Inflammatory conditions Flashcards
What is a common factor in all inflammatory conditions
inflammation affecting synovial membranes of joints, tendon sheaths, bursa and entheses
What is the aetiology of inflammatory conditions
unsure but a genetic predisposition and the environment have an effect
What part of the joint is usually found to be chronically inflamed
Synovial membrane
What appears to destroy the cartilage from the edges
infiltration of vascular synovium around the periphery of the articular cartilage, forming a dull red panes
What happens to the ligaments and the joint as a whole in inflammatory conditions
Ligaments become softened and the joint becomes lax –> considerable effusion
What might bone erosion lead to
subarticular cysts and in severe cases anklosis
What are some of the most important questions to ask in a rheumatology history
Pattern of joint involvement spinal involvement pre-existing CTD evidence of recent infection History of IBD or symptoms of IBD Psoriasis or family history of psoriasis Ocular inflammation Family history of inflammatory arthritis or CTD Constitutional symptoms History of malignancy Neuro symptoms - bladder and bowel! Extremes of age (65)
Why do we do a FBC in inflammatory conditions
joint inflammation can produce an anaemia
Many are associated with leucopenia, neutropenia, lymphopenia or thrombocytopenia
Why do we investigate Erythrocyte sedimentation rate (ESR)
it is a non-specific indicator f inflammation
Elevated in the presence of anaemia
What is the important of C-reactive protein
it is a non-specific indicator of inflammation
very sensitive to change and will reflect improvement or deterioration more than ESR
Why is a routine biochemical screen carried out
to assess the degree of systemic involvement
Many drugs can affect major organ function and so a baseline needs to be obtained prior to starting treatment
When is a blood culture mandatory
if septic arthritis is suspected
When might CPK (creatinine phosphokinase) be raised
metabolic or inflammatory myopathy
exercise
If the patient has not done much exercise and the CPK is high, then metabolic or inflammatory myopathy should be considered!
What is untreated haemochromatosis associated with
systemic complications including diabetes and hepatic and cardiac dysfunction
What is measured as an indication of haemochromatosis
ferritin
What are the first-line investigations for a patient with suspected inflammatory arthritis
X ray
What investigations can be done to provide more information about a joint with suspected inflammatory arthritis
MRI and US
What is ultrasound particularly useful in assessing
inflammation in other synovial-lined structure e.g. bursa and tendon sheaths
What is MRI useful to establish
the extent of invites and the involvement of soft tissue structures e.g. tendons, enthuses, bursae, capsules and muscles
Describe the appearance of normal synovial fluid
Very pale yellow hue
transparent
normal viscosity
Describe the appearance of synovial fluid in inflammatory arthritis
deeper yellow colour and some clarity
When should synovial fluid be obtained in suspected septic arthritis
prior to giving antibiotics
The presence of monosodium rate and calcium pyrophosphate crystals in synovial fluid is diagnostic for what
gout and pseudo-gout respectively
What are the 3 classes of drugs used to treat inflammatory arthritis
DMARDs
Biological therapies
steroids
What is the purpose of NSAIDs in inflammatory arthritis
they help to reduce pain, swelling and stiffness but do not influence the underlying inflammatory process in terms of reaching joint damage
Name some DMARDs
Methotrexate
sulfasalazine
Hydroxychloroquine
How do DMARDs work
reduce synovitis
improve symptoms
improve function
reduce the likelihood of permanent joint damage
What are some side effects of DMARDs
regular monitoring of bloods - FBC, U&E, LFT
What is an example of a biological
Anti-TNF (anti- tumour necrosis factor)
Name some biologics
Infliximab
How quickly do biologics work
4 weeks
How are biologics administered
injection
What are the main side effects of Biologics
increased risk of serious and non-serious infection in particular tuberculosis
Who does rheumatoid arthritis most commonly affect
middle age and in women more than men
What is the earliest radiological change in rheumatoid arthritis
diffuse porosis around the joint due to the effects of cytokines with increased vascularity
What is ankylosing
spontaneous fusion
What are the surgical options for rheumatoid arthritis
Synovectomy - remove diseased synovium
Repair of rupture tendons and capsular procedure - may restore active movements
