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MBChB YR2 MSK > Disease Profiles: Inflammatory Arthritis > Flashcards

Disease Profiles: Inflammatory Arthritis Flashcards

1
Q

What is the ASAS classification criteria for ankylosing spondylitis?

A

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

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2
Q

What is a Swan neck deformity?

A

PIP hyperextension and DIP flexion

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3
Q

Describe some x-ray signs of ankylosing spondylitis

A

Usually normal in early disease

Late disease - sclerosis and fusion of the sacroiliac joints, bony spurs from the vertebral bodies (syndesmophytes), skinny corners

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4
Q

What are gouty tophi?

A

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

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5
Q

What is Boutonniere deformity?

A

PIP flexion and DIP hyperextension

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6
Q

Describe the usual management of acute calcific tendonitis of the shoulder

A

NSAIDs, subacromial steriod and local anaethetic injections for pain relief

Physio

Usually self-limiting as calcification re-absorbs

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7
Q

Name two shared extra-articular features of the spondyloarthropathies

A

Ocular inflammation (anterior uveitis, conjunctivitis)

Mucocutaneous lesions e.g. oral ulcers

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8
Q

How are immune complexes formed in rheumatoid arthritis?

A

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

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9
Q

What is the specificity of rheumatoid factor for rheumatoid arthritis?

A

60-70% specific

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10
Q

Describe the appearance of monosodium urate crystals under polarised microscopy

A

Needle shaped, negative birefringent crystals

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11
Q

When would biological agents be considered in the treatment of rheumatoid arthritis?

A

If 2 DMARDs have been tried and patient still has very active disease (DAS28 score > 5.1)

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12
Q

Which patient group is reactive arthritis most common in?

A

Young adults (20-40 years), equal sex distribution, HLA B27 positive

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13
Q

Describe the management of refractory acute calcific tendonitis of the shoulder

A

Surgical removal of calcifications, partial/total arthroplasty is last line

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14
Q

What crystal is responsible for pseudogout?

A

Calcium pyrophosphate

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15
Q

What is anti-CCP?

A

Autoantibody found in rheumatoid arthritis associated with current/previous smoking history, more likely to be associated with smoking history

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16
Q

Why does gout prophylaxis require cover with NSAIDs for first 6 months (or colchicine/steroids)?

A

Rapid reduction in uric acid level may result in further exacerbation of gout

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17
Q

Which types of hypersensitivity reaction are associated with rheumatoid arthritis?

A

Driven by type IV (T cell mediated), secondary type III reactions also occur

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18
Q

What patient group is most affected by pseudogout and why?

A

The elderly, and because chondrocalcinosis increases with age

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19
Q

What is ankylosing spondylitis?

A

Chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine, 90% HLA B27 positive

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20
Q

What may an x-ray of late rheumatoid arthritis show?

A

Erosions, sublaxation

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21
Q

What may an MRI be used for in rheumatoid arthritis?

A

Extremely sensive but only use if diagnostic doubt

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22
Q

What is gout?

A

Inflammatory crystal arthropathy caused by the precipitation and deposition of monosodium urate crystals into joints and soft tissues

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23
Q

Which patient group is most commonly affected by Hydroxyapatite Deposition Disease?

A

Females, 50-60 years

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24
Q

What are Bouchard’s nodes?

A

Bony swellings of proximal IPJ seen in RA and OA

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25
Q

How long does acute gout take to settle with and without treatment?

A

10 days without treatment, 3 days with treatment

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26
Q

Describe the common x-ray findings in psoriatic arthritis

A

Marginal erosions and ‘whiskering’, osteolysis, enthesitis

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27
Q

What is the WHO target for serum uric acid to prevent further attacks of gout?

A

300-360µmol/L

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28
Q

Which forms of T cell are involved in rheumatoid arthritis?

A

CD4+ T cells, CD4+ Th1 and Th17 effector cells

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29
Q

What is pseudogout?

A

Deposition of calcium pyrophosphate in the joints and soft tissues, leading to inflammation

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30
Q

Name the diseases associated with HLA B27

A

Psoriatic arthritis, ankylosing spondylitis, IBS (+ enteropathic arthritis), reactive arthritis

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31
Q

Name two other treatment options for gout prophylaxis other than xanthine oxidase inhibitors

A

Uricosuric drugs, IL-1 inhibitors

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32
Q

Are autoimmune conditions more common in males or females?

A

Females

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33
Q

What is the first line treatment for rheumatoid arthritis?

