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Musculoskeletal > Inflammatory Arthropathies > Flashcards

Inflammatory Arthropathies Flashcards

1
Q

what is rheumatoid arthritis

A

autoimmune condition (type IV) that is inflammation in synovial membrane or articular cartilage

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2
Q

what joints are more commonly affected in RA

A

small joints of hands, feet and wrist - MCP (knuckles), PIPs (bendy bit) and wrist DIPs are not!

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3
Q

what joints can be affected as disease progresses in RA

A

larger joints such as knees, elbows and shoulders

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4
Q

what is prevalence of RA

A

can affect both sexes but women affected 3x more commonly than men any age but peaks 35-50

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5
Q

what is changes during acute phase of RA

A

pannus formation (inflammatory granulation tissue) and hyperplastic / reactive synovium

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6
Q

what is changes during chronic phase of RA

A

fibrosis and deformity

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7
Q

what is pathogenesis of RA

A

immune response initiated against synovium inflammatory pannus forms which then attacks and denudes articular cartilage leading to joint destruction tendon ruptures and soft tissue damage can occur leading to joint instability and subluxation

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8
Q

what causes RA

A

genetics rheumatoid factor (rheumatoid IgM) and auto antibody against Fc IgG anti CCP HLA-DR4 smoking post partum and breast feeding

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9
Q

what are the symptoms of RA

A

pain joint swelling morning stiffness fever leukocytosis malaise anorexia hyperfibrinogenemia

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10
Q

how is RA diagnosed

A

history and examination inflammatory markers (CRP, ESR, plasma viscosity) autoantibodies (not always reliable) X rays - pertiarticular osteopenia and swelling, periarticular erosion can occur later US - may be useful in detecting synovial inflammation if doubt MRI poor grip strength measured by squeeze test

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11
Q

how is RA severity measured

A

DAS28 score

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12
Q

DAS28 score for active RA

A

>5.1

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13
Q

DAS28 score for moderate RA

A

3.2-5.1

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14
Q

DAS28 score for low RA

A

2.6-3.2

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15
Q

DAS28 score for remission RA

A

<2.6

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16
Q

what are the DMARDs that used to treat RA

A

methotrexate sulfasalazine hydrocychlorquinine leflunomide gold, penicillamine, ciclosporin A

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17
Q

1st line treatment in RA

A

NSAIDs + steroids + DMARRD (methotrexate - start at 15mg/week and work up, max dose is 25mg/week)

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18
Q

2nd and 3rd line treatment in RA

A

add DMARD 2 and 3

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19
Q

what RA drugs are not safe in pregnancy

A

methotrexate sulfasalazine is safe :)

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20
Q

why do DMARDs need regular monitoring

A

bone marrow suppression, infection, liver function derangement, pneumonitis (methotrexate)

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21
Q

when should sulfasalazine be avoided

A

septrin allergy and G6DP

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22
Q

when are biological agents (anti TNF, CD 20 B cells, IL6, IL17, 12, 23) used in RA

A

failed to respond to 2 DMARDs including methotrecate and DAS28 >5.1 on 2 occasions 4 weeks apart

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23
Q

surgery can be performed for RA but this is increasingly less common. What surgeries?

A

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

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24
Q

what are the complications of RA

A

joint damage and deformities - swan antalo-axial subluxation - misalignment of 1st and 2nd cervical vertebrae rheumatoid nodules lung = pleural effusions, interstitial fibrosis and pulmonary nodules CV morbidity increased ocular involvement - keratoconjunctivitis sicca, episcleritis, uveitis and nodular scleritis which may lead to sceromalacia do screening for osteoporosis tendon rupture - tendon transfer and synovectomy to prevent future rupture

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25
Q

what is ankylosing spondylitis

A

chronic inflammatory disease of the spine and sacroiliac joints which can lead to eventual fusion of the intervertebral joints and S1 joints

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26
Q

what is prevalence of ank spond

A

males more commonly affected (3:1) age of onset = 20-40 yo

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27
Q

what % of ank spond are HLA-B27 positive

A

90%

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28
Q

what other conditions are associated with HLA-B27

A

reactive arthritis, crohns and uveitis

29
Q

what conditions are associated with ank spond

A

anterior uveitis, aortosis, pulmonary fibrosis and amyloidosis

30
Q

what are symptoms of ank spond

A

spinal pain and morning stiffness

31
Q

what happens as time progresses in ank spond

A

loss of spinal movement and development of question mark spine with loss of lumbar lordosis and increased thoracic kyphosis may also develop hip or knee arthritis

32
Q

why is ank spond known as “A” disease

A

axial arthritis anterior uveitis aortic regurgitation apical fibrosis amyloidosis / IgA nephropathy achilles tendonitis plantar fasciitis

33
Q

how is lumbar spine flexion measured

A

schobers test measure 5cm below posterior superior iliac crests and 10cm above whilst patient upright then asking them to bend forward and remeasure distance normal = should extend beyond 20cm

34
Q

what is shown on xray in ank spond

A

may show sclerosis and fusion of sacroiliac joints and bony spurs from vertebral bodies known as syndesmophytes which can bridge intervertebral disc resulting in fusion producing bamboo spine

