Disease Profiles: Inflammatory Arthritis Flashcards
What is the ASAS classification criteria for ankylosing spondylitis?
In patients with ≳ 3 months back pain and age of onset <45 years: Sacroiliitis on imaging and ≳1 SpA feature OR HLA-B27 positive and ≳ 2 other SpA features
Examples of SpA features include inflammatory back pain, arthritis, psoriasis, IBD, family history, uveitis and raised inflammatory markers
What is a Swan neck deformity?
PIP hyperextension and DIP flexion
Describe some x-ray signs of ankylosing spondylitis
Usually normal in early disease
Late disease - sclerosis and fusion of the sacroiliac joints, bony spurs from the vertebral bodies (syndesmophytes), skinny corners
What are gouty tophi?
Painless white accumulations of uric acid which can occur in the soft tissues and occasionally erupt through the skin, can result in a destructive erosive arthritis
What is Boutonniere deformity?
PIP flexion and DIP hyperextension
Describe the usual management of acute calcific tendonitis of the shoulder
NSAIDs, subacromial steriod and local anaethetic injections for pain relief
Physio
Usually self-limiting as calcification re-absorbs
Name two shared extra-articular features of the spondyloarthropathies
Ocular inflammation (anterior uveitis, conjunctivitis)
Mucocutaneous lesions e.g. oral ulcers
How are immune complexes formed in rheumatoid arthritis?
Anti-citrullinated peptide antibodies (can be generated in the lungs from smoking) can form immune complexes with the citrullinated proteins produced in an inflamed synovium
What is the specificity of rheumatoid factor for rheumatoid arthritis?
60-70% specific
Describe the appearance of monosodium urate crystals under polarised microscopy
Needle shaped, negative birefringent crystals
When would biological agents be considered in the treatment of rheumatoid arthritis?
If 2 DMARDs have been tried and patient still has very active disease (DAS28 score > 5.1)
Which patient group is reactive arthritis most common in?
Young adults (20-40 years), equal sex distribution, HLA B27 positive
Describe the management of refractory acute calcific tendonitis of the shoulder
Surgical removal of calcifications, partial/total arthroplasty is last line
What crystal is responsible for pseudogout?
Calcium pyrophosphate
What is anti-CCP?
Autoantibody found in rheumatoid arthritis associated with current/previous smoking history, more likely to be associated with smoking history
Why does gout prophylaxis require cover with NSAIDs for first 6 months (or colchicine/steroids)?
Rapid reduction in uric acid level may result in further exacerbation of gout
Which types of hypersensitivity reaction are associated with rheumatoid arthritis?
Driven by type IV (T cell mediated), secondary type III reactions also occur
What patient group is most affected by pseudogout and why?
The elderly, and because chondrocalcinosis increases with age
What is ankylosing spondylitis?
Chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine, 90% HLA B27 positive
What may an x-ray of late rheumatoid arthritis show?
Erosions, sublaxation
What may an MRI be used for in rheumatoid arthritis?
Extremely sensive but only use if diagnostic doubt
What is gout?
Inflammatory crystal arthropathy caused by the precipitation and deposition of monosodium urate crystals into joints and soft tissues
Which patient group is most commonly affected by Hydroxyapatite Deposition Disease?
Females, 50-60 years
What are Bouchard’s nodes?
Bony swellings of proximal IPJ seen in RA and OA
How long does acute gout take to settle with and without treatment?
10 days without treatment, 3 days with treatment
Describe the common x-ray findings in psoriatic arthritis
Marginal erosions and ‘whiskering’, osteolysis, enthesitis
What is the WHO target for serum uric acid to prevent further attacks of gout?
300-360µmol/L
Which forms of T cell are involved in rheumatoid arthritis?
CD4+ T cells, CD4+ Th1 and Th17 effector cells
What is pseudogout?
Deposition of calcium pyrophosphate in the joints and soft tissues, leading to inflammation
Name the diseases associated with HLA B27
Psoriatic arthritis, ankylosing spondylitis, IBS (+ enteropathic arthritis), reactive arthritis
Name two other treatment options for gout prophylaxis other than xanthine oxidase inhibitors
Uricosuric drugs, IL-1 inhibitors
Are autoimmune conditions more common in males or females?
Females
What is the first line treatment for rheumatoid arthritis?