A

DMARDs

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34
Q

Describe the main articular manifestations of rheumatoid arthritis

A

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

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35
Q

Describe the appearance of calcium pyrophosphate crystals under polarised microscopy

A

Envelope shaped, mild positively birefringent

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36
Q

Which joints are usually affected in reactive arthritis?

A

Asymmetrical monoarthritis or oligoarthritis of large joints e.g. the knee

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37
Q

What causes recurrent gout flares?

A

The acute inflammatory response to deposited MSU crystals

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38
Q

How many attacks of gout per year in spite of lifestyle modification would indicate the need for gout prophylaxis?

A

2+ attacks

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39
Q

Name the crystal responsible for gout

A

Monosodium urate crystals

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40
Q

How are autoantibodies generated in rheumatoid arthritis?

A

Susceptibility genes lead to the conversion of arginine (A) into citrulline (C), resulting in an unfolded protein

The unfolded protein acts as an antigen

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41
Q

Describe the x-ray findings in acute calcific tendonitis of the shoulder

A

Calcification can be seen just proximal to the greater tuberosity

42
Q

Which joint is most commonly affected by pseudogout?

A

Swollen, painful, warm knee

43
Q

What is arthritis mutilans?

A

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

44
Q

What is enteropathic arthritis?

A

Refers to an inflammatory arthritis involving the peripheral joints and sometimes the spine, occuring in patients with inflammatory bowel disease

45
Q

What is pannus?

A

Inflammatory granulation tissue that occurs in rheumatoid arthritis; it produces proteinases that destroy the cartilage extracellular matrix

46
Q

Describe the histology of gouty tophi

A

Amorphous eosinophilic debris and inflammation (giant cells)

47
Q

What is the first line treatment for ankylosing spondylitis?

A

NSAIDs (+ symptomatic relief e.g. corticosteroid injections, eyedrops)

48
Q

Patients with high titres of rheumatoid factor are more at risk of ____________

A

Extra-articular disease

49
Q

Which to antibodies are associated with rheumatoid arthritis?

A

Rheumatoid factor, anti-CCP

50
Q

Name a seropositive inflammatory arthritis

A

Rheumatoid arthritis

51
Q

What is the ‘question mark’ posture?

A

Loss of lumbar kyphosis with pronounced cervical lordosis seen in late ankylosing spondylitis

52
Q

Name two blood values which may be raised in gout

A

Serum uric acid, inflammatory markers

53
Q

What usually causes gout?

A

High serum uric acid levels (hyperuricaemia)

54
Q

Name a shared feature of the spondyloarthopathies that affects tendons

A

Enthesitis - inflammation at insertion of tendons into bones e.g. Achilles tendinitis, plantar fasciitis

55
Q

Describe the articular symptoms of ankylosing spondylitis

A

Gradual onset of dull spinal and neck pain, morning stiffness > 30 mins that improves with activity

56
Q

How would you treat unresponsive psoriatic arthritis?

A

Consider DMARDs, then anti-TNF or other biologics

57
Q

What is Reiter’s syndrome?

A

Triad of urethritis, conjuctivitis/uveitis/iritis and arthritis sometimes seen in reactive arthritis

58
Q

What is rheumatoid factor?

A

IgM or IgA antibody that binds to Fc region of IgG

59
Q

What may an ultrasound be used for in rheumatoid arthritis?

A

May be useful in detecting synovial inflammation if their is clinical uncertainty (especially in early RA), useful in making treatment changes

60
Q

Name a shared feature of the spondyloarthopathies that affects the fingers

A

Dactylitis (‘sausage’ digits) - inflammation of the entire digit

61
Q

If indicated, when should prophylactic therapy for gout be started?

A

4-6 weeks after acute attack

62
Q

What is psoriatic arthritis?

A

Inflammatory arthritis associated with psoriasis, HLA B27 positive

63
Q

Describe the histology of rheumatoid nodules

A

Necrotising granulomas with a palisade of macrophages surrounding a central area of collagen necrosis

64
Q

What is chondrocalcinosis?

A

Calcium pyrophosphate deposition occurs in cartilage and other soft tissues in the absence of acute inflammation

65
Q

How are infection and smoking implicated in rheumatoid arthritis?

A

Increase anti-CCP

66
Q

What medication is often associated with gouty tophi?

A

Diuretics

67
Q

What patient group is ankylosing spondylitis most common in?

A

Young males (20-40 years), HLA B27 positive

68
Q

What may an x-ray of early rheumatoid arthritis show?

A

Can be normal, may show soft tissue swelling and periarticular oseopenia

69
Q

Which antibody is most sensitive for rheumatoid arthritis?

