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MSK > Cortex 2 - Rheumatology > Flashcards

Cortex 2 - Rheumatology Flashcards

1
Q

what is the term arthropathy used to describe ?

A

disease of the joint

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2
Q

what does the term arthritis describe ?

A

inflammation of the joint

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3
Q

what does arthralgia describe ?

A

simply pain in a joint

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4
Q

what are the two main categories of arthritis ?

A

inflammatory and non-inflammatory arthritis (commonly osteoarthritis)

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5
Q

how can arthritis be further subdivided into more specific categories

A

use the tabel

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6
Q

what factor is characteristic of many rheumatological conditions and what are these conditions specifically referred to as ?

A

Autoantibody production

Tend to be referred to as seropositive conditions (auto-antibodies in serum).

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7
Q

what are auto-antibodies ?

A

Are antibodies generated by the immune system against the body’s own proteins. If the immune system loses its normal regulatory processes, it stops recognising these proteins as being its own. It perceives them as alien and then begins to form antibodies against them, as it would an external threat eg. a virus.These auto-antibodies then begin to attack various organs and tissues, causing inflammation and damage.
Some autoantibodies are organ specific eg. those causing auto-immune thyroid disease, or can attack a number of different structures (systemic)

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8
Q

what predisposes patients to rheumatological conditions ?

A

its multifactorial - prob due to genetics and environmental e.g. infection, chemical exposure etc.

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9
Q

what condition is associated with the anti-CCP antibody associated with?

A

rheumatoid athritis

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10
Q

what antibody are the following conditions associated with ?

SLE, Sjogrens syndrome, Systemic sclerosis, MCTD, autoimmune liver disease

A

Anti-nuclear antibody (ANA)

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11
Q

what condition is both of these antibodies associated with?

  • Anti-double stranded DNA antibody (dsDNA)
  • Anti-Sm
A

SLE - systemic lupus erythematosus

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12
Q

what 2 conditions is associated with Anti-Ro antibody?

A

SLE, sjorgens syndrome

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13
Q

what condition is Anti-centromere antibody associated with?

A

Systemic sclerosis (limited)

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14
Q

what condition is Anti-Scl-70 antibody associated with ?

A

Systemic sclerosis (diffuse)

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15
Q

what conditions is Anti-RNP antibody associated with ?

A

SLE, Mixed connective tissue disease (MCTD)

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16
Q

what condition is Anti-Jo-1 antibody associated with?

A

Myositis

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17
Q

what condition is Anti-cardiolipin antibody and lupus anti-coagulant

A

Anti-phospholipid syndrome

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18
Q

what conditions is Anti-neutrophil cytoplasmic antibody (ANCA) associated with?

A

Small vessel vasculitis (GPA, EGPA, MPA)

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19
Q

match the antibodies to there associated conditions:

  1. Anti-CCP antibody
  2. Anti-nuclear antibody (ANA)
  3. Anti-double stranded DNA antibody (dsDNA) also called Anti-DNA binding
  4. Anti-Sm
  5. Anti-Ro
  6. Anti-La
  7. Anti-centromere antibody
  8. Anti-Scl-70 antibody
  9. Anti-RNP antibody
  10. Anti-Jo-1 antibody
  11. Anti-cardiolipin antibody and lupus anti-coagulant
  12. Anti-neutrophil cytoplasmic antibody (ANCA)
  • Small vessel vasculitis (GPA, EGPA, MPA)
  • Anti-phospholipid syndrome
  • Systemic sclerosis (diffuse)
  • Systemic sclerosis (limited)
  • SLE, Mixed connective tissue disease (MCTD)
  • Myositis
  • Sjogrens syndrome
  • SLE
  • Rheumatoid arthritis
  • SLE, Sjogrens syndrome
  • SLE, Sjogrens syndrome, Systemic sclerosis, MCTD, autoimmune liver disease
  • SLE
A
  1. Rheumatoid arthritis
  2. SLE, Sjogrens syndrome, Systemic sclerosis, MCTD, autoimmune liver disease
  3. SLE
  4. SLE
  5. SLE, Sjogrens syndrome
  6. Sjogrens syndrome
  7. Systemic sclerosis (limited)
  8. Systemic sclerosis (diffuse)
  9. SLE, Mixed connective tissue disease (MCTD)
  10. Myositis
  11. Anti-phospholipid syndrome
  12. Small vessel vasculitis (GPA, EGPA, MPA)
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20
Q

what type of condition is osteoarthritis ?

