Inflammatory arthritis

Question 1

What is the effect of inflammatory cytokines on the organ systems?

Answer 1

Skeletal muscle- protein breakdown
Skin- rheumatoid nodules
Blood vessels- atheromatous plaques
Liver- hepcidin, low iron 
Lung- scar tissue in interstitium and pleural effusion 
Brain- fever

Question 2

What joints does RA affect?

Answer 2

Usually >5
Symmetrical 
Small joints: MCP, PIP, MTP
As disease worsens:
Shoulders, elbows, knees, ankles

Question 3

What are specific deformities of RA?

Answer 3

Ulnar deviation
Boutonniere (PIP flexion, DIP hyperextension)
Swan neck (PIP hyperextension, DIP flexion)

Question 4

What are the extra articular symptoms?

Answer 4

Baker’s cyst
Fever
Low appetite
Malaise, weakness

Question 5

What is felty syndrome?

Answer 5

Triad of RA, splenomegaly and granulocytopenia

Life threatening infections

Question 6

How is RA diagnosed?

Answer 6

Look for rheumatoid factor and anti-CCP antibody in blood test
X ray- decreased bone density, soft tissue swelling, bony erosions, narrowing of joint space

Question 7

Which drugs are used to treat RA long term?

Answer 7

Methotrexate
Hydroxychloroquine
Sulfalazine

Question 8

What are biologics?

Answer 8

Abatacept- suppress t-cells
Rituximab- suppress B-cells
Adalimumab- tumour necrosis factor

Question 9

What are the environmental triggers for psoriatic arthritis?

Answer 9

Physical trauma

Infection

Question 10

How is psoriatic arthritis diagnosed?

Answer 10

Presence of RF and absence of anti CCP

Pencil in cup x ray sign

Question 11

Which food precipitate the formation of irate crystals in gout?

Answer 11

Consumption of purines:
Shellfish, anchovies, red meat, organ meat
Increased production fo purines:
High fructose beverages 
Decreased clearance of uric acid:
Dehydration 
Alcohol consumption

Question 12

What is podagra?

Answer 12

When gout affects the first metatarsal joint of big toe
Toe on fire, wakes from sleep
Most severe pain hours after attack
Discomfort and swelling for weeks

Question 13

What are drugs used to treat gout?

Answer 13

Xanthine oxidase inhibitors- allopurinol (decrease uric acid levels)

Question 14

What are the clinical features of ankylosing spondylitis?

Answer 14

Young male 
Pain and morning stiffness int he lower back and buttocks 
Pain improves with exercise, not rest
Loss of lumbar lordosis and increased kyphosis 
Reduced spinal flexion by Schober test 
Achiles tendinitis 
Reduction in chest expansion 
Anterior uveitis

Question 15

How is AS diagnosed?

Answer 15

ESR and CRP raised

X-rays: erosion and sclerosis of the margins of the sacroiliac joints, bony spurs, progressive calcification

Question 16

What is reactive arthritis?

Answer 16

Sterile synovitis
GI infection (shigella, salmonella, yersinia, campylobacter)
STI

Question 17

What re the clinical features of reactive arthritis?

Answer 17

Presents shortly under 4 weeks after infection
Joints of lower limbs, asymmetrical
Skin lesions resemble psoriasis
Circinate balanitis
Pustular psoriasis on palms and soles
Nail dystrophy
Reiter’s Syndrome (urethritis, reactive arthritis, conjunctivitis )

Question 18

What is enteropathic arthritis?

Answer 18

Large joint mono-symmetrical oligoarthritits
10-15% of UC or Crohn’s
Improves as bowel symptoms improve

Question 19

What is pseudogout?

Answer 19

Deposition of calcium pyrophosphate dihydrate
More common in elderly women, affects knee or wrist
Maybe associated with haemochromatosis, hyperparathyroidism or Wilsons disease in young people

Question 20

What is osteomyelitis?

Answer 20

Staphylococcus most common (h. influenzae, salmonella)
Fever, local pain and erythema
Diagnosis: CT, MRI, bone scan

Question 21

What are the other features of AS?

Answer 21

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome
peripheral arthritis (25%, more common if female)

Question 22

What is an adverse effect of etanercept?

Answer 22

Can reactivate TB

Question 23

What is the most common extra-ocular feature of RA?

Answer 23

Keratoconjunctivitis sicca

Dry eye syndrome

Question 24

Which investigations confirm gout?

Answer 24

Serum uric acid
X-ray of left foot
Examien joint under polarised light microscopy for negatively birefringent crystals

Question 25

What are the other risk factors for gout?

Answer 25

Leukaemia 
Psoriasis 
Lesh-Nyhan syndrome 
Lead
Thiazide, loop diuretics, low dose aspirin

Question 26

What re the subtypes for psoriatic arthritis?

Answer 26

RA- symmetrical polyarthropathy
Distal arthritis (nail changes common)
Spondylitis
Arthritis mutilans (severe destructive of small joints)

Question 27

What are the pulmonary conditions that patient’s with RA can develop?

Answer 27

Interstitial lung disease
Pulmonary fibrosis 
Bronchiectasis
Pleural effusions 
Lung nodules
Caplan syndrome and pleurisy

Question 28

What is the triad of symptoms in reactive arthritis?

Answer 28

Urethritis, conjunctivitis and arthritis

Question 29

What are the factors associated with a poor prognosis in RA?

Answer 29

High serum level autoantibodies 
Extra-articular manifestations 
Female sex
Systemic symptoms 
<30
Involvement of multiple joints

Question 30

What is seen on an X-ray in osteoarthritis?

Answer 30

Osteophyte formation
Subchondral sclerosis (thickening of bone)
Joint space narrowing
Subchondral cysts

Question 31

What is seen on examination of OA?

Answer 31

Bony enlargement 
Reduced range of movement 
Crepitus
Deformity (varus)
Effusion 
Antalgic gait

Question 32

What is seen in the joint fluid in pseudogout?

Answer 32

Positively birefringent rhomboid shaped crystals