Inflammatory Arthritis ☺️ Flashcards
How would you differentiate between inflammatory and non inflammatory causes of joint pain?
Inflammatory
- systemic symptoms, v prominent fatigue
- insidious onset (seropositive, seronegative)
- sudden onset (infection, gout)
- morning stiffness, 1hr+
- worst pain on waking and when resting
- pain decreases with activity but increases with overuse
Non inflammatory
- unusual to have systemic symptoms
- gradual onset (mono/oligoarthritis)
- morning stiffness, U1hour
- pain increases as day progresses, worsens with activity
- pain improves with rest
What is the
- pathophysiology
- signs
- investigations for RA
HLA DR1-4 genetic predisposition to present citrullinated self proteins on surface => recognised as foreign by adaptive immune system
Release of pro inflammatory cytokines leads to
-osteoclast activation
-synovial membrane thickening, angiogenesis
-protease, collagenase production => bone and cartilage erosion
Signs
- tenderness and swelling
- hot
Early
- symmetrical swollen MCP, MTP, PIP, wrist joints
- tenosynovitis, bursitis
- spongy on palpation
Late
- ulnar deviated fingers
- hitchhiker thumbs, swan and Boutonnière fingers
- rheumatoid nodules
Medical history
-CVD, ILD
Investigation findings
- Anaemia of chronic disease
- RF, anti CCP
- raised CRP, ESR
- low albumin (leakage of protein into tissue due to inflammation)
What are the findings of RA on X-rays
Loss of joint space
Erosion of bone and cartilage
Soft tissue swelling
Soft bones (osteopenia)
How would you treat RA
- flare up
- maintenance of remission
Use DAS28 to judge remission or flare up
Flare up
-short term NSAIDS, CS
Long term (DMARDs) -methotrexate/HCQ/sulfasalazine
Long term (biologics)
- TNFa - adalimumab, influximab, etanercept
- IL1 - anakinra
- IL6 - toclizumab
- Bcell suppression - rituximab
- Tcell suppression - abatacept
What is the
- pathophysiology
- signs
- investigations for gout
Inflammatory crystal monoarthropathy caused by monosodium urate crystals in big toe
Signs
Rapid onset
Heat, pain, redness, swelling in big toe/knee
Tophi on tendon surfaces
Symptoms of renal calculi
Systemic symptoms like with septic arthritis
Investigations => RULE OUT SEPTIC ARTHRITIS FIRST
- FBC => leukocytosis
- high CRP, ESR
- U&E => assess for any kidney damage from renal stone
- synovial fluid aspiration => needle shaped negative birefringent monosodium urate crystals
What are the risk factors for gout
Genetics, age, male, post menopausal Overweight Purine rich diet -red meat, sea food, alcohol Thiazides, ACEi
Cytotoxic => tumour lysis
How would you manage gout
- flares
- remission
- lifestyle
Flares - 1st line -NSAIDs (avoid aspirin) or CS (PPI for gastroprotection) -Colchicine 2nd line -IL 1 - anankira, canakinumab
Ongoing
-allopurinol or febuxostat or sulfinpyrazone => urate lowering agent
Lifestyle
- reduce alcohol, low purine diet
- stop/swap thiazides, ACEi (CCB can be protective)
What is the
- pathophysiology
- signs
- investigations in pseudogout
Inflammatory crystal monoarthropathy caused by deposition of calcium pyrophosphate crystals in the knee/wrist/larger joints shed from cartilage
Similar to septic arthritis
- heat, pain, red, swelling
- larger joints, elbow, wrist, ankle
- joint effusion
Investigations
- FBC => leukocytosis
- high CRP, ESR
- U&E => assess for any kidney damage to rule out gout
- synovial fluid aspiration => positively birefringent rhomboid crystals under polarised light
What are the risk factors for pseudogout
Older age, genetics
Joint trauma
Excess Ca, not enough Mg
Hypothyroidism, hyperparathyroidism
How would you manage pseudogout
- acute (monoarticular/polyarticular)
- lifestyle
Aim to reduce pain and improve function of joints
Acute mono/oligoarticular
- CS injections and paracetamol for pain
- if not possible => NSAIDs and colchicine (1st line for polyarticular)
- delay use of systemic CS
Lifestyle
- joint replacement surgery
- cool packs, rest, aspiration
What is the
- pathophysiology
- signs
- investigations of reactive arthritis
Sterile arthritis 1-4wks after infection (STI, food poisoning)
Can’t see, pee, climb a tree (conjunctivitis, urethritis, enthesitis and dactylitis Rashes on soles Low back pain Joint stiffness Systemic constitutional symptoms
FBC => signs of infection
High ESR, CRP
If diarrhoea, urogenital symptoms => culture for cause
AutoAB => rule out seropositive arthritides, lupus
Synovial fluid aspiration => rule out septic arthritis, crystal arthropathies
XRay => sacroilitis, enthesitis
How would you manage reactive arthritis
- symptomatic
- chronic
Symptomatic
- NSAIDS (ibuprofen, naproxen)
- may add injected CS if NSAIDs aren’t enough
- Abx to manage bacterial infection
Chronic
-sulfasalazine or methotrexate
Describe the
- pathophysiology
- signs
- investigations for psoriatic arthritis
Inflammatory arthritis that affects some people with psoriasis in a relapsing remitting pattern
Well demarcated plaques with silvery scales
Joint pain, stiffness, swelling redness
Enthesitis, dactylitis, spine involvement
Affects DIP
Nail pitting, onycholysis, subungual hyperkeratosis
FBC => anemia of chronic disease
High ESR, CRP
No RF, CCP found
What might you find on X-ray in suspected psoriatic arthritis?
Pencil in cup deformity
Erosive change + bone proliferation
Enthesitis, dactylitis
Sacroiliitis
How would you manage psoriatic arthritis
Analgesia => NSAIDs
First line => Methotrexate (+folate)
-may consider sulfasalazine
If not controlled, add biologics
- Anti TNF => infliximab, adalimumab, golimumab, etanercept, certolizumab pegol
- IL17 => secukinumab
- Th17 inh => ustekinumab
Last line, surgery => for joint replacement