A

Rheumatoid factor

70
Q

Which joints are usually affected in psoriatic arthritis?

A

Usually an asymetrical oligoarthritis, predominantly affects joints of hands and feet, 20% of cases involve sacro-iliac joints

71
Q

Which infections most commonly proceed reactive arthritis?

A

Urogenital (e.g. chlamydia) or GI (e.g. salmonella, shigella, yersinia, campylobacter)

72
Q

How would you treat unresponsive ankylosing spondylitis?

A

Consider DMARDs, then anti-TNF or other biologics

73
Q

What are the spondyloarthopathies?

A

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

74
Q

What is the first line treatment for psoriatic arthritis?

A

NSAIDs (+ symptomatic relief e.g. corticosteroid injections, eyedrops)

75
Q

What is Schobers test?

A

Used to measure lumbar spine flexion, reduced in ankylosing spondylitis

76
Q

What is acute calcific tendonitis of the shoulder?

A

Hydroxyapatite crystal deposition in the supraspinatus tendon which causes the release of collagenases, serine proteinases and IL-1

77
Q

Describe the management of pseudogout

A

Treat acute episodes appropriately - NSAIDs, colchicine, steroids, rehydration

No prophylactic management

78
Q

What causes chronic gouty arthritis and tophaceous gout?

A

Chronic granulomatous inflammatory response to deposited crystals

79
Q

What is the first line medication for gout prophylaxis?

A

Allopurinol (xanthine oxidase inhibitor)

80
Q

Describe the management of acute gout

A
  1. NSAIDs
  2. Colchicine if NSAIDs contraindicated
  3. Steroids - orally, IM or intra-articular

+ lifestyle modification to prevent further flares

81
Q

How is rheumatoid arthritis usually diagnosed?

A

Usually clinical diagnosis using classification criteria

82
Q

Describe the classic presentation of acute gout

A

Severe pain, hot swollen joint, most commonly the first MTP joint

Ankle and knee are the other most commonly affected joints

83
Q

What causes symmetrical synovitis (doughy swelling) in rheumatoid arthritis?

A

Synovial proliferation and reactive joint effusion cause soft tissue swelling

84
Q

What results of a compression test indicates rheumatoid arthritis?

A

Positive - tenderness upon lateral compression (squeezing) of the MCP and/or MTP joints

85
Q

Name the seronegative inflammatory arthritis’s

A

Ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, reactive arthritis

86
Q

What is the second line medication for gout prophylaxis if allopurinol not tolerated?

A

Febuxostat (xanthine oxidase inhibitor)

87
Q

Name two clinical tests used in examination of ankylosing spondylitis, and what result would indicate AS

A

Schobers test >20 cm

Chest expansion - reduced

88
Q

Describe the articular manifestation of enteropathic arthritis

A

Patients present with arthritis in several joints, especially knees, ankles, elbows, and wrists, sometimes spine, hips, or shoulders

89
Q

How would you manage reactive arthritis?

A

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

90
Q

What is Caplan syndrome?

A

Combination of rheumatoid arthritis and pneumoconiosis

91
Q

Name a spinal complication of rheumatoid arthritis

A

In longstanding disease involvement of the cervical spine may cause atlanto-axial subluxation → cervical cord compression

92
Q

What is rheumatoid arthritis?

A

Inflammatory autoimmune disorder characterized by joint pain, swelling, and synovial destruction

93
Q

What is reactive arthritis?

A

Infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured

94
Q

Which gene complexes have been associated with rheumatoid arthritis?

A

Specific HLA gene types e.g. HLA DRB1 gene

95
Q

What patient group is rheumatoid arthritis most common in?

A

Middle aged females (35-50 years)

96
Q

What is the specificity of anti-CCP for rheumatoid arthritis?

A

90-99% specific

97
Q

How would you manage enteropathic arthritis?

A

Manage underlying IBD, manage arthritis with physio, DMARDs, anti-TNF

98
Q

Which imaging modality can detect early changes in ankylosing spondylitis such as sacrilitis and bone marrow oedema?

A

MRI

99
Q

Describe the clinical presentation of acute calcific tendonitis of the shoulder

A

Acute onset of severe shoulder pain

100
Q

How many weeks after the initial infection will a patient present with reactive arthritis?

A

1-4 weeks

101
Q

What are rheumatoid nodules?

A

Firm lumps that develop under the skin in 25% of RA patients, most commonly on extensor surfaces or sites of frequent mechanical irritation

102
Q

What percentage of patients with rheumatoid arthritis have rheumatoid factor?

A

~80% of patients

MBChB YR2 MSK (36 decks)

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