Inflammatory arthritis Flashcards
1
Q
What is the definition of soft tissue rheumatism?
A
Inflammation/damage to ligaments, tendons, muscles or nerves near a joint rather than either the bone or cartilage
2
Q
What is the most common area for pain for those who suffer with Soft tissue rheumatism?
A
Shoulder
3
Q
What conditions are associated with the elbow?
(To do with Soft tissue rheumatism)
A
- Medial and lateral epicondylitis
- Cubital tunnel syndrome
4
Q
What are the conditions associated with the wrist?
( To do with Soft tissue rheumatism )
A
- De-Quervains tenosynovitis
- Carpal tunnel syndrome
5
Q
What condition is associated with the foot?
(To do with Soft tissue rheumatism)
A
Plantar fascitis
6
Q
What are the two main clinical presentations of Soft tissue rheumatism
A
- Pain confined to a specific site
- Localised soft tissue pain (fibromyalgia)
7
Q
Treatment for soft tissue rheumatism
A
(1) Pain control
(2) Rest and ice compressions
(3) Physical Therapy (PT)
If fails, then steroids or surgery
8
Q
What does the mnemonic PAIR stand for in relation to diseases associated with HLA B27?
A
PAIR
Psoriatic arthritis
Ankylosing spondylitis
IBS
Reactive arthritis
9
Q
What type of MHC is HLA B27?
A
Class 1 MHC type
10
Q
What is the difference between mechanical and inflammatory back pain?
A
(1) Mechanical back pain worsens with activity and improves with rest
(2) Inflammatory back pain improves with activity and worsens with rest
11
Q
What is the first-line pharmacological treatment for spondyloarthropathies?
A
(1) NSAIDs like ibuprofen → not for IBS
(2) Corticosteroids → for joint injections
(3) Topical steroid eye drops → managing ocular inflammation
12
Q
What is the second treatment for spondyloarthropathies?
A
DMARDS
13
Q
What is the third-line treatment for spondyloarthropathies?
A
Biologics such as Anti-TNF
14
Q
What Spondyloarthropathies is
Seronegative arthritis?
A
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
15
Q
What Spondyloarthropathies is
seropositive arthiritis?
A
Rheumatoid arthritis
16
Q
Seronegative spondyloarthropathies should all be what?
A
RF and ANA negative
17
Q
What is Psoriatic Arthritis?
A
An inflammatory arthritis associated with psoriasis
18
Q
Clinical presentation of Psoriatic Arthritis
A
red scaly patches in skin
19
Q
Articular symptoms of Psoriatic Arthritis
A
(1) Usually an asymmetrical oligoarthritis (2-4 joints) but can affect the hands in a similar pattern to RA
(2) Predominantly affects joints of hands and feet
20
Q
What are common extra-articular symptoms of Psoriatic Arthritis?
A
Nail involvement - pitting
Eye disease - Uveitis
21
Q
What is opera-glass hand, and which conditions can cause it?
A
The opera-glass hand is a telescoping deformity where finger bones resorb, causing shortening, but soft tissues remain intact, allowing extension and retraction.
It is most commonly seen in arthritis mutilans in psoriatic arthritis but can also occur in severe rheumatoid arthritis and Hajdu-Cheney syndrome
22
Q
What blood test findings are common in Psoriatic Arthritis?
A
(1) ↑ inflammatory markers
(2) Negative RF and Anti-CCP to rule out RA
23
Q
What is seen in an XRAY of psoriatic arthritis?
A
- Marginal erosions and whiskering
- Pencil in cup deformity
24
Q
What is the first-line pharmacological treatment for Psoriatic Arthritis?
A
NSAID
25
What is the next step if NSAIDs do not control Psoriatic Arthritis symptoms?
DMARDs
first line - Leflunomide or methotrexate
second line - Sulfasalazine
+
Consider anti-TNF therapy in severe cases
26
What conditions are associated with psoriatic arthritis?
Psoriasis
Cardiovascular disease
Gout
Psychological issues
27
How does the pattern of joint involvement differ between rheumatoid and psoriatic arthritis?
Both have variable and overlapping joint involvement, but distal interphalangeal joint involvement is much more common in psoriatic than rheumatoid arthritis
28
What is Enteropathic Arthritis?
IBD associated arthritis
= Inflammatory arthritis, involving the (1) Peripheral joints
(2) Sometimes the spine
(3) Occurs in patients with inflammatory bowel disease
29
What are the symptoms of Enteropathic Arthritis
1. Patients present with arthritis in several joints
2. weight loss
3. GI - loose, watery stool with mucous and blood
30
What are the signs of Enteropathic Arthritis?