Joint fusion - subluxation of vertebra can cause a threat to cord damage
Arthroplasty - gives better function than fusion
What does Juvenile chronic arthritis include
Stills disease and a number of less well-defined conditions
What are the clinical features of Juvenile chronic arthritis
Fever lymph gland involvement anaemia joint pain and stiffness Uveitis occasionally
how can a diagnosis of Juvenile chronic arthritis be made
ESR is usually raised
history of preceding streptococcal infection favours the diagnosis of rheumatic fever
What is the treatment for Juvenile chronic arthritis
Physio
rarely surgery
same local and general measures as an adult
What is the prognosis for Juvenile chronic arthritis
Good - 60-75% of patents recover fully
What is diagnostic of sero-negative arthritis
Dactylitis, the uniform sausage-like swelling of a digit
What age of patients get polymyalgia rheumatica
usually those over 60
What is characteristic of polymyalgia rheumatica
Aching pain and stiffness i the muscles of the neck, shoulder girls and occasionally into back and pelvic girdle
What is polymyalgia often associated with
arteritis of the cranial vessels and sudden blindness due to occlusion of the retinal artery
What is the treatment for polymyalgia rheumatic
high dose of steroids (50-60mg prednisolone/ day)
The disease then subsides over a period of months or years
What is the histocompatibility antigen in ankylosing spondylitis
HLA-B27
What are associated conditions of ankylosing spondylitis
Anterior uveitis and Reiter’s syndrome
What are the symptoms of the beginning of ankylosing spondylitis
Pain and stiffness in the lumbar region - this then extends to involve the whole spine and the manubriosternal joints
What is the characteristic feature of AS
ossification of the imagines of the sine and the intervertebral discs - the spine is converted into a solid rod with an increasing kyphosis
What other joints are often affected in AS
sacro-iliac joints
Plantar fasciitis
Achilles tendinitis and tenderness over bony prominences
What drug is useful in relieving painful joint symptoms and backache
Phenylbutazone
This is only considered if other NSAIDs have failed
What is acute synovitis
Mono arthritis or the acute painful joint
How do patients present with acute synovitis
swollen painful joint with an obvious effusion and often with synovial thickening
What joint is most commonly affected in acute synovitis
knee
What is Reiter’s syndrome
the synovitis or arthritis associated with non specific urethritis and conjunctivitis
What are the clinical features of Reiter’s syndrome
Acute or gradual onset
ophthalmic symptoms and urethritis may occur separately
ESR raised
HLA-B27 often in patient
What is the treatment of Reiter’s syndrome
Urethritis is often related to a chlmaydia infection - Antibiotics may be needed
Chronic joint symptoms are treated by rest in the acute phase with physio and NSAIDs
What is reactive arthritis
inflammatory arthritis that has been triggered by an infection rather than infection within a joint
When does reactive arthritis usually develop
2 weeks post infection
What is the most common presentation of reactive arthritis
monoarthritis
What types of infection are most notable for Reactive arthritis
strep
gastroenteritis
genitourinary infection
viral URTI
What is gout
a metabolic disease characterised by the deposition of rates in the tissues, hyperuricaemia and increased excretion of uric acid i the urine
Who does gout affect
mostly men and some post-menopausal women
What are the features of gout
chronic disease with acute attacks
severly painful, swollen often red and impossible to move joints
What are some factors that can precipitate a gout attack
Trauma Surgery alcohol certain antibiotics purine rich foods (liver)
Describe what would be seen on Xray i a patient with gout
typical well demarcated rounded erosions close to the joint margins usually in the hands
What is the most useful investigation for gout
serum uric acid - usually very high
What are the drugs for treating an acute attack of gout
Colchicine (unpleasant to take)
NSAIDs
How does allopurinol work
it lowers the serum uric acid in the anticipation of preventing further attacks of gout
What is pseudo gout
similar to gout but is less acute
Describe the differenes of the crystals found in gout and in pseudo gout
Gout - uric acid crystals
Pseudogout - calcium pyrophosphate
What is a common feature of pseudo gout
Calcification of the menisci of the knees
What is the treatment of pseudo gout
None really known but NSAIDs are helpful
