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Rheumatology > Inflammatory Arthropathies > Flashcards

Inflammatory Arthropathies Flashcards

1
Q

What is Rheumatoid Arthritis

A

a chronic systemic inflammatory disease, characterised by potentially deforming symmetrical polyarthritis and extra-articular features (systemic disease)

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2
Q

RA: seropositive or seronegative

A

seropositive!!
Anti-CCP antibody
Rheumatoid Factor

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3
Q

joints most commonly affected by RA

A

small joints of hands and feet - most common
knees
shoulders
elbows

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4
Q

Which serological test is preferred for diagnosis of RA:

Rheumatoid factor or Anti-CCP, and why

A

Anti-CCP

rheumatoid factor is 70% sensitive, 90% specific
Anti CCP is 70% sensitive, 97% specific

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5
Q

Describe the pathology of RA

A

an immune response (type IV) is initiated against the synovium which lines synovial joints

the synovium proliferates and becomes invasive

cytokines are released into the synovial space

synovium becomes laden with macrophages

synovial membrane (pannus) expands, actively invades and erodes surrounding bone and cartilage

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6
Q

are women or men more affected by RA

A

women

2-3x more likely to develop than men

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7
Q

hypersensitivity response in RA

A

Type IV

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8
Q

causes of RA

A 
genetic factors (account for 50%)
triggers -smoking, infection, trauma
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9
Q

is RA usually unilateral or bilateral (in terms of joints)

A

bilateral - both hands, both feet etc

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10
Q

articular (relating to joint) presentation of RA

A 
pain 
swelling 
stiffness - relieved by exercise 
swelling 
tenderness
reduced ROM
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11
Q

extra-articular presentations of RA

A 
dry eye
sclera inflammation 
pulmonary fibrosis 
pleural effusions 
rheumatoid nodules of extensor surfaces 
anaemia 
Felty's syndrome 
osteoporosis
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12
Q

What is Felty’s syndrome

A

autoimmune triad:

  1. RA
  2. splenomegaly
  3. neutropenia
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13
Q

What are the classic deformities in the hands seen in RA

A
  1. Z-shaped thumb - ulnar deviation
  2. Swan neck deformity - hyperextension of the PIP and flexion of the DIP
  3. Boutonniere deformity - flexion of the PIP and hyperextension of the DIP
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14
Q

in untreated and aggressive RA, what can happen to the spine

A

atraumatic cervical instability

there is atlanto-axial subluxation that can result in spinal cord compression

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15
Q

where are rheumatoid nodules most commonly found

A

extensor surfaces e.g. elbows

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16
Q

lung involvement in RA

A

pleural effusions
interstitial fibrosis
pulmonary nodules

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17
Q

ocular involvement in RA

A

keratoconjunctivitis sicca
episcleritis
uveitis
nodular scleritis

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18
Q

What joints of the hands are usually spared in RA

A

DIP joints (not enough synovium)

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19
Q

Ix for RA

A

Clinical suspicion
Auto-antibodies (Anti-CCP)
X-ray
Bloods - CRP, ESR and plasma viscosity all raised

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20
Q

Tx of RA

A
  1. DMARD combination - methotrexate and one other
    + corticosteroid (prednisolone)
    + NSAIDS for short-term relief
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21
Q

If patient isn’t responding to DMARD, what can they be put on

A

Biologic therapy - e.g. anti-TNF (Infliximab)

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22
Q

What are the different types of DMARDs

A

Methotrexate
Sulphasalazine
Hydroxychloroquine
Leflunomide

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23
Q

What are the different classes of biologic drugs

A

Anti-TNF - infliximab

B cell depletion - rituximab

Disruption of T cell - abatacept

IL6 inhibition - tocilizumab

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24
Q

How do biologic drugs work

A

They all target a different part of the immune system with a view to reducing the inflammatory process driving the disease

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25
Q

Do all patients with RA get put on biologic therapy?

A

No - they must have evidence of high disease activity - measured using the DAS 28 score

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26
Q

What are the components of the DAS 28 scoring system

A
  1. tender joint count
  2. swollen joint count
  3. CRP/ESR
  4. visual analogue scale (patients own assessment of disease)
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27
Q

What DAS28 score qualifies the patient for biologic therapy?

A

> 5.1

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28
Q

Below what time limit is the aim to start patients with RA on treatment

A

within 12 weeks of onset of symptoms

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29
Q

main sign of RA on xray

A

marginal erosion

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30
Q

what role does surgery have in RA

A

becoming increasingly less common, but can be used for resistant disease

31
Q

surgeries that can be done for RA

A 
synovectomy 
joint replacement 
joint excision 
tendon transfers 
arthrodesis (fusion) 
cervical spine stabilisation
32
Q

List the 4 seronegative inflammatory arthropathies

A

ankylosing spondylitis
psoriatic arthritis
enteropathic arthritis
reactive arthritis

33
Q

what characterises the seronegative inflammatory arthropathies

A

they all involve arthritic disease of the spine (spondyloarthropathy) and an asymmetric oligoarthritis (arthritis affecting 1-4 joints)

34
Q

What individuals are more likely to have a seronegative inflammatory arthropathy

A

Genetically predisposed individuals - HLA-B27 positive

35
Q

Shared rheumatological features of the seronegative inflammatory arthropathies

A

sacroiliac and spinal involvement
enthesitis
dactylitis

36
Q

What is enthesitis

A

inflammation at insertion of tendons into bones e.g. achilles tendonitis, plantar fasciitis

37
Q

What is dactylitis

A

“sausage digits”

inflammation of the entire digits

38
Q

Shared extra-articular features of the seronegative inflammatory arthropathies

A 
ocular inflammation (anterior uveitis) 
mucocutaneous lesions
39
Q

compare characteristics of mechanical back pain to inflammatory back pain

A

mechanical:
worse with exercise, relieved by rest
worse at end of day

inflammatory:
worse with rest
early morning stiffness

40
Q

what is ankylosing spondylitis

A

a chronic progressive spondyloarthropathy (seronegative) of the spine and sacroiliac joints, which ultimately may lead to spinal fusion.

