Inflammatory arthritis Flashcards
1
Q
What are spondyloarthropathies
A
A group of conditions associated with the HLA B27 gene
2
Q
List of spondyloarthropathies
A
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthritis
3
Q
Shared features of the spondyloarthropathies
A
Sacroiliac and spinal involvement
Enthesitis
Asymmetrical arthritis
Dactylitis
Ocular inflammation
Mucocutaneous lesions
4
Q
What is enthesitis
A
Inflammation at insertion of tendons into bones
5
Q
Examples of enthesitis
A
Plantar fasciitis
Achilles tendinitis
6
Q
What are the features of inflammatory back pain
A
Morning stiffness
Worse at rest or inactivity
7
Q
Difference between inflammatory and mechanical back pain
A
Mechanical back pain is worse at activity whereas inflammatory back pain is better with activity
Mechanical back pain does not cause morning stiffness
8
Q
What is dactylitis
A
Inflammation of the entire digit causing “sausage” digits
9
Q
What is ankylosing spondylitis
A
Chronic systemic inflammatory disorder that mainly affects the spine
10
Q
Mechanism of ankylosing spondylitis
A
1) Annulus fibrosus undergoes ossification and forms syndesmophytes, reducing spinal mobility
2) Syndesmophytes can joint together along the spine which further reduces spinal mobility and causes spinal deformity
11
Q
What is annulus fibrosis
A
Outer fibrous layer of intervertebral discs
12
Q
Who are at risk of ankylosing spondylitis
A
Men
Late adolescents / young adults
Family history of spondyloarthropathies
13
Q
Who to suspect to have ankylosing spondylitis
A
< 45 years old
3 months back pain
Pain relieved by exercise, not rest
Patients with family history of spondyloarthropathies
14
Q
Clinical features of ankylosing spondylitis
A
Back pain
Spinal deformity (if left untreated for a long time)
Enthesitis
Anterior uveitis
Aortic regurgitation
Apical lung fibrosis
Asymptomatic enteric mucosal inflammation
Amyloidosis
15
Q
“A” disease is describing
A
Ankylosing spondylitis due to its clinical features:
Axial arthritis
Anterior uveitis
Aortic regurgitation
Apical fibrosis
Amyloidosis
Achilles tendinitis
plAntar fasciitis
16
Q
Investigations for ankylosing spondylitis
A
Xray / MRI
Blood tests
Schober test
Chest expansion
17
Q
What can be found on X-rays that suggest ankylosing spondylitis
A
Dagger sign
Bamboo spine
18
Q
What is Dagger sign
A
Central single radio dense line on X-rays due to fusion of syndesmophytes
19
Q
How does ankylosing spondylitis affect chest expansion
A
Reduces chest expansion
20
Q
Describe the schober test
A
- Palpate the PSIS on both sides
- Draw a horizontal line and a center point
- Measure 5cm below and 10 cm above the point
- Place measuring tape between the 2 points
- Ask the patient to bend over and measure the change in distance
- If the increase in distance <5cm = positive schober
21
Q
What does a positive schober test suggest
A
Limited lumbar motion
22
Q
Management of ankylosing spondylitis
A
Smoking cessation
Physiotherapy
Steroid eye drops
NSAID
Anti-TNF
Secukinumab
23
Q
When should you use secukinumab in AS
A
If the patient is unresponsive to NSAID + Anti TNF
24
Q
What should patients be screened for before using biologics
A
Whether they have
TB
Hepatitis B
HIV
Hepatitis C
25
Why should patients be screened before using biologics
Because biologics may reactivate those conditions
26
What is psoriatic arthritis
Inflammatory arthritis associated with psoriasis
27
Around how much % of patients with psoriasis has psoriatic arthritis and around how much % of patients with psoriatic arthritis will have psoriasis
20% of patients with psoriasis has psoriatic arthritis
90% of patients with psoriatic arthritis will have psoriasis
28
5 patterns of joint involvement in psoriatic arthritis
1. Symmetrical poly arthritis
2. Asymmetrical oligoarthritis
3. Arthritis mutilans
4. Spondylitis
5. Distal interphalangeal joints dominant
29
What is arthritis mutilans
Destructive form of arthritis causing loose skin and "telescoping" of the digits
30
Extra-articular manifestations of psoriatic arthritis
Dactylitis
Enthesitis - Achilles tendonitis
Nail pitting
Nail onycholysis
Nail ridging
31
What is nail onycholysis
Nail separating from nail bed
32
Since psoriatic arthritis can present with symmetrical poly arthritis which is same as RA, how should you differentiate between psoriatic arthritis and RA
Psoriatic arthritis is seronegative hence anti CCP and rheumatoid factor will not be present whereas RA is seropositive
Psoriatic arthritis can affect DIP whereas RA often spares DIP
33
Management of psoriatic arthritis
1. convetional synthetic DMARD (e.g. methotrexate )
