Inflammatory joint conditions II Flashcards
Describe the onset of ankylosing spondylitis [5]
Onset of back discomfort before age 40
Insidious onset
Duration longer than 3 months
Associated with morning stiffness
Improvement with exercise
95% of patients with ankylosing spondylitis have which gene? [1]
HLA B27
Why is AS referred to as a seronegative spondyloarthropathy? [2]
Lack of rheumatoid factor positivity
Abscence of specific antibodies
Describe the symptoms of SLE
90% of patients have arthritis:
* symmetrical small joint polyarticular arthiritis (most common)
* jaccoud arthropathy (rare)
* avascular necrosis
Fatigue
Weight loss
arthralgia
myalgia
fever
butterfly rash: gets worse with sunlight
shortness of breath
hair loss
Describe the pathophysiology of Scleroderma [1]
Autoimmune inflammatory and fibrotic connective tissue disease: immune mediated damage to vascular stuctures and excessive synthesis and depostion of extracellular martrix like collagen.
Cause chronic fibrosis, scarring and damage to organs
Cause of condition unknown
What is a characteristic finding of scleroderma? [1]
Hardening of the skin
What are the two main patterns of disease in scleroderma? [2]
Limited cutaneous systemic sclerosis / scleroderma: aka CREST syndrome
Diffuse cutaneous systemic sclerosis / scleroderma: progressive organ dysfunction due to fibrosis
Which organs are commonly affected by scleroderma? [6]
Skin
Lungs
Heart
GI
Kidneys
MSK
NS
Describe skin changes seen in scleroderma [8]
Pruritus (usually early)
‘Puffy’ appearance due to oedema (often seen in digits)
‘Salt and pepper’ appearance: due to hyperpigmentation and hypopigmentation
Loss of hair
Dryness
Changes to capillaries in nail bed: may only be seen with special dermatoscope (Capillaroscopy)
Atrophy of subcutaneous tissue
Ulcerations: may be seen over joints due to tight skin or on finger tips
Telangiectasia: abnormal dilation of capillary
Calcinosis: calcium deposits in the skin
Perioral skin tightening with decreased oral opening: gives rise to a ‘pursed-string’ appearance
Describe a phenomenon associated with scleroderma [1]
Raynaud phenomenon: skin colour changes that occur in the fingers and toes from vasospasm.
Desribe the characteristic features of CREST syndrome [5]
C - calcinosis: calcium deposits in the skin
R - Raynaud phenomenon
E - oEsophageal dysmotility: swallowing difficulty
S - sclerodactyly: skin thickening and hardening affecting the fingers and toes
T - telangiectasia: dilated capillaries. Usually appear on face, palms and mucous membranes
State the clinical definition of dermatomyositis [1]
Autoimmune myopathy characterised by symmetric proximal muscle weakness and rash
What is the key investigation for diagnosing dermatomyositis? [1]
Creatine kinase blood test: inflammation in the muscle cells (myositis) leads to release of creatine kinase.
Normal creatine kinase levels are 300 U/L; in dermatomyositis is usually over 1000 U/L
What are skin features of dermatoymyositis? [5]
Gottron lesions (scaly erythematous patches) on the knuckles, elbows and knees
Photosensitive erythematous rash on the back, shoulders and neck
Purple rash on the face and eyelids
Periorbital oedema (swelling around the eyes)
Subcutaneous calcinosis (calcium deposits in the subcutaneous tissue)
Which are the key joints effected by AS? [2]
Sacroiliac joint
Joints of the vertebral column
What are two key x-ray findings for AS? [1]
Bamboo spine (L): vertebral body fusion by marginal syndesmophytes and squaring of the vertebral bodies. Gives the impression of a continuous lateral spinal border on x-rays like a bamboo stem
Dagger sign (R): ossificaation of the supraspinatous and interspinatous ligaments leading to a radiodense line runnig up the spine
State and describe a test used to diagnose AS [2]
Schober’s Test:
* Patient stands straight
* Find L5 vert
* Make a point 10cm above and 5cm below this point
* Ask patient to bend forwards as much as possible
* Measure betwen two points
* If the distance is less than 20 cm: supports a diagnosis
How do you treat AS?
Conventional analgesia / NSAIDs:
* Naproxen
* Ibuprofen
* Celecoxib
Convetional DMARDs: although not much evidence for
Sulphasalazine, methotrexate
Biological DMARDs
State how a usual AS patient presents
- Lower back pain and stiffness and sacroiliac pain in the buttock region.
- The pain and stiffness is worse with rest and improves with movement
- The pain is worse at night and in the morning and may wake them from sleep.
- It takes at least 30 minutes for the stiffness to improve in the morning and it gets progressively better with activity throughout the day.
Describe extra-articular manifestations of AS [3]
Anterior uveitis: inflammation of the middle layer of the eye. Typically causes unilateral eye pain and redness
Aortitis: can lead to aortic regurg
Atrioventricular block
When does reactive arthritis occur? [2]
Seronegative asymmetric arthritis following:
Urethritis or cervicitis
Infectious diarrhea (e.g. C.diffe)
Articular features of reactive arthritis? [3]
Extra-articular associations of reactive arthritis? [3]
Articular features:
* Peripheral arthritis
* Axial arthritis: inflammatory back pain
* Enthesitis and/or dactylitis
Extra-articular associations
* Bilateral conjunctivitis (non-infective)
* Anterior uveitis
* Circinate balanitis is dermatitis of the head of the penis
Reactive arthritis is linked to which gene? [1]
HLA B27 gene (although less so than compared to AS)
Reactive arthritis is linked to which gene? [1]
HLA B27 gene (although less so than compared to AS)
Which infections are the most common cause of reactive arthritis? 2[]
Chlamydia is the most common sexually transmitted cause of reactive arthritis.
Gonorrhoea commonly causes a gonococcal septic arthritis
Describe the pathophysiology of reactive arthritis [1]
How does reactive arthritis compare to septic arthritis? [1]
Reactive arthritis is where synovitis occurs in the joints as a reaction to a recent infective trigger
In reactive arthritis (unlike septic RA) there is no infection in the joint.
Reactive arthritis has a triad of which 3 symptoms? [3]
Classic triad of urethritis, conjunctivitis and arthritis
‘Can’t see, pee or climb a tree’