DMARDs
Describe the main articular manifestations of rheumatoid arthritis
Symmetrical pain and swelling of affected joints, most commonly in the small joints of the hands and feet (larger joints affected as disease progresses)
Early morning stiffness > 30 mins that usually improves with activity
Describe the appearance of calcium pyrophosphate crystals under polarised microscopy
Envelope shaped, mild positively birefringent
Which joints are usually affected in reactive arthritis?
Asymmetrical monoarthritis or oligoarthritis of large joints e.g. the knee
What causes recurrent gout flares?
The acute inflammatory response to deposited MSU crystals
How many attacks of gout per year in spite of lifestyle modification would indicate the need for gout prophylaxis?
2+ attacks
Name the crystal responsible for gout
Monosodium urate crystals
How are autoantibodies generated in rheumatoid arthritis?
Susceptibility genes lead to the conversion of arginine (A) into citrulline (C), resulting in an unfolded protein
The unfolded protein acts as an antigen
Describe the x-ray findings in acute calcific tendonitis of the shoulder
Calcification can be seen just proximal to the greater tuberosity
Which joint is most commonly affected by pseudogout?
Swollen, painful, warm knee
What is arthritis mutilans?
A particularly aggressive and destructive form of psoriatic arthritis that usually occurs in the hands and involves the reabsorption of bone and collapse of soft tissue
What is enteropathic arthritis?
Refers to an inflammatory arthritis involving the peripheral joints and sometimes the spine, occuring in patients with inflammatory bowel disease
What is pannus?
Inflammatory granulation tissue that occurs in rheumatoid arthritis; it produces proteinases that destroy the cartilage extracellular matrix
Describe the histology of gouty tophi
Amorphous eosinophilic debris and inflammation (giant cells)
What is the first line treatment for ankylosing spondylitis?
NSAIDs (+ symptomatic relief e.g. corticosteroid injections, eyedrops)
Patients with high titres of rheumatoid factor are more at risk of ____________
Extra-articular disease
Which to antibodies are associated with rheumatoid arthritis?
Rheumatoid factor, anti-CCP
Name a seropositive inflammatory arthritis
Rheumatoid arthritis
What is the ‘question mark’ posture?
Loss of lumbar kyphosis with pronounced cervical lordosis seen in late ankylosing spondylitis
Name two blood values which may be raised in gout
Serum uric acid, inflammatory markers
What usually causes gout?
High serum uric acid levels (hyperuricaemia)
Name a shared feature of the spondyloarthopathies that affects tendons
Enthesitis - inflammation at insertion of tendons into bones e.g. Achilles tendinitis, plantar fasciitis
Describe the articular symptoms of ankylosing spondylitis
Gradual onset of dull spinal and neck pain, morning stiffness > 30 mins that improves with activity
How would you treat unresponsive psoriatic arthritis?
Consider DMARDs, then anti-TNF or other biologics
What is Reiter’s syndrome?
Triad of urethritis, conjuctivitis/uveitis/iritis and arthritis sometimes seen in reactive arthritis
What is rheumatoid factor?
IgM or IgA antibody that binds to Fc region of IgG
What may an ultrasound be used for in rheumatoid arthritis?
May be useful in detecting synovial inflammation if their is clinical uncertainty (especially in early RA), useful in making treatment changes
Name a shared feature of the spondyloarthopathies that affects the fingers
Dactylitis (‘sausage’ digits) - inflammation of the entire digit
If indicated, when should prophylactic therapy for gout be started?
4-6 weeks after acute attack
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis, HLA B27 positive
Describe the histology of rheumatoid nodules
Necrotising granulomas with a palisade of macrophages surrounding a central area of collagen necrosis
What is chondrocalcinosis?
Calcium pyrophosphate deposition occurs in cartilage and other soft tissues in the absence of acute inflammation
How are infection and smoking implicated in rheumatoid arthritis?
Increase anti-CCP
What medication is often associated with gouty tophi?
Diuretics
What patient group is ankylosing spondylitis most common in?
Young males (20-40 years), HLA B27 positive
What may an x-ray of early rheumatoid arthritis show?
Can be normal, may show soft tissue swelling and periarticular oseopenia
Which antibody is most sensitive for rheumatoid arthritis?
Rheumatoid factor
Which joints are usually affected in psoriatic arthritis?