2. Biologic DMARD (anti TNF)
3. targeted DMARD (tofacitinib)
34
What DMARDS are offered first line for psoriatic arthritis
methotrexate
leflunomide
35
What DMARDS are offered second line for psoriatic arthritis
anti-TNF
36
What DMARD is offered third line for psoriatic arthritis
tofacitinib
37
Why isn't steroid injection recommended for psoriatic arthritis
Because skin symptoms may flare up after stopping administration of steroids
38
What is reactive arthritis
Inflammatory arthritis that occurs after an infection
39
What are the common infection triggers of reactive arthritis
Gastroenteritis
Sexually transmitted diseases esp Chlamydia
40
What type of arthritis does gonorrhoea usually cause
Gonococcal septic arthritis
41
Clinical joint feature of reactive arthritis
Asymmetrical Acute monoarthritis / oligoarthritis
42
Which other arthropathy presents with acute asymmetrical mono arthritis / oligoarthritis
Septic arthritis
43
Extra-articular manifestations of reactive arthritis
Bilateral conjunctivitis
Circinate balantis
Anterior uveitis
Oral ulcers
Keratodema Blenorrhagica
Enthesitis
Dactylitis
44
What is circinate balantis
Ring shaped dermatitis of the head of the penis, present in reactive arthritis
45
What is keratodema blenorraghica
dark maculopapular rash on palms and soles seen in reactive arthritis
46
Keratoderma blenorrhagica is another term for
palmoplantar pustulosis - a form of psoriasis
47
What is an important differential diagnosis or reactive arthritis that must be ruled out ASAP
Septic arthritis
48
How do you rule out septic arthritis in the diagnosis of reactive arthritis
Joint aspiration of affected joint.
The joint fluid of reactive arthritis should not show infection (bacteria not present) because there is no infection in the joint in reactive arthritis
49
Investigations for reactive arthritis
Bloods
Cultures
Joint aspiration
Xray
50
Management of reactive arthritis
NSAID
Steroid injections into the joints (after ruling out septic arthritis)
Smoking cessation
51
What is enteropathic arthritis
Inflammatory arthritis associated with IBD
52
Which condition in IBD is more commonly associated with enteropathic arthritis
Crohn's
53
Clinical joint features of enteropathic arthritis
Asymmetrical oligoarthritis
Sacrolilits
Spondylitis
54
Extra-articular manifestations of enteropathic arthritis
Pyoderma gangrenosum
Erythema nodosum
Anterior uveitis
GI symptoms (abdominal pain, loose watery stool with mucous and blood)
Mouth ulcers
Enthesitis
Dactylitis
55
Signs of pyoderma gangrenosum
Large painful ulcers on skin
56
What is erythema nodosum
Inflammatory condition affecting subcutaneous fat layer causing red, tender, swollen bumps ; present in enteropathic arthritis
57
Investigations for enteropathic arthritis
Upper and Lower GI endoscopy to look for IBD
Joint aspiration
Bloods
Xray
58
Which DMARD is most recommended to be used in enteropathic arthritis and why
Sulfasalazine because it treats symptoms of arthritis and IBD
59
What is gout
erosive inflammatory arthritis caused by the deposition of monosodium urate crystals into joints and soft tissues
60
Risk factors of gout
Male
Over 50 years old
Family history
61
What causes deposition of urate crystals into soft tissues and joint
High uric acid (hyperuricaemia)
62
2 types of causes of hyperuricaemia
Increased urate production
Reduced urate excretion
63
What causes increased urate production
Diet
Alcohol
Inherited enzyme defects
Psoriasis
Haemolytic disorders
64
What kind of diet can cause increased urate production
High intake of
- red meat
- seafood
- corn syrup
65
What inherited enzyme disorders can cause increase in urate production
Mostly idiopathic
HGPRT enzyme deficiency
66
What causes decrease in urate excretion
Chronic renal impairment
Drugs (loop and thiazide diuretics, ACEi, aspirin)
Lead toxicity
67
What is the syndrome of HGPRT enzyme deficiency called
Lesch-Nyhan syndrome
68
Lesch-Nyhan syndrome is only present in
Males
69
Inheritance pattern of Lesch-Nyhan syndrome
X linked recessive
70
Why is gout rare in women before menopause
Due to oestrogen. Oestrogen is protective against gout
71
What are the 2 main general reasons of flares of gout
Increased uric acid production due to
- increased cell turnover
- increased digestion of protein
72
What factors can cause an acute flare of gout
Seafood/ protein binges
Chemotherapy - increases cell break down
Trauma and surgery - increases cell break down
73
Symptoms of acute flares of gout
Asymmetrical
Sudden, excruciating pain
Swelling and redness
Warmth
Stiffness
Mild fever
Tachycardia (due to pain)