(1) Low grade fever
(2) Weight loss
(3) Uveitis
(4) Pyoderma gangrenosum
= necrotic skin condition that causes painful ulcers with purple, undermined edges
(5) Aphthous ulcers (mouth)
31
Why is a joint aspirate performed in suspected enteropathic arthritis?
To rule out septic arthritis and crystal arthropathies, as no organisms or crystals should be present
32
What findings on GI endoscopy with biopsy support enteropathic arthritis?
Ulceration or colitis, indicating underlying inflammatory bowel disease
33
What imaging findings suggest sacroiliitis in enteropathic arthritis?
X-ray or MRI showing sacroiliitis
- inflammation
34
What can an ultrasound (USS) show in enteropathic arthritis?
Synovitis or tenosynovitis, indicating joint or tendon inflammation
35
A 21-year-old female presents to the rheumatology clinic with a 6-week history of joint pain, swelling and early morning stiffness affecting her left ankle and right knee. The pain is improved with movement. On further questioning, over the past few years, she has also been experiencing recurrent episodes of crampy central abdominal pain and diarrhoea, sometimes with blood in the stool and this has been especially bad during the last few weeks too.
What is the most likely cause of her joint pain?
Enteropathic arthritis
36
What is reactive arthritis?
An infection-induced systemic illness characterised by inflammatory synovitis
= where viable microorganisms cannot be cultured from the affected joints
37
What are the most common infections preceding reactive arthritis?
1. Urogenital infections
= chlamydia, neisseria
2. Enterogenic infections
= salmonella, campylobacter
38
Which genetic factor is associated with reactive arthritis?
HLA B27 positive
39
What is the typical age group affected by reactive arthritis?
Young adults (20-40 years)
40
What is the clinical presentation of reactive arthritis?
(1) fever
(2) fatigue
(3) malaise
(4) asymmetrical monoarthritis or oligoarthritis
(swelling of a single large joint)
41
What is Reiter's syndrome?
A triad of urethritis, conjunctivitis/uveitis/iritis, and arthritis seen in reactive arthritis
42
What is the treatment for reactive arthritis?
Most cases are self-limiting, but NSAIDS and steriods .chronic cases may require DMARDs
43
What percentage of reactive arthritis cases resolve spontaneously?
90% resolve spontaneously within 6 months.
44
What are the potential complications of reactive arthritis?
Reiter’s Syndrome, which includes
1. urethritis
2. conjunctivitis/uveitis/iritis
3. arthritis
45
What are the main triggers of reactive arthritis?
Sexually transmitted infections (STI) or gastroenteritis
46
When do symptoms of reactive arthritis typically appear?
1-4 weeks after the initial infection
47
What is the main differential diagnosis of diarrhoea in combination with arthritis?
Enteropathic arthritis (during arthritis)
Reactive arthritis (preceding arthritis)
48
A 28-year-old man presents to general practice with a 3-day history of right knee and right ring finger swelling. Over the last 24 hours, he has also developed “grittiness,” redness, and pain in the left eye.
On examination he is systemically well and afebrile. There is tender swelling and pain around the right knee joint, and the right ring is diffusely swollen. His visual acuity is normal, but the eye appears red. There is no hypopyon or abnormalities on direct fundoscopy.
He denies recent chest, urinary or enteric infection. But underwent treatment for an undisclosed infection 2 weeks ago.
What is the single most appropriate management? and w
Oral NSAIDs
= reactive arthritis likely due to a sexually transmitted infection
49
A 25-year-old woman presents to the GP with ankle pain. She does not recall a history of trauma. On further questioning, she reveals that she has had a red, gritty eye for the last few days and generalised joint pains. She was treated for Chlamydia two weeks ago when she presented with dysuria.
On examination, she has swelling of the Achilles tendon and tenderness on palpation. What is the likely cause of her ankle pain?
Reactive arthritis
50
What is the main difference in joint involvement between rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and reactive arthritis?
(1) RA
= Small joints of the hands and feet, symmetrical
(2) PsA
= DIP joints, asymmetrical, may involve spine
(3) AS
= Sacroiliac joints, spine, large joints.
(4) Reactive arthritis
= Large joints (knees, ankles), sacroiliac joints, and entheses
51
A 28-year-old woman is referred to outpatient rheumatology for review.
She presents with a four-month history of worsening pain and stiffness in the joints of her knee, wrists and hands which is worse in the morning and improves with exercise
On examination, there is redness, warmth and swelling of the entire right index finger and wrist, as well as the left knee. No skin lesions are noted, but there are widespread nail changes including pitting and onycholysis.