A

degenerative condition - sometimes there is associated swelling which can cause flare ups of OA (remember it itself is not an inflam rheumatoid condition though).

Generally it is accepted that there is an imbalance between wear and repair of cartilage within joints.

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21
Q

when there is no known causative facotr causing the OA what is the classed as ?

A

primary OA

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22
Q

when there is causative factors causing the OA what is it known as ?

A

secondary OA

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23
Q

what are some of the causes of secondary OA?(10)

A
  • Congenital dislocation of the hip
  • Perthes
  • SUFE
  • Previous intra‐articular fracture
  • Extra‐articular fracture with malunion
  • Osteochondral / hyaline cartilage injury
  • Crystal arthropathy
  • Inflammatory arthritis (can give rise to mixed pattern arthritis)
  • Meniscal tears
  • Genu Varum or Valgum
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24
Q

what mneunmonic do use to assess an X-ray for OA ?

A

LOSS

L- loss of joint space

0- Osteophytes

S - Sclerosis

S - Subchondral cysts

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25
Q

what is the management of OA?

A

Simple analgesia and mild opiates may be helpful. Physiotherapy is useful in strengthening surrounding structures. Weight loss and exercise are also important.

In some situations surgery may be an option e.g. hip and knee replacement, but this depends on the joint affected.

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26
Q

what 4 broad categories can inflammatory conditions be classed into?

A

seropositive, seronegative, infectious and crystal deposition disorders.

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27
Q

what are many of the inflammatory arthropathies due to ?

A

Due to auto‐immune mediated conditions where the patient’s own immune system attacks the joints and sometimes the connective tissues of the musculoskeletal (and other) systems.

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28
Q

what mainstay for treatment of inflammatory arthropathies ?

A

Simple analgesia, anti‐ inflammatory medications (steroids & NSAIDs), steroid injections and Disease Modifying Anti Rheumatic Drugs (DMARDs).

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29
Q

describe the joint involvement in osteoarthritis

A
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30
Q

describe the joint involvement in rheumatoid arthritis

A
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31
Q

describe the joint involvement in psoratic arthritis

A
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32
Q

describe the joint involvement in inflammatory spondylitis

A
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33
Q

what are the features of inflammatory arthritis ?(6)

A
  • Joint pain with associated swelling
  • Morning stiffness
  • Improvement in symptoms with exercise
  • Synovitis on examination
  • Raised inflammatory markers (CRP and plasma viscosity)
  • Extra-articular symptoms
34
Q

what is the most prevalent seropositive inflammatory arthropathy ?

A

rheumatoid arthritis

35
Q

what joints does rheumatoid arthritis commonly affect?

A

the small joints of thehands and feet.(earlier on) Larger joints such as the knees, shoulders and elbows can also be affected as the disease progresses.

36
Q

who is affected more by rheumatoid arthritis ?

A

women are 2-3 times more commonly affected

37
Q

what is the peak age range for developing rheumatoid arthritis and what factor accounts for 50% of the risk of developing RA?

A

35-50

genetic factors

38
Q

describe the disease process of rheumatoid arthritis ?

A

An immune response is initiated against synovium which lines synovial joints and some tendons.

Inflammatory pannus (Pannus is an abnormal layer of fibrovascular tissue or granulation tissue.) forms which then attacks and denudes articular cartilage leading to joint destruction. Tendon ruptures and soft tissue damage can occur leading to joint instability and subluxation.

39
Q

how is RA diagnosed ?

A

using clinical presentation, radiographic findings and serological analysis. The ACR and EULAR Rheumatoid Arthritis Criteria scoring systems assist in the diagnosis.

40
Q

what are some of the clinical features of RA?

A

Symmetrical synovitis (doughy swelling), pain and morning stiffness.

