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MSK > Inflammatory Arthritis > Flashcards

Inflammatory Arthritis Flashcards

Rheumatoid arthritis Seronegative Spondylo-arthropathy Crystal Arthirtis

1
Q

What clinical features do Seronegative Spondylarthritis conditions share? (SPINEACHE).

A
  1. They are all seronegative i.e. they have no specific antibodies linked to them e.g. -ve RF
  2. Asymmetrical large-joint oligoarthritic or monoarthritic WITH spine involvement

Remember SPINE-ACHE

  • Sausage digit inflammation (dactylitis)
  • Psoriaform rash
  • Inflammatory back pain
  • NSAIDs good response
  • Enthesitis (heel) inflammation of the site of insertion of tendon
  • ‘Axial arthritis’ - pathology is spine and sacroiliac (SI) joints
  • Crohn’s, Collitis (IBD) CRP elevated
  • HLA B27
  • Eye (uveitis)
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2
Q

Where is HLA B27 found

A
  • Class 1 surface antigen i.e. found on all cells but RBC

- Antigen Presenting Cell

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3
Q

Name 4 Spondylarthritis Conditions

A
  • Ankylosing spondylitis
  • Enteric Arthritis (IBD, GI bypass, coeliac) -> both arthritis + bowel disease present
  • Psoriatic arthritis
  • Reactive arthritis
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4
Q

What is Reactive arthritis

A

Triad of arthritis, conjunctivitis, urethritis

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5
Q

RF, Signs and Sx of Ankylosing Spondylitis

A
  • Often <40y male
  • SoB due to ribs being affected
  • Lower back pain: worsens during the night, spinal morning stiffness, relieved by exercise
  • Pain radiates from sacroiliac joints to hips/buttocks
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6
Q

Examination of Ankylosing Spondylitis

A

(1. ) Measure chest expansion, lateral lumbar flexion and forward lumbar flexion.
(2. ) Palpate and stress the sacroiliac joints
(3. ) Examine peripheral joints for synovitis or enthesitis (esp. behind heel look for redness in eye)
(4. ) Look for ‘question mark’ posture

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7
Q

Tests for Ankylosing Spondylitis (3.)

A

(1. ) Pelvic XR
- SI joint = narrowing or widening, sclerosis, erosion, ankylosis/fusion
- Later stages, calcification with ankylosis leads to a bamboo spine appearance

(2.) Blood = FBC, elevated ESR & CRP, +ve HLA-B27

(3. ) Consider MRI
- Detect inflammation (oedema) erosions, sclerosis, ankylosis

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8
Q

ASAS Classification Criteria for Axial Spondyloarthirits

A

Either one of the three:

  1. Back pain >3m, age <45years
  2. Sacroiliitis on imaging PLUS SpA feature
  3. HLA-B27 PLUS >2 SpA features

SpA features

  • Inflammatory back pain
  • Arthritis
  • Enthesitis (heel)
  • Uveitis
  • Dactylitis
  • Psoriases
  • Crohn’s/colitis
  • Good response to NSAIDs
  • Fx for SpA
  • HLA-B27
  • Elevated CRP
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9
Q

Treatment of Axial Spondyloarthirits (4) + what risks does it carry

A

(1.) Physiotherapy = help maintain posture and mobility

(2. ) NSAIDs (and PPI) relieve Sx within 48h or whilst waiting for referral;
- Additional pain relief if poor sleep
- Local steroid injections are useful for sacroiliitis, enthesitis, arthritis.

(3. ) TNF-alpha inhibitors: etanercept, adalimumab
- Severe or poorly controlled by NSAIDs

(4. ) Surgery
- correct spinal deformities or to repair damaged peripheral joints.
- Hip replacements if hip affected and improves pain

(5. ) Preventions
- AS carries CVD risk so important to manage modifiable CV RF
- bisphosphonates are often used to treat osteoporosis and reduce the risk of fracture in AS

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10
Q

What is Psoriatic Arthritis

A

Joint inflammation that happens in individuals with psoriasis. It is part of seronegative spondyloarthropathies (i.e. no specific antibodies linked to them).

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11
Q

Presentation of Psoriatic Arthritis (5).

A

Pain, swelling, stiffness, inflammation in affected joints. Depending on the type of PA the following could occur:

  1. RA-like sx = polyarthritis affects >5 joints
  2. DIP involvement (unlike RA!!!!!)
  3. Asymmetrical large joints and spine (unlike RA!)
  4. Associated with nail changes, dactylitis, acneiform rashes
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12
Q

Ix of Psoriatic Arthritis (2).

