intro to rheum Flashcards
what is rheumatology
medical specialty dealing with diseases of msk system incl: joints,tendons, ligaments, muscles and bones
what are tendons
strong fibrous collagen tissues attaching muscle to bone
ligaments?
flexible fibrous connective tissue which connect two bones
what is arthritis
disease of the joints
what is the main type of inflammatory arthritis
rheumatoid arthritis
what is inflammation - manifests clinically as:
rubor - red calor - hot dolor - painful swelling - tumor loss of function
what are the physiological,cellular and molecular changes in inflammation
increased blood flow migration of white blood cells - leucocytes into tissues activation/differentiation of leucocytes cytokine production e.g tnf alpha, il1, il6,il17
what are the 2 types of crystal arthritis
gout
pseudogout
what is gout
syndrome caused by deposition of urate (uric acid) crystals -> inflammation
hyperuricaemia = risk factor for gout
what are the causes of hyperuricaemia
genetic tendency
increased intake of purine rich foods
reduced excretion - kidney failure
what is pseudogout
syndrome caused by deposition of calcium pyrophosphate dihydrate (cppd) crystal deposition crystals -> leading to inflammation
risk factors for pseudogout
background osteoarthritis
elderly patients
intercurrent infections
what does gout arthritis commonly affect
metatarsophalangeal joint of big toe - 1st mtp joint
what are the symptoms of gout
abrupt onset
extremely painful
joint - red,warm,swollen and tender
resolves spontaneously over 3-10 days
what foods tend to be heavy in uric acid
meat
certain fish
heavier foods
what is tophi
aggregated deposits of urate crystals in tissue
investigation of gout
joint aspiration - synovial fluid analysis
management of gout
acute attack - colchine, NSAIDs, steroids
management of chronic gout
allopurinol - reduces uric acid prod in body
differences in synovial fluid between gout and psuedogout
gout - needle shape crystals, negative birefringement
psuedogout - brick shaped cystals, postive birefringement
what is rheumatoid arthritis
chronic autoimmune disease characterised by pain, stiffness and symmetrical synovitis (inflammation of synovial membrane) of synovial (diathrodial) joints.
in rheumatoid arthritis the synovium becomes a proliferated mass of tissue(pannus) due to:
- neovascularisation
- lymphangiogenesis
- inflammatory cells: activated b and t cells, plasma cells, mast cells and activated macrophages
what is the dominant pro inflammatory cytokine in rheumatoid arthritis
tumour necrosis factor alpha tnfa
what are some actions of tnf alpha
leukocyte accumulation endothelial cell activation angiogenesis hepcidin induction osteoclast activation pge2 production chemokine release pro inflammatory cytokine release
what are the key features of chronic arthritis
polyarthritis - swelling of small joints of hand and wrist is common
symmetrical
early morning stiffness
may lead to joint damage and destruction - ‘joint erosions’
what are some extra articular diseases than can occur in ra
fever, weightloss, rheumatoid nodules
rare - vasculitis, episcleritis, neuropathies, amyloidosis, lung disease, feltys syndrome.
what is rheumatoid factor
autoantibody against igG
what are the most commonly affected joints in ra
mcp pip wrists knees ankle mtps
what are subcutaneous nodules
central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue
occur in ~30% patients
2 types of antibodies found in ra
- rheumatoid factor - typically igM anti igG antibodies
2. citrullinated protein antigens
what is the treatment goal for ra
prevent joint damage
drug treatment for ra
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
alongside drug treatment what else is required for management of ra
multidisciplinary approach - physiotherapy, occupational therapy, hydrotherapy and surgery
biological therapies for ra
- inhibition of tnfalpha - inflixumab, fusion proteins - etanercept.
- b cell depletion, rituxumab - against cd20
- modulation of t cell costimulation, abatacept - fusion protein of ctla4 and igg
- inhibition of interleukin 6 signalling- tocilizumab - against il6 receptor, sarilumab - antibody against il6 receptor
what is ankylosing spondylitis
seronegative spondyloarthropathy -
no specific positive autoantibodies
what is the main sign seen in ankylosing spondylitis
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
clinical presentation of as
lower back pain
in early morning and improves with exercise, reduced spinal movements, peripheral arthritis, plantar fasciitis, achilles tendonitis, fatigue
investigations of as
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
management of as
physiotherapy, exercise regimes, nsaids,
if perimanagpheral joint disease - dmards
what is psoriatic arthritis
also seronegative
autoimmune disease affecting skin
10% also have joint inflammation
clinical presentation of psoriatic arthritis
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
investigations for psoriatic arthritis
bloods - no antibodies as seronegative, can chec for ala, hlab27 to rule out other causes
xrays of affected joints
mri - sacroiliitis and enthesitis
management of psoriatic arthritis
dmards -methotrexate
avoid oral steroids - risk of pustular psoriasis due to skin lesions
what is reactive arthritis
sterile inflamamtion of joints following infections esp urogenital (chlamydia) and gi(salmonella, shigella)
could be first maifestation of hiv/hepc
important extra articular manifestations of reactive arthritis
enthesitis - tendon inflammation
skin inflammation
eye inflammation
management of reactive arthritis
condition is self limiting
can be managed by dmards or nsaids
what is sle
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
what clinical tests can be used for diagnosis
- ana - highly senstive for sle, but not specific, neg test rules out sle, pos test does not mean sle
- anti double stranded dna antibodies - highly specific for sle in context of appropriate clinical signs
epidemiology of sle
f:m 9:1
presentation 15-40 yrs
increased prevalence in african/asian populations
other connective tissue disease
systemic sclerosis
myositis
sjogrens syndrome
mixed connective tissue disease