41
Q

during early RA what joints are affected?

A

The hands and feet tend to be involved early.

MCP and PIPs joints are affected, as well as wrists.

42
Q

what joints are specially spared in patients with RA?

A

DIP joints

43
Q

in later stage RA what joints can also be affected ? and what is an important joint to look for that can be affected?

A

Larger type joints - such as the alanto-axial joint in the cervical spine. As in longstanding disease there may be atlanto-axial subluxation which can result in cervical cord compression.

44
Q

what clinical feature of RA is shown here?

A

small joint synovitis

45
Q

what are some of the extra-articular manifestations of RA?

A

Rheumatoid nodules occur in approximately 25% of patients with RA.

Lung involvement includes pleural effusions, interstitial fibrosis and pulmonary nodules.

Increased Cardiovascular morbidity and mortality.

Ocular involvement is common and includes keratoconjunctivitis sicca, episcleritis, uveitis, and nodular scleritis that may lead to scleromalacia.

46
Q

which of the two autoantibodies to test for RA is the preffered test?

  1. Rheumatoid factor
  2. Anti-CCP antibody
A

Anti-CCP antibody because it is more specific

47
Q

can RA patients be seronegative i.e. have no autoantibodies present ?

A

yes - 15 to 20% are

48
Q

what are the usual changes in CRP, ESR and plasma viscosity for patients with RA?

A

all raised

49
Q

what are some of the features of RA on X-ray?

A

Early features can include peri-articular osteopenia (bone thinning) and soft tissue swelling. Periarticular erosions can occur later.

50
Q

what is the use of US in RA?

A

for detecting synvoial inflam if their is clinical uncertainty

51
Q

what is the goal of RA treatment?

A

to start DMARD therapy within 3 months

52
Q

which DMARD is used first line?

A

methotrexate

53
Q

give some examples of other DMARD’s

A

sulphasalazine, hydroxychloroquine and leflunomide

54
Q

what are side effects of DMARD’s and what monitoring do they require ?

A

They are immunosuppressive so may increase the risk of infection and can cause bone marrow suppression. Regular blood monitoring is therefore required.

55
Q

what are some of the short term symptom reliveing treatments of RA?

A

Include simple analgesia, NSAIDs and Intramuscular/intra-articular and oral steroids.

56
Q

what type of therapy can be used to treat RA if DMARD therapy is shown to not be effective ?

A

Biologic therapy.

57
Q

what is the most common type of biologic therapy given to RA patients?

A

anti-TNF alpha drugs, given by injection.

58
Q

what are some of the other biologics that could be given to RA patients ?

A

toclizumab, rituximab and abatacept

59
Q

what does biologic therapy increase the risk of ?

A

Increased risk of infection, especially tuberculosis.

60
Q

what is the DAS 28 score ? and what does it fundamentally measure?

A

measures disease activity

Made up a composit score of 4 domains, which are: tender joint count, swollen joint count, CRP/ESR and visual analogue score

61
Q

what DAS 28 score do patients need to be able to receive biologic therapy if required?

A

DAS 28 > 5.1

62
Q

what are the different cut off levels of DAS 28 score mean?

A

The lower the DAS 28 score the better. Cut off values are as follows:

DAS 28 < 2.6 Remission

DAS 28 2.7-3.2 Low disease activity

DAS 28 3.3-5.1 Moderate disease activity

DAS 28 >5.1 High disease activity

63
Q

what are some of the other therapies used to treat RA outwidth medications ?

A

Physiotherapists, occupational therapists, podiatrists and orthotists also have a very important role.

Surgery can be used for resistant disease, but increasingly this is less often the case . Operations performed include:

  • Synovectomy
  • Joint replacement
  • Joint excision
  • Tendon transfers
  • Arthrodesis (fusion)
  • Cervical spine stabilisation
64
Q

what diseases are encompassed by the umbrella term - seronegative inflammatory arthropathies

A

Ankylosing spondylitis, psroiatic arthritis, enteropathic arthritis and reactive arthritis.

65
Q

what are some common features of seronegative inflam arthropathies ?