A

PA and RA present similarly so important to rule out RA

  1. Absence of CRP, Rheumatoid factor & anti-CCP
    - Commonly seen in RA, and are generally absent in PA
  2. X ray
    - show joint erosion
    - pencil in cup deformity
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13
Q

Tx of Psoriatic Arthritis

A

Reduce pain and stiffness

(1. ) NSAIDs
(2. ) Localised steroids injection

Prevent joint damage

(1. ) DMARDs e.g. Sulfasalazine, methotrexate
(2. ) If above fail consider biological therapy: Anti-TNFa

Minimise disability
(1.) Surgery: If it's severe, there's a risk of the joints becoming permanently damaged or deformed.
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14
Q

How does an inflammatory joint present?

A
  1. Joint Swelling
    - New onset
    - Synovial swelling: squishy, tender, compressible
    - Red
    - Warm to touch
  2. Worse in morning/inactivity
    - Stiffness >30mins
  3. Can be constant or intermittent
  4. Patterns of joints +/- spine involvement vary by arthritis type
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15
Q

What would cause an inflammatory joint?

A
  1. Inflammatory arthritis
    - RA
    - Seronegative spondylarthritis
    - Crystal arthritis
  2. Septic Arthritis
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16
Q

What is Rheumatoid Arthritis and RF?

A
  • Chronic systemic inflammation disease
  • Symmetrical small joints of hand wrists feet and NO spinal involvement
  • Big joints can be involved later, bad prognostic sign if involved at start/presentation
  • Inc risk of CVD.
  • RF = Female, Fx, smoking, middle age, severity associated with HLA DR1, DR4
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17
Q

How does RA differ to SpA?

A

In RA

  • Symmetrical inflammation
  • No spine involvement
  • CRP present
  • RF +ve
  • Anti-CCP +ve
18
Q

Presentation of RA?

A
  1. Symmetrical arthritis of small joints of hands and feet
  2. Morning stiffness >30mins
  3. Systemic illness and extra-auricular sx

Specific Signs

  1. Ulnar deviation
  2. Boutonniere deformity
  3. Swan neck deformity
19
Q

Why may RA present with extra-auricular manifestations and what are these?

A
  • Cytokines that causes swelling of synovial mb, are amplified and able to travel and affect multiple organ system so extra-auricular problems are seen

Examples:

  • Rheumatoid nodules on elbow, lungs, cardiac etc
  • Lungs = pleural disease, interstitial fibrosis etc
  • Cardiac = pericarditis etc
  • Eye = episcleritis, scleritis etc
  • Osteoporosis amyloidosis
  • Vasculitis
20
Q

Physical Examination of RA

A
  1. Dec grip strength, fist formation
  2. Often subtle synovitis - MCP, PIP, MTPs, ankles
  3. Usually symmetrical
  4. Deformity unusual at presentation
21
Q

Investigations of RA

A

Bloods

  • CRP +/- ESR
  • RF +ve (70%)
  • Anti-CCP (70%)
  • ANA positive

X-rays

  • Used as Dx, prognostic tool and monitor therapy
  • Periarticular osteopenia
  • Joint space narrowing
  • Bone erosion and deformity
  • Soft tissues swelling
22
Q

Tx and Mx of RA (4)

A

Requires early and aggressive treatment

  1. DMARDs** (methotrexate)
  2. Biological treatment
    - Anti-TNF = infliximab
    - Supress T-cells = abatacept
    - Suppress B-cells = rituximab
  3. NSAIDs or short-term glucocorticoids
    - Can be used for acute flares and pain
  4. Referral to physio, OT, podiatry as indicated
23
Q

What is it Septic Arthritis and when would it be suspected?

A
  1. Inflammation in a native or prosthetic joint.
  2. This can be acute or chronic
  3. Consider septic arthritis in any acutely inflamed joint, as it can destroy a joint in under 24hrs and has a 11% mortality rate
24
Q

Common pathogens in Septic Arthritis?

A
  • Staph aureus = any age group

- N.gonorrhoea = elderly w/multiple morbidities, immunosuppressed individuals. Causes Gonococcal arthritis

25
Q

RF of Septic Arthritis

A
  • > 80 years
  • DM
  • Prior joint damage e.g. RA, gout, CTD
  • Joint surgery, hip or knee prosthesis
  • Skin infection in combination with joint prosthesis
  • Weakened immune system e.g. HIV or medication
  • IV drug abuse
  • Any causes for bacteraemia
  • Cutaneous Ulcers
26
Q

Sx of septic arthritis (5).

A

Look for: pre-existing joint disease, immunosuppressive disease, recent steroid injection, sexually transmitted disease, IV drug use.

