intro to rheumatology Flashcards
1
Q
what is rheumataology
A
The medical specialty dealing with diseases of the musculoskeletal system including:
2
Q
what is a joint
A
where 2 bone meets
3
Q
what is a tendon
A
cords of strong fibrous collagen tissue attaching muscle to bone
4
Q
Ligaments
A
flexible fibrous connective tissue which connect two bones
5
Q
Structural classification:
A
Fibrous Joints
Cartilaginous Joints
Synovial Joints
6
Q
Fibrous Joints
A
No space between the bones
Examples:
-sutures in the skull
-syndesmosis (sheet of connective tissue) in tibia and fibula joint (ankle)
7
Q
Cartilaginous Joints
A
Joints in which the bones are connected by cartilage
E.g. joints between spinal vertebrae
8
Q
Synovial Joints
A
- have a space between the adjoining bones (synovial cavity)
- This space is filled with synovial fluid.
9
Q
syndesmosis
A
sheet of connective tissue) in tibia and fibula joint (ankle)
10
Q
Functional classification:
A
Synarthroses
Amphiarthroses
Diarthroses
11
Q
Diarthroses
A
Allow for free movement of the joint
12
Q
Amphiarthroses
A
Allow very limited movement
13
Q
Synarthroses
A
Generally allow no movement
14
Q
synovial joints allow what sort of movement/s
A
Diarthroses
15
Q
Cartilaginous Joints
A
Synarthroses
Amphiarthroses
16
Q
Fibrous Joints
A
Synarthroses
Amphiarthroses
17
Q
structure of synovial joint
A
Bone
artciular cartilage
joint cavity containing the synovial fluid
18
Q
Synovium
what type of cell
A
1-3 cell deep lining containing macrophage-like phagocytic cells (type A synoviocyte) and fibroblast-like cells that produce hyaluronic acid (type B synoviocyte)
19
Q
which collagen
A
Type I collagen
20
Q
what is type A synoviocyte
A
macrophage like phagocytic cell
21
Q
what is type B synoviocyte
A
fibroblast like cell that produces hyaluronic acid
22
Q
Synovial fluid
function
A
lubricating fluid allows the joint to move freely
23
Q
contains
A
Hyaluronic acid-rich viscous fluid
24
Q
Articular cartilage
function
A
smooth lining to end of bone
25
conatins
Type II collagen
| Proteoglycan (aggrecan)
26
Cartilage is composed of:
1) specialized cells (chondrocytes)
2) extracellular matrix: water, collagen and proteoglycans
(mainly aggrecan)
27
why does cartliage heal poorly after injury
Cartilage is avascular – it has no blood supply
28
what is Aggrecan- contains
| and function
a proteoglycan that possesses many chondroitin sulfate and keratin sulfate chains
-characterized by its ability to interact with hyaluronan (HA) to form large proteoglycan aggregates
29
Arthritis is
= disease of the joints
30
what are the 2 main diviosns
Osteoarthritis
(Degenerative arthritis)
```
Inflammatory arthritis
(main type is rheumatoid arthritis)
```
31
main problem in OA
cartlilage is worn out
| bony remodelling
32
main prob with IA
inflammation
33
what factors increase chacnce
- more prevalent as age increases,
- previous joint trauma (e.g. footballer’s knees)
- jobs involving heavy manual labour
34
onset of disease
gradual. Slowly progressive disorder
35
joints affected in the hand
Distal interphalangeal joints (DIP)
Proximal interphalangeal joints (PIP)
First carpometacarpal joint (CMC)
36
joints else where
Spine
Weight-bearing joints of lower limbs
esp. knees and hips
First metatarsophalangeal joint (MTP)
37
symptoms and sign
```
Joint pain
(worse with activity, better with rest)
Joint crepitus
(creaking, cracking grinding sound on moving affected joint)
Joint instability (‘giving way’)
Joint enlargement
(e.g. Heberden’s nodes)
Joint stiffness after immobility (‘gelling’)
Limitation of range of motion
```
38
Heberden's nodes.
Bony bumps on the finger joint closest to the fingernail
39
Bouchard's nodes
bony bumps on the middle joint of the finger are known
40
Radiographic features of osteoarthritis:
Joint space narrowing
Subchondral bony sclerosis
Osteophytes
Subchondral cysts
41
what is Subchondral bony sclerosis shown on x ray
appears as a region of increased density on an X-ray
42
what do Osteophytes show on x ray
are bony lumps (bone spurs) that grow on the bones of the spine or around the joints
43
Subchondral cysts
is a fluid-filled space inside a joint that extends from one of the bones that forms the joint. This type of bone cyst is caused by osteoarthritis. It may require aspiration (drawing the fluid out), but the arthritis condition usually must also be addressed to prevent further cyst formation.
44
What is inflammation?