74
Which joint is the most commonly affected by acute gout
1st MTP joint (big toe)
75
What joints can be affected by acute gout
1st MTP joint
Ankle
Knee
76
What are the main differentials of monoarthropathy
Septic arthritis
Gout / pseudogout
Acute flares of rheumatoid arthritis / osteoarthritis
77
How do you differentiate between septic arthritis and gout
Aspirate the joint fluid
Send for culture
78
How long does acute gout usually take to settle with and without treatment
without - 10 days
with - 3 days
79
What is chronic tophaceous gout
Chronic inflammatory response to deposited urate crystals
80
Presentation of chronic tophaceous gout
Painless
White accumulation of uric acid forming a bulge
May get acute flares
81
Most common cause of chronic tophaceous gout
Diuretics
82
Investigations for gout
1. joint aspiration with synovial fluid analysis
2. xray
3. bloods 2 weeks after the flare
83
Why is uric acid level only measured 2 weeks after the flare
Because it can be falsely normal during the attack
OR
Low during the attack
84
Use of synovial fluid analysis
To differentiate between gout and pseudogout
To rule out septic arthritis
85
What synovial fluid result confirms gout and differentiates it from pseudogout
Needle shaped, negative birefringent crystals
86
management of acute gout
1. NSAID- indomethacin
2. Colchicine if NSAID is not suitable
3. Intra-articular Steroids
87
Contraindications of NSAID
Those with
- HF
- chronic kidney disease
- peptic ulcers
88
Side effect of colchicine
Diarrhoea
89
What should not be used if you suspect septic arthritis
Intra-articular steroids
90
When is intra-articular steroids used for gout
If the side effect of colchicine (diarrhoea) is intolerable
91
What should be managed after treating acute gout
Lifestyle modification to prevent more flares
Prophylactic therapy
Bloods - uric acid level
92
What are the lifestyle modification advised for gout
Reduction of alcohol consumption
Reduction of purine-based foods- meat and seafood
Review medications if using diuretics / aspirin / ACEi / chemotherapy
93
When should prophylactic therapy for gout be started
4-6 weeks after acute attack
94
Describe the prophylactic therapy for gout
Allopurinol to lower uric acid level
+ NSAID indometacin or colchicine for first 6 months
95
Why is NSAID indometacin / colchicine required in prophylactic therapy of gout in the first 6 months
Because rapid reduction in uric acid level can cause acute flare of gout
96
Which drug is used if allopurinol is not suitable for prophylactic therapy of gout
febuxostat
97
What is pseudogout
Deposition of calcium pyrophosphate in the joints and soft tissues leads to inflammation
98
Risk factors of pseudogout
Increasing age
Hyperparathyroidism
Haemochromatosis
Hypothyroidism
Trauma / previous joint surgery
Hypomagnesaemia
Hypophosphataemia
99
Which joint disease is pseudogout related to
Osteoarthritis - calcium deposit can occur in some OA
100
Symptoms of pseudogout
Monoarthritis - painful, swollen, warm
101
Which joint is most commonly affected by pseudogout
Knee
102
Investigations for pseudogout
Aspiration of synovial fluid and analysis
Bloods
103
What will the synovial fluid analysis result be for pseudogout
Positively birefringent
rhomboid shaped calcium pyrophosphate crystals
104
Management of pseudogout
NSAID (naproxen)
Colchicine if NSAID contraindicated
Oral / intra-articular steroids
105
Is there a prophylactic treatment for pseudogout
No
106
What is rheumatoid arthritis
Chronic inflammatory autoimmune disorder causing joint pain, swelling and synovial destruction
107
Risk factors of RA
Female
40-60 years old
Smoking
Genetic predisposition
108
Pathophysiology of RA
1. Susceptibility genes lead unfold of proteins due to conversion of arginine into citrulline
2. the unfolded protein acts as an antigen
3. triggers autoimmune inflammation by T cells
4. Causes progressive destruction and deterioration of cartilage and bone
109
Which type of hypersensitivity is RA part of
Type 4
can be type 3
110
How can RA be type 3 hypersensitivity as well
1. Anti-CCP antibodies generated in lungs by smoking
2. Form immune complexes with the citrullinated proteins
3. Deposit and triggers inflammation in the snyovium
111
Describe the erosive arthritis in RA
Initially
- Hyperplasia of synovium causing eroded cartilage
- Increase in osteoclast activity due to cytokines release = bone loss
later on progresses into
- Fibrosis
- deformity
- Damage tendons, ligaments and blood vessels
112
Articular presentation of RA
symmetrical, polyarthralgia
Inflammatory type of arthritis
- better with movement