Usually an asymetrical oligoarthritis, predominantly affects joints of hands and feet, 20% of cases involve sacro-iliac joints
Which infections most commonly proceed reactive arthritis?
Urogenital (e.g. chlamydia) or GI (e.g. salmonella, shigella, yersinia, campylobacter)
How would you treat unresponsive ankylosing spondylitis?
Consider DMARDs, then anti-TNF or other biologics
What are the spondyloarthopathies?
Family of inflammatory arthritides characterised by the involvement of both the spine and the joints, principally in genetically predisposed individuals
Anklosing spondylitis is the most common form, but the family also includes reactive arthritis, psoriatic arthritis and enteropathic arthritis
What is the first line treatment for psoriatic arthritis?
NSAIDs (+ symptomatic relief e.g. corticosteroid injections, eyedrops)
What is Schobers test?
Used to measure lumbar spine flexion, reduced in ankylosing spondylitis
What is acute calcific tendonitis of the shoulder?
Hydroxyapatite crystal deposition in the supraspinatus tendon which causes the release of collagenases, serine proteinases and IL-1
Describe the management of pseudogout
Treat acute episodes appropriately - NSAIDs, colchicine, steroids, rehydration
No prophylactic management
What causes chronic gouty arthritis and tophaceous gout?
Chronic granulomatous inflammatory response to deposited crystals
What is the first line medication for gout prophylaxis?
Allopurinol (xanthine oxidase inhibitor)
Describe the management of acute gout
- NSAIDs
- Colchicine if NSAIDs contraindicated
- Steroids - orally, IM or intra-articular
+ lifestyle modification to prevent further flares
How is rheumatoid arthritis usually diagnosed?
Usually clinical diagnosis using classification criteria
Describe the classic presentation of acute gout
Severe pain, hot swollen joint, most commonly the first MTP joint
Ankle and knee are the other most commonly affected joints
What causes symmetrical synovitis (doughy swelling) in rheumatoid arthritis?
Synovial proliferation and reactive joint effusion cause soft tissue swelling
What results of a compression test indicates rheumatoid arthritis?
Positive - tenderness upon lateral compression (squeezing) of the MCP and/or MTP joints
Name the seronegative inflammatory arthritis’s
Ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, reactive arthritis
What is the second line medication for gout prophylaxis if allopurinol not tolerated?
Febuxostat (xanthine oxidase inhibitor)
Name two clinical tests used in examination of ankylosing spondylitis, and what result would indicate AS
Schobers test >20 cm
Chest expansion - reduced
Describe the articular manifestation of enteropathic arthritis
Patients present with arthritis in several joints, especially knees, ankles, elbows, and wrists, sometimes spine, hips, or shoulders
How would you manage reactive arthritis?
Treatment is aimed at the underlying infectious cause and symptomatic relief, including IA or IM steroid injections
90% self limiting
10% will develop chronic disease - require DMARDs
What is Caplan syndrome?
Combination of rheumatoid arthritis and pneumoconiosis
Name a spinal complication of rheumatoid arthritis
In longstanding disease involvement of the cervical spine may cause atlanto-axial subluxation → cervical cord compression
What is rheumatoid arthritis?
Inflammatory autoimmune disorder characterized by joint pain, swelling, and synovial destruction
What is reactive arthritis?
Infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured
Which gene complexes have been associated with rheumatoid arthritis?
Specific HLA gene types e.g. HLA DRB1 gene
What patient group is rheumatoid arthritis most common in?
Middle aged females (35-50 years)
What is the specificity of anti-CCP for rheumatoid arthritis?
90-99% specific
How would you manage enteropathic arthritis?
Manage underlying IBD, manage arthritis with physio, DMARDs, anti-TNF
Which imaging modality can detect early changes in ankylosing spondylitis such as sacrilitis and bone marrow oedema?
MRI
Describe the clinical presentation of acute calcific tendonitis of the shoulder
Acute onset of severe shoulder pain
How many weeks after the initial infection will a patient present with reactive arthritis?
1-4 weeks
What are rheumatoid nodules?
Firm lumps that develop under the skin in 25% of RA patients, most commonly on extensor surfaces or sites of frequent mechanical irritation
What percentage of patients with rheumatoid arthritis have rheumatoid factor?
~80% of patients