Inflammation = a physiological response to deal with injury or infection
However, excessive/inappropriate inflammatory reactions can damage the host tissues
45
signs of inflammation
1. RED (rubor)
2. PAIN (dolor)
3. HOT (calor)
4. SWELLING (tumor)
5. LOSS OF FUNCTION
46
Physiological, cellular and molecular changes:
Increased blood flow
-Migration of white blood cells (leucocytes) into the tissues
-Activation/differentiation of leucocytes
-Cytokine production
E.g. TNF-alpha, IL1, IL6, IL17
47
Causes of joint inflammation
1 ) Infection
2) Crystal arthritis
3) Immune-mediated (“autoimmune”)
48
example of infection as a cause for joint inflammation
Septic arthritis
| Tuberculosis
49
Crystal arthritis
Gout
| Pseudogout
50
Immune-mediated (“autoimmune”)
Rheumatoid arthritis
Psoriatic arthritis
Reactive arthritis
Systemic lupus erythematosus (SLE)
51
what causes Septic arthritis
Bacterial infection of a joint (usually caused by spread from the blood)
52
risk factors
immunosuppressed, pre-existing joint damage, intravenous drug use (IVDU)
53
why is it bad
-> Untreated, septic arthritis can rapidly destroy a joint
54
does it affect both joints
Usually only 1 joint is affected* (monoarthritis)
55
signs/symptoms
Consider septic arthritis in any patient with an acute painful, red, hot, swelling of a joint, especially if there is fever
56
how to formely diagnose
Diagnosis is by joint aspiration. Send sample for urgent Gram stain and culture
57
common microorganisms
Staphylococcus aureus, Streptococci, Gonococcus*
58
how to treat
Treatment is with surgical wash-out (‘lavage’) and intravenous antibiotics
59
exception to 1 joint rule
It often affects multiple joints (polyarthritis)
| -It is less likely to cause joint destruction
60
what are the 2 forms of Crystal arthritis
Gout
| Pseudogout
61
what is gout
Gout is a syndrome caused by deposition of urate (uric acid) crystals -> inflammation
62
does high levesl of gout ensure you have artittis
nope, High uric acid levels (hyperuricaemia) = risk factor for gout
63
Causes of hyperuricaemia:
Genetic tendency
Increased intake of purine rich foods
Reduced excretion (kidney failure
beer drinkers
64
what is Pseudogout
Pseudogout is a syndrome caused by deposition of calcium pyrophosphate dihydrate (CPPD) crystal deposition crystals -> inflammation
65
risk factors
: background osteoarthritis, elderly patients, intercurrent infection
66
clinical features of gout
presents as an acute monoarthritis of rapid onset
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which joint is first affected
metatarsophalangeal joint is the most commonly affected joint (podagra
68
what is tophi
Crystal deposits (tophi) may develop around hands, feet, elbows, and ears.
69
when gout has been chrinic causes
erosions- looks like rat butes in x ray
70
a great way to identify whether pseudo or gout
The diagnosis of crystal arthritis is made by aspirating fluid from the affected joint and examining it under a microscope using polarized light
(synovial fluid anaylsis under polarised light)
71
how is gout shown
needle shaped crystals with negative birefringence
72
Pseudogout
rhomboid shaped crystals with positive birefringence
73
most common cause of . Immune-mediated inflammatory joint disease
is rheumatoid arthritis (RA)
74
what does it do
= chronic autoimmune disease characterised by pain, stiffness and symmetrical synovitis
(inflammation of the synovial membrane) of synovial (diarthrodial) joints
75
key features
Chronic arthritis
Polyarthritis - swelling of the small joints of the hand and wrists is common
Symmetrical
Early morning stiffness in and around joints
May lead to joint damage and destruction - ‘joint erosions’ on radiographs
76
Extra-articular disease can occur like
Rheumatoid nodules
| Others rare e.g. vasculitis, episcleritis
77
what may be detected in the blood
Autoantibody against IgG - should really call this rheumatoid ‘antibody’
78
what does Symmetrical mean in terms of ra
effects left and right sides of the body equaly
79
define polyarthritis
Affects multiple joints
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what is the primary site of pathology
synovium
81
why does ra have extra articular features
becuase it is an utoimmune disease
82
common extra articular features
Fever, weight loss
| Subcutaneous nodules
83
uncommon features
Ocular inflammation e.g. episcleritis
Neuropathies
Amyloidosis
Lung disease – nodules, fibrosis, pleuritis
Felty’s syndrome – triad of splenomegaly, leukopenia and rheumatoid arthritis
84
what do Subcutaneous nodules contain
Central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue
85
what (factor) is it associated
Rheumatoid factor
86
what is the main problem in ra
synovial membrane is abnormal in ra and is inflammed
| the synovial becomes a proliferated mass of tissue (pannus)
87
why a pannus
```
Neovascularisation
Lymphangiogenesis
inflammatory cells:
activated B and T cells
plasma cells
mast cells
activated macrophages
```
88
what is Neovascularisation
Neovascularization is the natural formation of new blood vessels
89
Lymphangiogenesis
s the formation of lymphatic vessels from pre-existing lymphatic vessels
90
why is there inflammation
an excess of pro-inflammatory vs. anti-inflammatory cytokines (‘cytokine imbalance’)
91
a dominant pro inflamm cytokine
tnf alpha
92
does it only affect 1 system
no Its pleotropic actions are detrimental in this setting:
93
affect in osteoclast
bone resoption and erosion
94
affect in synoviocytes
joint inflammation and pain joint swelling
95
chondrocytes
cartilage degradation
| joint space narrowing
96
how to combact tnf alpha
TNFα inhibition is achieved through parenteral administration (most commonly sub-cutaneous injection) of antibodies or fusion proteins
97
what are the Two types of antibodies are found in the blood of RA patients:
1. Rheumatoid factor
| 2. Antibodies to citrullinated protein antigens (ACPA)
98
what is rf
Antibodies that recognize the Fc portion of IgG as their target antigen
typically IgM antibodies i.e. IgM anti-IgG antibody !
