intro to rheum

Question 1

what is rheumatology

Answer 1

medical specialty dealing with diseases of msk system incl: joints,tendons, ligaments, muscles and bones

Question 2

what are tendons

Answer 2

strong fibrous collagen tissues attaching muscle to bone

Question 3

ligaments?

Answer 3

flexible fibrous connective tissue which connect two bones

Question 4

what is arthritis

Answer 4

disease of the joints

Question 5

what is the main type of inflammatory arthritis

Answer 5

rheumatoid arthritis

Question 6

what is inflammation - manifests clinically as:

Answer 6

rubor - red
calor - hot
dolor - painful
swelling - tumor
loss of function

Question 7

what are the physiological,cellular and molecular changes in inflammation

Answer 7

increased blood flow
migration of white blood cells - leucocytes into tissues
activation/differentiation of leucocytes
cytokine production
e.g tnf alpha, il1, il6,il17

Question 8

what are the 2 types of crystal arthritis

Answer 8

gout

pseudogout

Question 9

what is gout

Answer 9

syndrome caused by deposition of urate (uric acid) crystals -> inflammation
hyperuricaemia = risk factor for gout

Question 10

what are the causes of hyperuricaemia

Answer 10

genetic tendency
increased intake of purine rich foods
reduced excretion - kidney failure

Question 11

what is pseudogout

Answer 11

syndrome caused by deposition of calcium pyrophosphate dihydrate (cppd) crystal deposition crystals -> leading to inflammation

Question 12

risk factors for pseudogout

Answer 12

background osteoarthritis
elderly patients
intercurrent infections

Question 13

what does gout arthritis commonly affect

Answer 13

metatarsophalangeal joint of big toe - 1st mtp joint

Question 14

what are the symptoms of gout

Answer 14

abrupt onset
extremely painful
joint - red,warm,swollen and tender
resolves spontaneously over 3-10 days

Question 15

what foods tend to be heavy in uric acid

Answer 15

meat
certain fish
heavier foods

Question 16

what is tophi

Answer 16

aggregated deposits of urate crystals in tissue

Question 17

investigation of gout

Answer 17

joint aspiration - synovial fluid analysis

Question 18

management of gout

Answer 18

acute attack - colchine, NSAIDs, steroids

Question 19

management of chronic gout

Answer 19

allopurinol - reduces uric acid prod in body

Question 20

differences in synovial fluid between gout and psuedogout

Answer 20

gout - needle shape crystals, negative birefringement

psuedogout - brick shaped cystals, postive birefringement

Question 21

what is rheumatoid arthritis

Answer 21

chronic autoimmune disease characterised by pain, stiffness and symmetrical synovitis (inflammation of synovial membrane) of synovial (diathrodial) joints.

Question 22

in rheumatoid arthritis the synovium becomes a proliferated mass of tissue(pannus) due to:

Answer 22

• neovascularisation
• lymphangiogenesis
• inflammatory cells: activated b and t cells, plasma cells, mast cells and activated macrophages

Question 23

what is the dominant pro inflammatory cytokine in rheumatoid arthritis

Answer 23

tumour necrosis factor alpha tnfa

Question 24

what are some actions of tnf alpha

Answer 24

leukocyte accumulation
endothelial cell activation
angiogenesis
hepcidin induction
osteoclast activation pge2 production
chemokine release
pro inflammatory cytokine release

Question 25

what are the key features of chronic arthritis

Answer 25

polyarthritis - swelling of small joints of hand and wrist is common symmetrical early morning stiffness may lead to joint damage and destruction - 'joint erosions'

Question 26

what are some extra articular diseases than can occur in ra

Answer 26

fever, weightloss, rheumatoid nodules | rare - vasculitis, episcleritis, neuropathies, amyloidosis, lung disease, feltys syndrome.

