Frailty- joints Flashcards
Polymyalgia rheumatica
An inflammatory syndrome of older individuals >50 but normally >70 characterised by pain and sitffness in the proximal muscles of the shoulder, neck and/or pelvic girdle in the absence of any true weakness, might appear limited due to pain
Polymyalgia rheumatica- core manifestations
- Patient aged >50
- Symmetrical shoulder girdle ache >2 weeks
- ESR >40 and or elevated CRP
- Morning stiffness
- Bilateral hip pain or limited range of movement
- Absence of rheumatoid factor and anti CCP
- Rapid response to corticosteroids
- Constitutional symptoms common (in one third)
Polymyalgia rheumatica- medicine
Rapid (24072hr) response to low dose prednisolone (15mg), slowly tapered over months. Require steroids for 1-2 years, bone protection and gastro-protection should be considered, and the steroids should not be stopped abruptly.
May have relapses as the steroid dose is reduced and require it to be increased. DMARDS like methotrexate may be initiated by specialists
Polymyalgia rheumatica- associated conditions
GCA is a large and medium vessel arteritis associated with PMR (15% of patients with PMR) that can lead to irreversible sight loss. Features include headache (usually temporal or occipital), temporal/scalp tenderness, jaw or tongue claudication, visual disturbances and double vison (diplopia). May have absent temporal pulse or thickening of the temporal artery, important to prevent sight loss
Diagnosing GCA
Unlikely if ESR and CRP are normal. Once suspected treatment with high dose steroids are started urgently. Diagnosis can be confirmed with temporal artery ultrasound or biopsy
Psoriatic arthritis- examination findings
- Pitting of nails
- Oncholysis (nail plate separating from nail bed)
- Beau lines (transverse nail ridge), subungual hyperkeratosis, splinter haemorrhages, oil drop sign, salmon patch
- Dactylitis (sausage digits- due to synovitis and flexor tenosynovitis)
- Asymmetrical joint involvement including DIPJ
- Enthesitis: inflammation of tendons
- Uveitis
- Tenosynovitis: inflammation of the myelin sheath
Psoriatic arthritis
A chronic inflammatory joint disease associated with psoriasis- however it can present before, alongside or after the onset of psoriasis.
Affects men and women equally and tends to present between 20-40 and present in 20-30% of those with psoriasis
Spondyloarthropathies
A group of seronegative (RhF negative conditions)
Psoriatic arthritis, ankolysing spondylitis, enteric arthropathy (IBD associated), reactive arthritis and undifferentiated axial spondylarthritis
5 sub types of psoriatic arthritis
There is overlap between them
- Asymmetrical oligoarthritis
- Predominant DIPJ involvement
- Arthritis mutilans: destruction of the whole bone
- ‘Rheumatoid like’ symmetrical polyarthritis
- Axial involvement: usually asymmetrical rather than symmetrical in ankolysing spondylitis
Extra articular features of psoriatic arthritis
Include eye involvement- conjunctivitis or uveitis
Medical treatment of psoriatic arthritis
Similar to RA- remission or goal targeted therapy, can be simple NSAIDs and joint injections but may require esclating to DMARDS like methotrexate or leflunomide. Biologics (usually anti-TNF’s) can be used
Distinguishing psoriatic arthritis from rheumatoid arthritis
- Asymmetrical often oligoarticular joint involvement
- Significant nail pitting/dystrophy
- Involvement of DIPJ in absence of OA
- Dactylitis
- Enthesitis (usually achilles/plantar fascia_
Hx/FHx of psoriasis - Absence of rheumatoid factor/anti-CCP
- X-ray findings can be distinctive with absence of juxta articular osteoporosis, fluffy juxta-articular periosteal new bone and pencil in cup deformity. Where the middle phalanx is narrowed like a pencil and the distal phalanx is eroded centrally like a cup
Reactive arthritis
A sterile inflammatory arthritis that occurs within 1-4 weeks of an infection elsewhere in the body (usually genitourinary or gastrointestinal i.e. chlamydia, Salmonella, Shigella, Yersina although the initial infection can be hard to identify
Reactive arthritis- genes, distribution and course
- Strong association with being HLA-B27 positive which is present in 60-80% of cases,
- An asymmetrical peripheral oligoarthritis (often knees) and sometimes axial involvement
- Approximately 50% have a self limiting course of 3-5 months, 30% have recurrent episodes and 10-20% develop a chronic course needing immunosuppressive therapy
Reiters syndrome
The triad of conjunctivitis, nongonococcal urethritis and arthritis (cant see, cant pee, cant climb a tree)
Associated symptoms of reactive arthritis
- Cant pee: urethritis, prostatis, haemorrhagic cystitis, salphingitis, circinate balanitis
- Cant see: sterile conjuncitivitis, anterior uveitis
- Cant climb a tree: Asymmetric oligoarthritis, Enthesitis, Sacroilitis, Dactylitis
- Other: Keratoderma blennorrhagicum, Hyperkeratotic nails, painless oral ulcers, rarely IgA nephropathy and cardiac features
Investigations into reactive arthritis
Will show elevated CRP, ESR and negative antibodies- HLAB27 status may be determined as it is associated with poorer prognosis, but has limited diagostic utility. Cultures at this stage will most likely be negative with no organisms in the joint cavity. Management is mostly NSAIDs and steroids, although some go on to require DMARDS
Cauda equina syndrome
Emergency compression of the lumbar sacral nerve roots at the end of the spinal cord (around L1/L2) when they fan out and leave the spinal column. Will require emergency MRI and operative management to prevent persistent disability
Superficial spreading melanoma
Common in the lower limbs, in young and middle ages adults. Related to intermittent high intensity UV exposure. 70% of all melanoma
The three other types of malignant melanomas
Lentigo maligna melanoma: common on the face, in the elderly population, related to long term cummulative sun exposure
Nodular melanoma: common on the trunk, in young and middle aged adults, related to intermittent high intensity UV exposure
Acral lentiginous melanoma: common on the palms, soles and nail beds, in elderly population, no clear relation with UV exposure
What are some skin infections and what are they commonly caused by
Cellulitis - strep pyogenes and staph aureus
Erysipelas - Group A strep (strep pyogenes)
Impetigo - staph aureus, group A strep
Furuncle - staph aureus
Meningococcal rash - neisseria meningitis
Chancre - treponema pallidum
Definition of infection and sepsis
Infection- caused by pathogenic microorganisms such as bacteria, viruses, parasites, prions or fungi. The diseases can be spread directly or indirectly