35
Q

what may an MRI detect in ank spond

A

earlier features such as bone marrow oedema and enthesitis of spinal ligaments

36
Q

how is ank spond diagnosed

A

in patients with >3 months back pain: sacroiliitis on imaging AND >/=1 SpA feature or HLA-B27 positive AND >/=2 SpA features

37
Q

what are these “SpA features”

A

inflammatory back pain arthritis enthesitis (heel) uveitis dactylitis psoriasis crohns / colitis good response to NSAIDs family history of SpA HLA-B27 elevated CRP

38
Q

what is the treatment of ank spond

A

physio and exercise NSAIDs anti-TNF (target TNF that causes inflammation) DMARDs do not have impact but may be used if there is peripheral joint inflammation secukinuman (anti-IL17) is newest licensed agent

39
Q

why is surgery not really used in ank spond

A

as it is reserved for hip and knee arthritis kyphoplasty to straighten out spine is controversial and carries risk

40
Q

what is psoriatic arthritis

A

arthritis which occurs in up to 30% of people with psoriasis or family member who does (10-15% patients can have PsA without psoriasis) HLA-B27 associated

41
Q

what is the pattern of arthritis in psoriatic arthritis

A

usually an asymmetric oligoarthritis (affecting 4 or more joints) but may also affect hands in similar pattern to RA

42
Q

what are symptoms of psoriatic arthritis

A

sacroiliitis (often asymmetric) spondylitis (inflammation of spine) dactylitis (digits) enthesis (where tendon or ligaments insert into bone) = eg achilles tendonitis nail changes - pitting and onycholysis (lifting of nail from bed)

43
Q

how is psoriatic arthritis diagnosed

A

history, exam, bloods, xrays

44
Q

what is shown in bloods in psoriatic arthritis

A

inflammatory parameters (raised) negative RF

45
Q

what is shown on Xray in psoriatic arthritis

A

marginal erosions “pencil in cup” deformity osteolysis enthesitis

46
Q

how is psoriatic arthritis treated

A

similarly to RA with DMARDs - usually methotrexate

47
Q

what is given to those who do not respond to standard treatment in psoriatic arthritis

A

anti-TNF

48
Q

what can be considered in larger joints which are severely affected by psoriatic arthritis

A

joint replacement DIP fusion can occasionally help in affected DIP joints

49
Q

what is the really aggressive and destructive form of psoriatic arthritis which can develop

A

5% have particularly aggressive and destructive form of condition known as arthritis mutilans

50
Q

what is enteropathic arthritis

A

inflammatory arthritis involving peripheral joints and sometimes spine which occurs in patients with IBD

51
Q

how many of IBD patients develop enteropathic arthritis

A

10%

52
Q

what are symptoms of enteropathic arthritis

A

large joint asymmetrical oligoarthritis 20% of crohns patients have sacroiliitis loose watery stool weight loss, low grade fever eye involvement (uveitis) skin involvement (pyoderma gangrenosum) enthesitis (achilles tendonitis, plantar fasciitis, lateral epicondylitis) oral-apthous ulcers

53
Q

how is enteropathic arthritis diagnosed

A

endoscopy with biopsy = ulceration / colitis raised inflammatory markers xray or MRI showing sacroilitis USS showing synovitis / tenosynovitis

54
Q

how it enteropathic arthritis treated

A

finding medication to manage both underlying condition and arthritis

55
Q

what is not a good idea in enteropathic arthritis as it may exacerbate IBD

A

NSAIDs

56
Q

what medications are given in enteropathic arthritis

A

paracetomal or cocodamol DMARDs (methotrexate, sulfasalazine, azathioprine) anti-TNF licensed for both crohns and inflammatory arthritis

57
Q

what are examples of anti TNF used in enteropathic arthritis

A

infliximab adalimumab

58
Q

what is reactive arthritis

A

arthritis which occurs in response to infection

59
Q

what infections most commonly cause reactive arthritis

A

GU (chalmydia, neisseria) GI (salmonella, campylobacter)

60
Q

how does it cause reactive arthritis

A

infection triggers autoimmune arthropathy

61
Q

is reactive arthritis HLAB27 positive

A

yes

62
Q

what joints are affected in reactive arthritis

A

large joints eg knee become inflamed 1-3 weeks following infection asymmetrical mono arthritis or oligoarthritis

63
Q

some patients with reactive arthritis have Reiter’s syndrome, what three conditions is this a triad of

A

urethritis uveitis or conjunctivitis arthritis

64
Q

what are other symptoms of reactive arthritis

A

enthesitis mucocutaneous lesions ocular lesions (conjunctivitis, iritis) visceral manifestations (mild renal disease, carditis)

65
Q

what mucocutaneous lesions can be present in reactive arthritis

A

keratodema blenorrhagica circinate balanitis painless oral ulcers hyperkeratotic nails

66
Q

how is reactive arthritis diagnosed

A

history, exam, bloods, joint fluid analysis to rule out infection, xray of affected joint and opthalmology opinion

67
Q

what shows up in bloods in reactive arthritis

A

inflammatory parameters (ESR, CRP, PV) can do HLA B27 but rarely necessary

68
Q

how is reactive arthritis treated

A

mostly self limiting - resolve in 6 months treatment aimed at underlying cause and symptomatic relief including IA and IM steroids

69
Q

can reactive arthritis become chronic

A

yeah, 12-20% do occasionally require DMARDs if so

Musculoskeletal (55 decks)

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