A

Characterised by inflammation and/or arthritic disease of the spine, known as spondyloarthropathy, and an asymmetric oligoarthritis. . Sacroiliitis, uveitis, dactylitis (inflammation of a digit) and enthesopathies are common (especially achilles insertional tendonitis and plantar fasciitis)

66
Q

what blood test is usually positive in patients with seronegative arthropathies?

A

HLA-B27 also CRP and ESR are often elevated.

67
Q

what is ankylosing spondylitis ?

A

A chronic inflammatory disease of the spine and sacro‐iliac joints which can lead to eventual fusion of the intervertebral joints and SI joints

68
Q

who is more commonly affected by ankylosing spondylitis ? and what age range are most people affected?

A

males (3:1)

age range of 20-40 most common

69
Q

what are some of the clinical features of ankylosing spondylitis?

A

spinal pain and stiffness - imporves with exercise

may also develop knee or hip arthritis.

Over time there is loss of spinal movement and development of a “question mark” spine, with loss of lumbar lordosis and increased thoracic kyphosis.

70
Q

what clinical sign is shown and what disease does it relate to?

A

'’question mark spine’’

ankylosing spondylitis

71
Q

what does the schobers test measure and explain the test?

A

Lumbar spine flexion

Involves measuring 5cm below the posterior superior iliac crests and 10cm above, whilst the patient is upright, then asking them to bend forwards and remeasuring the distance. In normal situations it should extend beyond 20cm.

72
Q

Give some associated conditions of ankylosing spondylitis ?

A

anterior uveitis, aortitis, pulmonary fibrosis and amyloidosis

73
Q

what are some of the X-ray features seen in ankylosing spondylitis?

A

Xrays may show sclerosis and fusion of the sacroiliac joints and bony spurs from the vertebral bodies, known as syndesmophytes, which can bridge the intervertebral disc resulting in fusion, producing a “bamboo spine”.

74
Q

describe the treatment for ankylosing spondylitis in general

A

Treatment consists of physiotherapy, exercise, NSAIDs and anti-TNF inhibitors for more aggressive disease. DMARDs do not have any impact on spinal disease but may be used if there is peripheral joint inflammation.

Surgery is mainly reserved for hip and knee arthritis

75
Q

Describe psoriatic arthritis and how it presents

A

occurs in 30% of people with psoriasis

The arthritis is usually an asymmetrical oligoarthritis, but may also affect the hands in a pattern similar to RA. Spondylitis, dactylitis and enthesitis commonly occur.

Nail changes including pitting and onycholysis (lifting of the nail from its nailbed). Some patients have a prediliction for arthritis of the DIP joints of the fingers and/or toes.

76
Q

what is the aggressive form of psoriatic arthritis that 5% of patients develop ?

A

arthritis mutilans

77
Q

what is the treatment of psoriatic arthritis?

A

similar to RA with DMARDs starting with methotrexate and if patients don’t respond to DMARD’s then they can be treated with Anti-TNF therapy.

joint replacement considered in larger joints and DIP joint fusion can occasionally help.

78
Q

what is enteropathic arthritis ?

A

An inflammatory arthritis involving the peripheral joints and sometimes spine, occurring in patients with inflammatory bowel disease (Crohn’s disease and Ulcerative Colitis).

Tends to be a large joint asymmetrical oligoarthritis.

79
Q

what is the treatment of enteropathic arthritis?

A

usually involves finding medication to manage both the underlying condition and the arthritis..

80
Q

what is reactive arthritis in response to ?

A

In response to an infection in another part of the body, most commonly genitourinary infections (Chlamydia, Neisseria) or GI infections (Salmonella, Campylobacter).

Around 1‐3 weeks following the infection

81
Q

what is the symptoms of reactive arthritis? and know that they can present in a triad sometimes

A

uveitis or conjunctivits and arthritis known as Reiter’s syndrome.

82
Q

what is the treatment of reactive arthritis?

A

Aimed at the underlying infectious cause and symptomatic relief, including IA or IM steroid injections. Occasionally DMARDs are required in chronic cases.

MSK (22 decks)

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