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Human Diseases > HD 5 - Clinico-pathology of musculoskeletal disorders > Flashcards

HD 5 - Clinico-pathology of musculoskeletal disorders Flashcards

1
Q

Name 2 inflammatory rheumatological diseases.

A
  • Rheumatoid arthritis
  • Psoriatic Arthritis
  • Enteropathic
  • Ankylosing spondylitis
  • Reactive Arthritis
  • Juvenile Idiopathic Arthritis
  • Gout
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2
Q

Name 1 mechanical rheumatological disease.

A
  • Osteoarthritis
  • Back & Neck pain
  • Sports injuries
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3
Q

Name 1 connective tissue disease rheumatological disease.

A
  • Sjogren’s syndrome
  • SLE
  • Scleroderma
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4
Q

What joints does osteoarthritis affect?

A

Polyarthritis, affecting distal interproximal pharyngeal joints

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5
Q

What happens to the finger movements in osteoarthririts?

A

Reduced finger flexion

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6
Q

Define osteoarthritis.

A

Condition in which low-grade inflammation results in pain in the joints, caused by wearing of the cartilage that covers and acts as a cushion inside joints

Degenerative joint disease

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7
Q

Why do people suffer pain with osteoarthritis?

A

As the bone surfaces become less well protected by cartilage, the patient experiences pain upon weight bearing, including walking and standing.

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8
Q

What happens to muscles and ligaments if patient has osteoarthritis?

A

Due to decreased movement because of the pain, regional muscles may atrophy, and ligaments may become more slack.

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9
Q

What are the symptoms of osteoarthritis?

A
  • Localised pain
  • Increased on weight-bearing
  • Advanced disease causes non-weight bearing/ nocturnal pain (probably through raised intraosseous pressure)
  • Night pain = cartilage worn away (no nerve fibres) & bone compressed (has nerves)
  • Short-lived/absent early morning stiffness (<30 mins)
  • May be asymptomatic
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10
Q

What are the hand signs of osteroarthritis?

A

Heberden’s (DIP)/Bouchard’s (PIP) Nodes – bony swellings of distal and proximal interproximal pharyngeal joints
1st CMC squaring (carpometocarpal)
Generalised wasting

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11
Q

What are the knee signs of osteroarthritis?

A

Quadriceps wasting – front thigh mucles
Crepitus
Cool effusion

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12
Q

What are the hip signs of osteroarthritis?

A

Reduced rotation (internal)

Antalgic gait/Trendelenburg gait = pelvis tilting down on affected side of sore leg, therefore more pressure on opposite foot

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13
Q

What radiographic changes are shown in osteoarthritis?

A

Sclerosis - whitening
Subchondral bone cysts
Joint space narrowing
Osteophytes - benign outgrowths of bone

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14
Q

How many hip and knee replacements take place per year in uk due to osteosrthritis?

A

> 160,000

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15
Q

How is osteoarthritis managed?

A

Pharmacological: Analgesics, NSAIDs, Coxibs with omeprazole, injections (steroid/hyaluronan)
Non-pharmacological: Quads exercises, weight loss if BMI >25, provision of aids/orthoses, education & support, glucosamine sulphate 1.5g od (+/- chondroitin)
Surgical: Total hip/knee replacements and Resurfacing (not done really anymore)

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16
Q

What joints are affected in rheumatoid arthritis?

A

Polyarthritis: symmetrical = affects every synovial joint except distal inter-pharyngeal joints
Z thumb = enlargement over the joint

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17
Q

What effect does rheumatoid arthritis have on hands?

A

Reduced finger flexion, difficulty holding a fork

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18
Q

What are the typical features of rheumatoid arthritis according to ARA?

A 
Symmetrical arthritis
Hand joints
At least 3 areas
Morning stiffness >60 minutes
Rheumatoid nodules
Serum rheumatoid factor (RF) = antibody which binds to Fc portion of an antibody = BINDS TO ITSELF
Radiographic changes
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19
Q

On the EULAR/ACR criteria in 2010, how many points were needed to show rheumatoid arthritis?

A

6 or more

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20
Q

What is the genetic susceptibility to rheumatoid arthritis?

A

Onset may be associated with HLA DR4
Severity predicted by presence of TNFa polymorphisms, HLA DR4 & RF/CCP
Twin studies show weak, variable effect
Hence environmental triggers likely

21
Q

What are the early radiographic changes in rheumatoid arthritis?

A

Peri-articular osteoporosis – thinner blacker bone

Peri-articular erosions (action of synovitis on ‘bare area’ of bone)

22
Q

What are the late radiographic changes in rheumatoid arthritis?

A

Joint space narrowing
Subluxation/dislocation
Ankylosis

23
Q

What are the extra-articular manifestations of rheumatoid arthritis in the body?

A 
Nodules = growth of abnormal tissue
Lymphadenopathy
Lung = Pleurisy /effusion/ fibrosis
Heart = pericarditis
Skin
Muscle = atrophy/ myositis
Bone = osteoporosis, also spine has moth eaten look so beware in dental chair 
Eye
Secondary Sjogren’s syndrome
Vasculitis
24
Q

How is rheumatoid arthritis managed?

A
  • Education
  • Joint protection
  • Support
  • Painkillers
  • NSAIDs
  • DMARDs – disease modifying anti-rheumatic drugs which slows progression but cure
  • Surgery
25
Q

What is the function of DMARDS?

A

Reduce symptoms of rheumatoid arthritis and prevent joint damage

26
Q

What is the mechanism of action of DMARDs?

A

Slow action, not quick fix

27
Q

What is a common technique used when DMARDs are prescribed?