- morning stiffness >30mintues
Atlanto-axial subluxation
Joint deformities
113
What is atlanto-axial subluxation
Instability and subluxation of the atlanto-axial joint due to damage of stability ligaments
114
What does atlanto-axial subluxation cause
neck pain radiating to the occiput
weakness in upper limbs
altered sensation in the upper limbs
115
Back pain in spondyloarthropathies vs RA
RA tends to spare lumbar region and affect the upper region
whereas spondyloarthropathies cause lower back pain
116
Where is the atlanto-axial joint
C1-C2
117
Progression of affected joints in RA
small joints of the hands and feet
-PIP
-MCP
-MTP
then
Larger joints
- knees
- shoulders
- elbows
- atlantoaxial joints
118
Which joints are often spared by RA
Distal interphalangeal joint (DIP)
119
What joint deformities are seen in RA
Swan neck deformity (hand
Boutonniere deformity (hand
Hallux valgus
Hammer toes
MTP subluxation
120
What causes swan neck deformity
PIP hyperextension
DIP hyperflexion
121
What causes boutounniere deformity
PIP flexion
DIP hyperextension
122
What causes hallux valgus
proximal phalanx deviating laterally
1st metatarsal bone deviating medially
123
What are the organs involved in extra-articular manifestations of RA
lungs
Heart
Skin
Eye
124
What are the lung manifestations in RA
Interstitial fibrosis
Caplan syndrome
Rheumatoid lung nodules
Pleuritis
Pleural effusion
Infections secondary to immunosuppression
125
What is Caplan syndrome
Inflammation and scarring of the lungs occurs in people with rheumatoid arthritis who have breathed in dust, such as from coal
126
What are the heart manifestations of RA
Pericarditis
Myocarditis
Increased risk of CVD
127
What are the skin manifestations of RA
Pyoderma gangrenosum
Raynaud's phenomenon
Rheumatoid skin nodules
128
What are the eye manifestations of the RA
keratoconjunctivitis
scleritis
129
What are the peri-articular manifestations of RA
Carpal tunnel syndrome
Tenosynovitis
Bursitis
130
Which tendons are most commonly affected by RA causing tenosynovitis
Flexors of hands
131
Which bursae are most commonly affected by RA causing bursitis
olecranon (elbow) bursae
sub-acromial (shoulder) bursae
132
Complications of RA
Amyloidosis
Felty's syndrome
133
What is Felty's syndrome
Triad of
- RA
- Splenomegaly
- Neutropenia
134
Investigations for RA
Bloods
Xray - first line
US
MRI (only if in doubt)
135
What are tested in blood tests for RA
CRP - raised
ESR - raised
Plasma viscosity - raised
Autoantibodies
136
What autoantibodies are present in RA
Anti CCP
Rheumatoid factor
137
Which autoantibody is more specific to RA
Anti CCP
138
Does presence of autoantibodies confirm the diagnosis of RA
No
139
What is shown in xray in patient with RA
Can be normal in early stages
Erosions
Soft tissue swelling
Narrowing of joint space
140
What can be used to detect RA at early stages
US
Xray not used because it is often normal
141
What scoring is used to monitor RA disease activity
DAS score
142
DAS score of 2.6 indicates
RA in remission
143
2 types of treatment for RA
Symptomatic relief
Disease modifying treatment
144
Symptomatic relief management for RA
NSAID
paracetamol
Oral steroids short course
145
When is disease modifying treatment for RA indicated
DAS > 5.1
146
Describe the disease modifying treatment for RA
1. csDMARD (conventional)
2. csDMARD + bDMARD (biologic)
147
csDMARD used in RA
Methotrexate
Sulfasalazine
hydroxychloroquine
leflunomide
148
Describe the first line DM treatment of RA
1. 1 csDMARD
2. If no remission + another csDMARD
149
When should you start DMARD in RA
within 3 months of symptom onset
150
What are the bDMARD (biological DMARD) used
anti TNF - infliximab
151
When is bDMARD indicated in RA
If after csDMARD therapy the DAS score is still >5.1
152
What should patients be aware of before starting DMARD
Risk of infections
Must use contraception during therapy
153
What should patients also get once they start their DMARD therapy
Influenza vaccine and the Pneumococcal vaccine every 5 years
Regular blood tests checking WCC
Cardiovascular monitoring
154
Side effect of DMARD
immunosuppression
low WCC
risk of infection
155
Why should patients with RA have regular cardiovascular monitoring
Because they are at increased risk of CVD
156
Side effects of methotrexate
Teratogenicity
Interstitial pneumonitis
Pulmonary fibrosis
Liver toxicity
Folate deficiency
GI disturbance
Immunosuppression
157
What is the most common causative pathogen of septic arthritis
S aureus
158
What is the most common causative pathogen of septic arthritis in prosthetic joint
Staph. epidermidis
