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Lily BRS Musculoskeletal And Rheumatology > Intro To Rheumatology > Flashcards

Intro To Rheumatology Flashcards

1
Q

What is rheumatology?

A

Deals with:

Joints -mostly

Tendons (muscle to bone)

Ligaments (bone to bone)

Muscles

Bones

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2
Q

What are some joint classifications?

A

Structural:

Fibrous (no space)

Cartilaginous (bones connected by cartilage)

Synovial joints (have a synovial cavity)

Functional:

Synarthroses (no movement)

Amphiarthroses (limited movement)

Diarthroses (free movement)

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3
Q

What are the components of a synovial joint?

A

Two bones with a joint cavity in the middle. This contains synovial fluid

Articular cartilage lines the ends of the bones either side

Synovium: 1-3 cell deep lining containing macrophage like phagocytosis cells (type A synoviocyte) and fibroblast like cells that produce hyaluronic acid (type B synoviocyte). Also contains type I collagen

Synovial fluid: hyaluronic acid rich viscous fluid

Articular cartilage: type II collagen. Proteoglycan (aggrecan)

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4
Q

What is the composition of cartilage?

A
  1. Specialised cells (chondrocytes)
  2. Extracellular matrix: water, collagen and proteoglycans (aggrecan)

It is avascular- has no blood supply

Aggrecan- a proteoglycan that possesses many chondroitin sulfate and keratin sulfate chains. It is characterised by its ability to interact with HA to form large proteoglycan aggregates

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5
Q

What is arthritis?

A

Disease of the joints

2 major divisions:

Osteoarthritis (degenerative)

Inflammatory (main type is rheumatoid arthritis)

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6
Q

What is osteoarthritis?

A

Cartilage work out, bony remodelling

More prevalent: as age increases, with previous trauma, jobs involving heavy manual labour

Gradual onset, slowly progressive disorder

Typically effects:

Joints of the hand (DIP, PIP, CMC of the thumb)

Spine

Weight bearing lower limb (knees, hips, MTP)

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7
Q

What are symptoms of osteoarthritis?

A

Joint pain - worse with activity, better with rest

Joint crepitus - creaking/cracking/grinding

Joint instability

Joint enlargement (heberdens nodes at DIP) (Bouchards nodes at PIP)

Joint stiffness after immobility (gelling)

Limitation of range of motions

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8
Q

What are the radiographic features of osteoarthritis?

A

Joint space narrowing

Subchondral bony sclerosis

Osteophytes

Subchondral cysts

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9
Q

What is inflammation?

A

A physiological response to deal with injury or infection

However inappropriate inflammatory reactions can damage host tissue

Redness (rubor)

Heat (calor)

Pain (Dolor)

Swelling (tumor)

Loss of function

Molecular changes:

Increased blood flow

White blood cells

Activation/differentiation of leukocytes

Cytokine production (TBF-a, IL1,IL6,IL17)

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10
Q

What are some causes of joint inflammations?

A

1.infection

Septic arthritis

Tuberculosis

  1. Crystal arthritis

Gout

Pseudogout

  1. Immune mediated (autoimmune)

Rheumatoid arthritis

Psoriatic arthritis

Reactive arthritis

Systemic lupus erythematosus (SLE)

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11
Q

What is septic arthritis?

A

Cause: bacterial infection of joint

Risk factors: immunosuppressed, pre existing joint damage, intravenous drug use

It is a medical emergency - can rapidly destroy a joint

Monoarthritis - usually o ly kne joint is affected

Consider when a patient has: acute painful, red, swollen, hot, especially with a fever

Diagnosis: joint aspiration, sample sent for urgent gram stain and culture

Common organisms: staphylococcus aureus, streptococci, Gonococcus (poly arthritis)

Treatment: surgical wash out (lavage) and IV antibiotics

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12
Q

What is Crystal arthritis?

A

2 main types:

Gout:

Deposition of uric acid crystals -> inflammation

High uric acid (hyperuricaemia) is a risk factor

Causes- genetic tendency, increased intake of purine rich foods (beer), reduced excretion (kidney failure)

Paeudogout:

Deposition of calcium pyrophosphate dihydrate(CPPD) crystals -> inflammation

Risk factors - background osteoarthritis, elderly, intercurent infection

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13
Q

What are the clinical features of gout?

A

Acute monoarthritis of rapid onset

Often first metatarsopharyngeal joint

Also foot, ankle, knee, wrist, finger and elbow

Crystal deposits (tophi) may develop around hands, feet, elbows and ears

Recurrent/chronic can cause erosions (juxta articular ‘rat bite’ erosions at the MTP joint of the big toe

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14
Q

How is Crystal arthritis diagnosed?