A

Triple therapy, giving out 3 drugs at the same time

28
Q

What are commonly and less commonly used DMARDs?

A 
Commonly-used – TRIPLE THERAPY 
• Methotrexate
• Sulphasalazine
• Leflunomide 
• Hydroxychloroquine
• Steroids - usually IA/IM/ rarely oral – can’t be used long term, but works well 
Less-commonly used
• Myocrisin (gold) – injections 
• Minocycline
• Cyclosporin
• Azathioprine
• Penicillamine
29
Q

What combination drugs are used in rheumatoid arthritis treatment?

A

Methotrexate/ sulphasalazine/ hydroxychloroquine triple

Methotrexate/leflunomide

30
Q

Name a biologic used to treat rheumatoid arthritis?

A

Anti-TNF agents 1st ‘Biologic therapy’ = BIOLOGICS
Infliximab (humanised anti-TNF mouse monoclonal ab)
Etanercept (recombinant soluble anti-TNF receptor)
Adalimumab (fully human anti-TNF monoclonal ab)
Certolizumab (PEGylated anti-TNF)
Golimumab (fully human anti-TNF monoclonal ab)
Infection risk esp. dissemination/TB

Anti CD20 monoclonal: Rituximab

Anti CTLA-4 Ig: Abatacept

Anti IL-6: Tocilizumab

31
Q

Why does a dentist need to be aware if rheumatoid arthritic patient is on biologic therapy?

A

Look harder/more extensively – if pt on biologics less likely to notice symptoms of disease i.e. abscess

32
Q

What joints are affected in ankylosing spondylitis?

A

Axial +/- oligoarthritis

↓ spinal movement

33
Q

What other conditions does ankylosing spondylitis affect in other parts of the body?

A
  • Iritis & conjunctivitis
  • Pulmonary –> Upper lobe fibrosis/ Restrictive
  • Fatigue
  • Aortic valve disease
34
Q

What treatment is used for ankylosing spondylitis?

A
  • Daily exercises to maintain spinal mobility and posture, maintained with regular physiotherapy input
  • Education
  • Support
  • NSAIDs/coxibs
  • DMARDs: for peripheral arthritis
  • Anti-TNF drugs: for peripheral & spinal disease
  • Surgery - for spinal complications
35
Q

What are the clinical features of ankylosing spondylitis?

A
  • Gradual onset
  • Teens/twenties
  • Morning or nocturnal stiffness
  • Persistence (>6/52)
  • Improvement with exercise (e.g. worse at weekends)
  • Improvement with NSAIDs
36
Q

What are the joints affected in psoriatic arthritis?

A
  • Mono/Oligo/polyarthritis, Sparing/involving DIP (distal inter-proximal pharyngeal)
  • Axial: deformans
37
Q

What is the moll and wright classification?

A

1) DIPJ only (DISTO INTERPHARYNGEAL JOINTS)
2) Arthritis mutilans
3) Clinically indistinguishable from RA
4) Asymmetrical oligoarthritis
5) Ankylosing spondylitis

38
Q

What are the symptoms of psoriatic arthritis?

A
  • More common in those with nail lesions
  • Dactylitis – inflammation of whole finger – sausage like fingers/toes
  • Iritis
  • Enthesitis = inflammation at ligament/tendon insertion
  • RF is usually negative
39
Q

What is the treatment of psoriatic arthritis?

A
  • Education
  • Support
  • Simple analgesia
  • NSAIDs/coxibs
  • DMARDs: Arthritis alone (sufasalazine), Arthritis and psoriasis (methotrexate/anti-TNF)
  • Surgery – only if very painful deforming joint
40
Q

What joint does reactive arthritis affect mostly?

A
  • Mono/oligoarthritis
  • Reduced ROM knee - Difficulty walking/ can’t go clubbing
  • Sterile synovitis
  • Typically, asymmetrical oligoarthritic (other patterns)
41
Q

Who is mostly affected by reactive arthritis?

A

Young people

42
Q

What infections can cause reactive arthritis? And how many days after does it start after the infection?

A

Onset peaks 10-14 days after a distant infection:

Gastrointestinal (campylobacter, yersinia, salmonella)

Urogenital (chlamydia)

Causative infection not found in >50%

43
Q

What is reiter’s syndrome?

A

Reactive arthritis, plus: Conjunctivitis/ Urethritis

May be associated with rash of hands & feet, histologically indistinguishable from psoriasis

44
Q

What is the recurrance rate of reactive arthritis after treatment?

45
Q

What treatment is used for reiters and reactive arthritis?

A

usually self-limiting

benefit from NSAIDs

may require joint injection

occasionally require DMARD therapy

46
Q

What antibodies and factors are associated with sjogren’s syndrome?

A

Anti-Ro (SS-A) & anti-La (SS-B) antibodies
RF
Hypergammaglobulinaemia

47
Q

What is the ratio F:M of having sjogren’s syndrome?

48
Q

What are the clinical features of sjogren’s syndrome?

A
  • Fatigue/malaise
  • Dry eyes
  • Xerostomia
  • Dyspareunia – pain during sex, due to dry mucous membranes
  • Arthralgia, arthritis
  • Raynaud’s phenomenon (with hyperviscosity)
  • Lung: interstitial lung disease
  • Renal: renal tubular acidosis
49
Q

How is sjogren’s syndrome managed?

A

Chronic incurable disease

  • Eye drops, ointments
  • Oral sprays, gels, lozenges
  • Vaginal lubricants
  • Steroids/immunosuppressants reserved for pneumonitis, glomerulonephritis, vasculitis (rare)

Human Diseases (17 decks)

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