Long term conditions Flashcards
Vit D def risk factors
Pigmented skin • Use of sun cream/concealing clothes • Old age • Nursing home • Malabsorption • Short bowel • Renal disease • Cholestatic liver disease • Drugs (anticonvulsants, rifampicin, HAART)
Vit D présentation
- Proximal muscle weakness/pain (osteomalacia may be asymptomatic)
- ↓ bone density on DEXA or osteopenia on plain x-ray may indicate vitamin D deficiency
- Severe vitamin D deficiency causes hypocalcaemia, tetany, seizures
- Rickets in children presents with deformities (knock knees, bowed legs) and impaired growth
Investigations for Vitamin D Deficiency
- ↓ serum 25-hydroxy-D3
- <25mmol/Linosteomalacia
- 25-50mmol/LinvitaminDinsufficiency
- ↑ ALP, PTH
- ↓/normal phosphate and calcium
- X-ray shows characteristic defective mineralisation and Looser’s pseudofractures (low density bands running perpendicular to the cortex, commonest in femur/pelvis)
Management of Vitamin D Deficiency
Vitamin D supplementation
• Initial loading dose stage and subsequent maintenance
phase (oral/IM)
• Supplementary calcium (1000-1200mg/day)
• e.g. Cholecalciferol / calcichew
RA presentation
- Insidious onset of pain, early morning stiffness (>30 mins)
- Symmetrical swelling of proximal joints of hands/feet
- PIPJs affected, but DIPJs not affected
- Ulnar deviation, MCP/PIPJ swelling, Z-shaped thumb, Boutonniere deformity, Swan-neck deformity
- May also involve wrists, elbows, shoulders, cervical spine, knees, ankles, feet
joints for RA
• PIPJs affected
MCP/PIPJ swelling, Z-shaped thumb, Boutonniere deformity, Swan-neck deformity
Investigation for RA
Investigations for Rheumatoid Arthritis
• FBC: Normochromic, normocytic anaemia; thrombocytosis
• ESR, CRP raised in proportion with inflammatory activity
• Rheumatoid Factor (RhF) not specific for RA
• Anti-CCP
• X-ray
• Synovial fluid: sterile, raised neutrophils
Management of Rheumatoid Arthritis
• NSAIDs and Coxibs (± Paracetamol, codine)
• Relieve pain but do not slow disease progression
• Corticosteroids
• Suppress disease activity but require high doses (short-term use)
• Disease Modifying Anti-Rheumatic Drugs (DMARDs); start <6 weeks from first presentation
• Methotrexate (mouth ulcers, diarrhoea, liver fibrosis, pulmonary fibrosis, renal impairment,
teratogenic)
• Sulfasalazine (mouth ulcers, hepatitis, reversible male infertility)
• Leflunomide (diarrhoea, hypertension, hepatitis, alopecia)
• Biologics
• TNF-α blockers (CXR before starting; immunosuppression risks latent TB)
• Stop smoking
Clinical Features of Psoriatic Arthritis
Peripheral arthritis
• Absence of RhF or Anti-CCP (“seronegative”)
• DIPJ swelling
• Dactylitis (“sausage fingers”)
• Arthritis mutilans is a severe form with destruction of small bones in hands and feet
Investigations for Psoriatic Arthritis
Routine bloods, ESR normal
• RhF, anti-CCP negative
• X-ray: “pencil-in-cup” deformity in IPJs
Management of Psoriatic Arthritis
- NSAIDs ± paracetamol
- Intra-articular corticosteroid injections
- If severe, methotrexate/TNF-α blockers
- Emollients for skin disease
Parathyroid hormone (PTH)
Kidney→increased calcium resorption and reduced reabsorption of phosphate convert vitamin D to active form
Bone→release of calcium
Small intestine→increased absorption of dietary calcium
Primary Hyperparathyroidism causes
Primary = Hypersecretion of PTH Causes:
• 85% isolated parathyroid adenoma
• 15% diffuse parathyroid hyperplasia
• <1% parathyroid carcinoma
Primary Hyperparathyroidism presentation
PTH - raised
Calcium - increased
phosphate decreased
2ndary Hyperparathyroidsim causes
Causes:
• Chronic kidney disease
• Vitamin D deficiency
2ndary Hyperparathyroidsim presentation
PTH - raised
Calcium - low or normal
phosphate increased or decreased
Hypercalcaemia presentation
Thirst • Increased urination • Constipation • Bone pain • Fatigue • Depression • Confusion • Kidney stones • Palpitations
Hypoparathyroidism = Reduced or absent PTH
PTH low
Calcium decreased
Phosphate increased
Clinical Features of Paget’s Disease of bone
Common sites: pelvis, femur, lumbar spine, skull, tibia
• Most cases asymptomatic
• Pain in bone/nearby joint (cartilage/adjacent bone damage)
• Deformities: enlargement of skull, bowing of tibia
• Complications: nerve compression (deafness, paraparesis), pathological fractures, high output heart failure, osteosarcoma
Investigations for Paget’s Disease
- ↑ ALP (reflects level of bone formation) • Often >1000 u/L
- Normal Ca2+, PO43-
- Urine hydroxyproline excretion ↑
- X-ray shows localised bony enlargement and distortion, sclerotic changes (↑ density) and osteolytic areas (loss of bone and ↓ density)
- Radionucleotide bone scan shows ↑ uptake of bone- seeking radionucleotides
Management of Paget’s Disease
- Bisphosphonates (zoledronate IV)
- Inhibitboneresorptionby↓osteoclasticactivity
- Indicated in symptomatic patients and asymptomatic patients at risk of complications
- Disease activity monitored by serum ALP or urinary hydroxyproline
Osteoporosis vs Osteopenia
Osteoporosis = bone mineral density >2.5 SD below young adult mean value (T-score ≤ –2.5) •Osteopenia = T-score –1 to –2.5
Risk Factors for Osteoporosis
- ↑ age
- Previous fragility fracture • Family history of #NOF
- ↓ BMI
- Smoking
- Alcohol abuse
- Glucocorticoid therapy
- ↑ bone turnover
- ↑ risk of falls
- Rheumatoid arthritis
Clinical Features of Osteoporosis
- Symptoms result from fractures, typically • Thoracicvertebrae
- Lumbarvertebrae
- Proximalfemur
- Distal radius (Colles’ fracture)
- Thoracic vertebral fractures may lead to kyphosis and loss of height (“widow’s stoop”)