41
Q

are male or females more affected by ank spond?

what is the typical age of onset?

A

men (3:1)

age onset 20-40 years

42
Q

characteristic appearance of spine in ank spond

A

“question mark spine”

loss of lumbar lordosis and increased thoracic kyphosis

43
Q

presentation of ank spond

A

inflammatory back pain - early morning stiffness that improves with exercise
improvement with NSAIDs
alternating buttock pain

eye involvement - iritis, anterior uveitis
enthesitis
psoriasis
IBD

44
Q

normal curvatures of the spine

A

cervical lordosis
thoracic kyphosis
lumbar lordosis
sacral kyphosis

45
Q

how is lumbar flexion measured in a patient suspected of having ank spond

A

Schober’s test -
measure 5cm below the posterior superior iliac crests and 10cm above, then ask them to bend forwards and remeasure the distance.
Normal - should extend beyond 20cm.

46
Q

Ix for ank spond

A

No diagnostic test

  • Clinical suspicion
  • xray pelvis (may be normal, do MRI if so)
  • HLA-B27 testing
  • inflammatory markers
47
Q

what does xray of pelvis show in ank spond

A

N.B. may be normal

sclerosis and fusion of sacroiliac joints

48
Q

what does xray of spine show in ank spond

A

syndesmophytes
- bony spurs from vertebral bodies that bridge the IV disc and result in fusion
“BAMBOO SPINE”

49
Q

Tx ank spond

A
  1. NSAIDs (naproxen, ibuprofen, diclofenac)
    also
    physio
    exercise
  2. Anti-TNF inhibitors (infliximab, etanercept)
50
Q

what treatment is appropriate in ank spond if there is peripheral joint involvement

A

DMARDs (sulfasalazine)

51
Q

what % of people with psoriasis also have joint disease (psoriatic arthritis)

A

30%

52
Q

joints most commonly affected in psoriatic arthritis

A

DIP joints of fingers and/or toes

53
Q

is psoriatic arthritis commonly symmetrical or asymmetrical

A

asymmetrical!

54
Q

presentation of psoriatic arthritis

A

spondylitis
dactylitis
enthesitis
nail changes - pitting, onycholysis

55
Q

arthritis mutilans

A

aggressive and destructive form of psoriatic arthritis

56
Q

Ix for psoriatic arthritis

A

xrays of hands and feet
inflammatory markers - raised
anti-ccp - negative

57
Q

classic x-ray sign in psoriatic arthritis

A

pencil in cup deformity at DIP joints

58
Q

Tx psoriatic arthritis

A
  1. DMARDs - methotrexate
    also NSAIDs
  2. Biologic therapy - anti-TNF (infliximab)
59
Q

what is enteropathic arthritis

A

inflammatory arthritis involving the peripheral joints and sometimes spine, associated with IBD (Crohn’s, UC)

60
Q

presentation of enteropathic arthritis

A 
loose watery stools 
weight loss 
eye involvement (iritis, anterior uveitis) 
enthesitis 
aphthous ulcers
61
Q

What Tx cannot be given for enteropathic arthritis

A

NSAIDs - exacerbates IBD

62
Q

what is reactive arthritis

A

inflammatory seronegative arthritis that occurs in response to infection in another part of the body. The infection triggers an autoimmune arthropathy

63
Q

most common infections that result in reactive arthritis

A 
genitourinary infections (Chlamydia, Neisseria) 
GI infections (salmonella, campylobacter)
64
Q

what is Reiter’s syndrome

A

triad of symptoms of reactive arthritis

urethritis
uveitis/conjunctivitis
arthritis

65
Q

presentation of reactive arthritis

A

large joints e.g. knee, hip, wrist become inflamed 1-3 weeks following infection.

66
Q

Tx of reactive arthritis

A

treat underlying cause
most cases are self limiting

symptomatic: analgesia, NSAIDs, intra-articular steroids
persistent disease: sulphasalazine, methotrexate

67
Q

Biologic drugs are associated with what infection

A

TB

68
Q

saying to remember the symptoms of reactive arthritis

A

“cant see, cant pee, cant climb a tree”

69
Q

“A’s” of ank spond

A 
Atypical Fibrosis 
Anterior Uveitis 
Aortic Regurgitation 
Achilles Tendonitis 
AV node block 
Amyloidosis
70
Q

respiratory problems seen in RA

A 
pulmonary fibrosis 
pleural effusion 
pulmonary nodules
bronchiolitis obliterans 
pleurisy 
Caplan's syndrome
71
Q

imaging that should be performed pre-operatively in patients with RA

A

anteroposterior and lateral Cervical spine radiographs - check for atlanto-axial subluxation so head can be placed in collar during op if necessary

72
Q

what are the skin abnormalities that can be seen in Reactive Arthritis

A
  1. Circinate Balanitis
    (painless lesions on the coronal margins of the prepuce)
  2. Keratoderma Blennorhagica
    (waxy brown/yellow pap§ules on the soles of the feet/palms)
73
Q

Extra-articular complications of RA

A 
respiratory complications
ocular complications 
ischaemic heart disease
osteoporosis 
increased risk of infections 
depression

Rheumatology (9 decks)

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