  1. Painful, red, swollen, hot joint
  2. Fever and rigors
  3. Prostration, vomiting or hypotension (If bacteriaemia)
  4. 90% monoarthritic
  5. Pain Location
    - Joints commonly affected (in order) = Knee > hip > shoulder > ankle > wrist
27
Q

Investigations of septic arthritis (4)

A
  1. Urgent joint aspiration
    - if fails, or fungi, mycobacteria suspected –> Synovial Biopsy, Tissue culture
  2. Bloods + culture
  3. Swab around rectal, cervical, urethral, pharyngeal - If gonococcal infection is suspected
  4. Imaging
    (a. ) Plain radiographs: can be normal OR:
    - Joint space widening may be seen –> oedema, effusion present
    - Joint space narrowing –> later stage, cartilage destruction
    - Calcium pyrophosphate/ chondrocalcinosis may be detected which would indicate pseudo gout and thus rule out septic arthritis

(b.) Ultrasound: May reveal presence of effusion, can guide aspiration

28
Q

Management and Treatment of septic arthritis (2.)

A

(1.) Referral if suspected septic arthritis of hip, prosthetic joint. US-guided joint aspiration and surgical debridement performed by orthopaedics

(2. ) 6w Abx Therapy
- ***note: joint aspirationt for microscopy, culture, sensitivities must be taken before starting abx
- IV flucloxacillin (clindamycin is penicillin allergy)
- IV Vancomycin plus cephalosporin if MRSA risk
- IV cephalosporin if gram -ve suspected
- Ceftriaxone if gonococcus suspected
- If sx improve after 2w, move onto PO administration for 2-4w

29
Q

Pathophysiology of Gout

A
  • Inflammatory disease
  • It is acute but can become a chronic problem within deposits of tophi crystals.
  • Deposits of monosodium urate crystals (hyperuricemia) into a joint, making it red, hot, tender and swollen within hours (gouty attack).
  • Over time, repeated gouty attacks can cause destruction of the joint tissue which results in arthritis.
30
Q

RF of gout

A
  1. Reduced Urate excretion
    - impaired renal function, CKI, diuretics, anti-hypertensives, aspirin
    - Metabolic syndrome: Heart disease, obesity, lipid problems, HTN, T2D
  2. Excess urate production
    - Dietary, westernised diets (beer, sweeteners, red meat, seafood)
    - Genetic disorders
  3. Others
    - Elderly
    - men
    - post-menopausal women
31
Q

Triggers for gout

A
  • Direct trauma to the joint
  • Intercurrent illness
  • Alcohol or shellfish binge
  • Surgery
  • Dehydration
  • Most are spontaneous
  • Starting hypouricaemic therapy
32
Q

Presentation of gout

A
  1. Acute severe joint inflammation causing pain, erythema swollen hot area
  2. Most commonly affected joints:
    - Toe, Ankle foot, knee, finger, elbow etc
    - 1st MTP joint
  3. Chronic tophaceous gout
    - large crystal deposits produce irregular firm nodules mainly around extensor surfaces of the fingers, hands, forearms, elbows, ears
33
Q

Investigation of gout (4).

A
  1. Serum Urate
  2. Xray: if fracture is suspected
  3. Joint Aspiration
    - if septic arthritis suspected
    - confirms the diagnosis
    - Polarised light microscopy of synovial fluid show NEGATIVELY bi-refringement urate crystals
34
Q

Tx and Management of acute and chronic gout

A

Conservative

  • Elevate, rest, ice. keep affected area open and uncovered.
  • Avoid trauma to the joint.
  • Reduce Alcohol intake, eat balanced diet + restrict purine foods
  • Keep well hydrated

Medical - acute
1. NSAIDs or Colchicine or Oral Corticosteroids

Medical - chronic

  1. NSAIDs and Colchicine for up to 6m
  2. Allopurinol: prophylaxis if >1 attack in 12months or tophi or urate renal stones
35
Q

Pseudogout

A
  • Calcium Pyrophosphate Dihydrate (CPPD) deposits in larger joints usually the knee
  • Self-limiting usually - 1-3w
36
Q

RF of Pseudogout

A

RF = older age, trauma to joint, women, mineral imbalance, hypomagnesaemia, hyperparathyroidism, thyroid disorders, acromegaly, haemochromatosis, wilson’s disease, overlap with OA

37
Q

Presentation of Pseudogout

A
  • Pain and swelling of joint
  • Affects larger joints
  • Sudden onset of pain and can last for 7-14d
38
Q

Physical Examination of Pseudogout

A
  • Sudden onset of hot swollen joint
  • Locations: Knees > wrists > shoulder> ankles >elbows
  • Limited range of motion
  • Pain when moving or palpating the joint
  • Stiffness of joint
  • Erythema or discolouration of skin
39
Q

Ix of Pseudogout

A
  1. Joint Aspiration
    - Rhomboid shaped crystals
    - Polarised light microscopy of synovial fluid, shows weakly positive bi-fringence
  2. Bloods
    - Rule out imbalances or underlying causes
    - TFT, U&E
  3. Xray
    - Chrondrocalcinosis (CPPD deposits) on xray
40
Q

Mx and Tx of Pseudogout

A
  1. Conservative: Ice, Rest, Elevation
  2. Medical
    - NSAIDs
    - Colchicine
    - Predinisolane

MSK (6 decks)

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