On further questioning, she is fit and well and denies a personal or family history of similar problems. She is sexually active in a long-term relationship, is a non-smoker and drinks socially.
What is the single most likely diagnosis?
Psoriatic arthritis
52
"Painless vesicle of the prepuce suggests that he has circinate balanitis"
This indicates what disease?
Reactive Arthritis
53
What is the most common organism associated with reactive arthritis?
Chlamydia trachomatis
54
A 21-year-old female presents to the rheumatology clinic with a 6-week history of joint pain, swelling and early morning stiffness affecting her left ankle and right knee. The pain is improved with movement.
On further questioning, over the past few years, she has also been experiencing recurrent episodes of crampy central abdominal pain and diarrhoea, sometimes with blood in the stool and this has been especially bad during the last few weeks too.
What is the most likely cause of her joint pain? and why?
Enteropathic arthritis
= 1. Joint pain, swelling, and stiffness in ankles and knees (common sites for enteropathic arthritis)
2. The patient has a history of crampy abdominal pain, diarrhoea, and blood in the stool, which are all signs of inflammatory bowel disease (IBD), like Crohn's disease or ulcerative colitis
3. Joint symptoms are often linked to flare-ups of IBD, which can present with joint involvement, particularly in the lower limbs
55
A 29-year-old man presents to his GP complaining of 2 weeks of pain and swelling in his left knee. He has been applying ibuprofen gel to the area, which has helped somewhat. He cannot think of any possible precipitating injury. He is feeling well in himself. He has no past medical history. On examination, his left knee appears swollen and has a limited range of movement. The soles of his feet have multiple painless keratinised lesions
What is most strongly associated with the likely diagnosis and what does he have/ how do you know?
HLA-B27
= reactive arthritis (also known as Reiter's syndrome)
He has presented with keratoderma blennorrhagica on his feet which is a dark maculopapular rash is characteristic of reactive arthritis
56
A 35-year-old female presents to her general practitioner with a 10-day history of asymmetrical oligoarthritis predominantly affecting her lower limbs, associated with dysuria and conjunctivitis. She is usually well apart from suffering from a diarrhoea illness 1 month ago
What is this describing?
Reactive arthritis
57
A 24-year-old male presents to the emergency department with a painful right knee associated with lethargy and feverish symptoms. His past medical history includes a Chlamydia trachomatis infection two weeks previously. Observations show:
Respiratory rate 17 breaths/min
Heart rate 84 beats/min
Blood pressure 122/76mmHg
Temp 37.3ºC
Oxygen saturation 97% on room air
What would most likely be observed in a sample of synovial fluid taken from this patient's knee?
Reactive arthritis: develops after an infection where the organism cannot be recovered from the joint
= therefore the sample would show sterile synovial fluid with a high white blood cell count
58
A 29-year-old man visits his general practitioner with a 1-week history of left knee pain. He complains of pain on weight-bearing and swelling around the joint. There is no pain in his other joints although he does complain of pain when passing urine.
On examination, he has a temperature of 37.9ºC. His left knee is swollen and slightly warm to the touch. He has inflamed conjunctivae.
What in the above scenario suggests reactive arthritis?
(1) Knee pain and swelling, especially with weight-bearing, suggests arthritis.
(2) Conjunctivitis is a hallmark feature of reactive arthritis
(3) Painful urination (dysuria) suggests urethritis, which often accompanies reactive arthritis
(4) A low-grade fever is common in reactive arthritis as part of the inflammatory response.
59
A 27-year-old man presents to his GP feeling generally unwell complaining of joint pain and swelling. He returned from a walking trip in Thailand one month ago and one day after his return he developed severe watery diarrhoea and abdominal cramps that lasted for one week.
On examination, he appears unwell and looks fatigued. He has large effusions of the left knee and right ankle along with tender plantar fascia bilaterally. He also has tender metatarsophalangeal joints on both feet. On closer inspection of the feet, he has a papular rash on the soles of both feet.
For the last week, he has been taking regular paracetamol and ibuprofen with minimal improvement in symptoms.
Given the most likely diagnosis, what is the most appropriate next step in this patient's management?
Oral prednisolone
60
A 42-year-old man with a 6-month history of joint pain, stiffness, and swelling, along with a recent episode of eye pain and blurry vision, seeks treatment at a rheumatology clinic. He has not tried any medication. He has had a diagnosis of psoriasis for the past ten years. On examination, he has tender, swollen joints involving both hands, wrists and knees.
Laboratory investigations reveal elevated C-reactive protein and erythrocyte sedimentation rate. Radiographs of the hands show erosive changes in the affected joints.
What long-term medication is appropriate for this patient?
Moderate/severe psoriatic arthropathy
= methotrexate