Question 27

what is rheumatoid factor

Answer 27

autoantibody against igG

Question 28

what are the most commonly affected joints in ra

Answer 28

``` mcp pip wrists knees ankle mtps ```

Question 29

what are subcutaneous nodules

Answer 29

central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue occur in ~30% patients

Question 30

2 types of antibodies found in ra

Answer 30

1. rheumatoid factor - typically igM anti igG antibodies | 2. citrullinated protein antigens

Question 31

what is the treatment goal for ra

Answer 31

prevent joint damage

Question 32

drug treatment for ra

Answer 32

disease modifying anti-rheumatic drugs - dmards 1st line treatment - methotrexate in combination with hydroxychloroquine/sulfaslazine 2nd line - biological therapies and targeted treatment strategies important role for glucocorticoid therapy (prednisolone) - but avoid long term use due to side effects

Question 33

alongside drug treatment what else is required for management of ra

Answer 33

multidisciplinary approach - physiotherapy, occupational therapy, hydrotherapy and surgery

Question 34

biological therapies for ra

Answer 34

1. inhibition of tnfalpha - inflixumab, fusion proteins - etanercept. 2. b cell depletion, rituxumab - against cd20 3. modulation of t cell costimulation, abatacept - fusion protein of ctla4 and igg 4. inhibition of interleukin 6 signalling- tocilizumab - against il6 receptor, sarilumab - antibody against il6 receptor

Question 35

what is ankylosing spondylitis

Answer 35

seronegative spondyloarthropathy - | no specific positive autoantibodies

Question 36

what is the main sign seen in ankylosing spondylitis

Answer 36

chronic sacroillitis - inflammation of sacroiliac joints at bottom of spine can also result in spinal fusion - ankylosis 20-30yrs old males associated with hla b27

Question 37

clinical presentation of as

Answer 37

lower back pain in early morning and improves with exercise, reduced spinal movements, peripheral arthritis, plantar fasciitis, achilles tendonitis, fatigue

Question 38

investigations of as

Answer 38

bloods: normocytic anaemia, raised crp,esr, hlab27 imaging : x ray and mri(best): squaring vertebral bodies, romanus lesion, erosion, sclerosis, narrowing sij, bamboo spine and bone marrow oedema

Question 39

management of as

Answer 39

physiotherapy, exercise regimes, nsaids, | if perimanagpheral joint disease - dmards

Question 40

what is psoriatic arthritis

Answer 40

also seronegative autoimmune disease affecting skin 10% also have joint inflammation

Question 41

clinical presentation of psoriatic arthritis

Answer 41

varied classically asymmetrical arthritis affecting IPJs can also manifest as: symmetrical involvement of small joints, spinal and sacroiliac joint inflammation, oligoarthritis of large joints, arthritis mutilans

Question 42

investigations for psoriatic arthritis

Answer 42

bloods - no antibodies as seronegative, can chec for ala, hlab27 to rule out other causes xrays of affected joints mri - sacroiliitis and enthesitis

Question 43

management of psoriatic arthritis

Answer 43

dmards -methotrexate | avoid oral steroids - risk of pustular psoriasis due to skin lesions

Question 44

what is reactive arthritis

Answer 44

sterile inflamamtion of joints following infections esp urogenital (chlamydia) and gi(salmonella, shigella) could be first maifestation of hiv/hepc

Question 45

important extra articular manifestations of reactive arthritis

Answer 45

enthesitis - tendon inflammation skin inflammation eye inflammation

Question 46

management of reactive arthritis

Answer 46

condition is self limiting | can be managed by dmards or nsaids

Question 47

what is sle

Answer 47

multi system autoimmune disease can affect almost any organ: kidneys, joints, skin, haematology, lungs and cns too. autoantibodies are directed against components of cell nucleus - nucleic acids and proteins

Question 48

what clinical tests can be used for diagnosis

Answer 48

1. ana - highly senstive for sle, but not specific, neg test rules out sle, pos test does not mean sle 2. anti double stranded dna antibodies - highly specific for sle in context of appropriate clinical signs

Question 49

epidemiology of sle

Answer 49

f:m 9:1 presentation 15-40 yrs increased prevalence in african/asian populations

Question 50

other connective tissue disease

Answer 50

systemic sclerosis myositis sjogrens syndrome mixed connective tissue disease