A

Aspirating fluid from affected joint

Examined under microscope using polarised light

Gout: needle shaped crystals with negative Birefringence

Pseudogout: rhomboid shaped crystals with Positive birefringence

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15
Q

What is rheumatoid arthritis?

A

Chronic autoimmune disease, characterised by pain, stiffness, and symmetrical Synovitis of synovial joints

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16
Q

What are the key features of rheumatoid arthritis?

A

Chronic arthritis

Polyarthritis

Small joints of hand and wrist common

Symmetrical

Early morning stiffness

May lead to joint damage and destruction (joint erosions on X rays)

Extra articular disease can occur: rheumatoid modules, vasculitis, episcleritis

Rheumatoid factor may be detected in blood - autoantibody against IgG

Also anti-CCP may be present

Joints commonly affected: MCP, PIP, wrists, knees, ankles, MTP

Primary site of pathology is the synovium

17
Q

What are some extra articular features of RA?

A

Common: weight loss, fever, subcutaneous nodules

Rare: vasculitis, ocular inflammation (episcleritis), neuropathies, amyloidosis, lung disease, Feltys syndrome (triad of splenomegaly, leukopenia and RA)

18
Q

What are subcutaneous nodules associated with rheumatoid arthritis?

A

Central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue

Occur in 30% of people

Associated with: severe disease, extra articular manifestations, rheumatoid factor

19
Q

What is the pathogenesis of rheumatoid arthritis?

A

The synovium becomes a proliferated mass of tissue (pannus) due to:

Neovascularisation

Lymphangiogenesis

Inflammatory cells: activated B and T cells, plasma cells, mast cells, activated macrophages

There is a cytokine imbalance - more pro inflammatory than anti inflammatory

Key cytokine is TNF-a, it has pleotrophic actions (pro inflammatory cytokine release, osteoclast activation, chondrocyte activation, angiogenesis, leukocyte activation, hepcidin induction)

20
Q

What are the two types of autoantibodies found in the blood in RA?

A
  1. rheumatoid factor

Antibodies that recognise the Fc portion of the IgG as their target antigen

Typically IgM antibodies themselves

Positive in 70% at disease onset but a further 10-15% after 2 years of diagnosis (seropositive)

  1. Antibodies to citrullinated protein antigens (ACPA)

Antibodies to citrullinated peptides are highly specific for rheumatoid arthritis

Anti-CPP antibody test

Citrullination of peptides is mediated by enzymes: peptidyl arginine deiminases (PADs)

21
Q

How is rheumatoid arthritis managed?

A

Prevents further joint damage

Requires early recognition and diagnosis

Aggressive treatment to suppress inflammation

Drugs:

1st line - DMARDs (disease modifying antirheumatic drugs)

Eg. Methotrexate in combination with hydroxychloroquine or sulfasalazine

2nd line - biological therapies

Eg. JAK inhibitors

Glucocorticoid therapy eg. Prednisolone but avoid long term use coz of side effects

Also remember holistic approach

22
Q

What are some biological therapies used with RA?

A

Biological therapies are proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine

  1. Anti TNF - antibodies eg. Infliximab. Fusion proteins eg. Etanercept
  2. B cell depletion - rituximab: antibody against the B cell antigen CD20
  3. Modulation of T cell co-stimulation - abatacept
  4. Inhibition of IL-6 - tocilizumab and sarilumab - antibodies against IL-6 receptor
23
Q

What is psoriatic arthritis?

A

10% of psoriasis patients also have joint inflammation

Rheumatoid factors aren’t present (seronegative)

Asymmetrical

Often affects inter phalangeal joints

Can also manifest as:

Symmetrical involvement of small joints

Spinal and sacroiliac joint inflammation

Oligo arthritis of large joints

Arthritis mutilans

24
Q

What is reactive arthritis?

A

Sterile inflammation in joints following infection (especially urogenital and gastrointestinal)

Extra articular manifestations: enthesitis (tendon), skin inflammation, eye inflammation

May be first manifestation in hepatitis C and HIV

Commonly affects young adults with genetic predisposition and environmental trigger

Symptoms follow 1-4 weeks after infection, infection may also be mild

It is distinct from infection in joints (septic arthritis)

25
Q

What is systemic lupus erythematosis?

A

SLE

A multi system auto immune disease

Can affect almost any organ

Joint pain, skin rashes, kidney involvement, abnormalities of the blood, lung involvement, CNS involvement m

Diagnostics:

  1. ANA (anti nuclear antibodies) - high sensitivity for lupus but not specific
  2. Anti double stranded DNA antibodies - high specificity for SLE in the context of the appropriate clinical signs

Females get it 9 times more often than males

Presents at 15-40 years

Increased prevalence in African and Asian population

4-280/100000

Lily BRS Musculoskeletal And Rheumatology (5 decks)

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