99
what is Citrullination
ARGININE --- CITRULLINE
100
WHAT ENZYME
Peptidyl arginine deiminases (PADs)
101
treatment goal for ra
: prevent joint damage
| becuase once its damaged there is no going back
102
what is the drug class used
Disease-modifying anti-rheumatic drugs (‘DMARDs’)
103
what is DMARDs
= drugs that control the disease process
104
what is the first line treatment
methotrexate in combination with hydroxychloroquine or sulfasalazine
105
2nd line
Biological therapies offer potent and targeted treatment strategies
106
what are biological therapies for ra
Biological therapies are proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine
107
what are the 4 biological therapies
1. Inhibition of tumour necrosis factor-alpha (‘anti-TNF’)
2. B cell depletion
3. Modulation of T cell co-stimulation
4. Inhibition of interleukin-6 signalling
108
what is b cell depletion
antibody against the B cell antigen, CD20
| causes near complete depletion of b cell in peripheral blood
109
what is Modulation of T cell co-stimulation
Abatacept - fusion protein - extracellular domain of human cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) linked to modified Fc (hinge, CH2, and CH3 domains) of human immunoglobulin G1
110
what is Inhibition of interleukin-6 signalling
antibody against interleukin-6 receptor
111
what is a limitation to part mouse part human antibody
overtime you can develop antibodies against the mouse part, rendering the antibody inneffective
112
ra vs oa in age of onset
ra : 30-50
| oa: 50+
113
speed
ra: rapid
oa: slow
114
joint pattern
ra: bilateral symmetrical
oa: asymmetrcial
115
movement
ra: often better after moveement
oa: worse
116
am stiffness
ra: more than an hour
oa: uncommon rarely more than 30
117
systemic symptoms
ra: common
oa: not present
118
joint swelling
ra: effusion, red, warm
oa: bony
119
serology
ra: rf+
oa: ra-
120
x ray findings that are common
both have joint space narrowing
121
what can you see in ra and cant see in oa
Osteopenia
| bony errosions
122
what u see in oa not in ra
Subchondral sclerosis
| Osteophytes
123
what is Psoriatic arthritis and how doe sit show
Psoriasis is an autoimmune disease affecting the skin (scaly red plaques on extensor surfaces eg elbows and knees)
124
does it have the rf
no
125
is it symmetrical or asymmetrical
a
126
other possible signs
Symmetrical involvement of small joints (rheumatoid pattern)
- Spinal and sacroiliac joint inflammation
- Oligoarthritis of large joints
- Arthritis mutilans
127
what is -Arthritis mutilans
An extremely severe form of chronic rheumatoid or psoriatic arthritis characterized by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as 'telescoping fingers. '- - - - - - short fingers excess skin
128
what is Reactive arthritis
Sterile inflammation in joints following infection especially urogenital (e.g. Chlamydia trachomatis) and gastrointestinal (e.g. Salmonella, Shigella, Campylobacter infections) infections
129
what extra articular manifestation occur
Enthesitis (tendon inflammation)
Skin inflammation
Eye inflammation
130
does it have a genetic component and an enviromental component
Commonly young adults with genetic predisposition (e.g. HLA-B27) and environmental trigger (e.g. Salmonella infection)
131
what is sterile inflammation
inflammation without pathogens
132
would you wash the joint in septic a or reaxtive a
septic (for larger joints) not reactive
133
what is Lupus
a multi-system autoimmune disease
134
Systemic Lupus Erythematous (SLE) as well as an inflmmatory joint disease is a...
Multi-site inflammation: can affect any almost any organ.
| Often joints, skin, kidneys, haematology. Also: lungs, CNS involvement
135
what sort of antibodies do you have if you have sle
autoantibodies
| Autoantibodies are directed against components of the cell nucleus (nucleic acids and proteins)
136
clinical test for sle
1. Antinuclear antibodies (ANA):
| 2. Anti-double stranded DNA antibodies (anti-dsDNA Abs):
137
what is ana/Antinuclear antibodies
| e.g. what is a positive result and negative
High sensitivity for SLE but not specific.
| A negative test rules out SLE, but a positive test does not mean SLE.
138
is sle more prevalent in males or females
female
139
how old
15 to 40
