Medicine - Rheumatology Flashcards
Rheumatoid Arthritis Pathophysiology: Joints affected: Symptoms: Deformities seen: Multi-system presentations: Risk factors: Investigations: X-ray signs of RA: Management: Complications:
Pathophysiology: Rheumatoid factor (Fc of IgG and anti-CCP -> citrullination of proteins, leading to antibody production, macrophages and TNF-a release from fibroblasts, causing synoviocyte proliferation and osteoclast work, leading to cartilage damage.
Joints affected: MCPJs, PIPJs, not DIPJs, Elbows, Wrists, Ankles, Knees
Symptoms: Bilateral warmth and swelling, MCPJs and PIPJs affected, Soreness in the morning for more than 30 minutes, CARPAL TUNNEL SYNDROME
Deformities seen: Rheumatoid nodules on the elbows, Swan neck deformity (PIP hyperextension), Boutonniere’s (DIP hyperextension)
Multi-system presentations: 3 Cs = Carpal tunnel, Cardiac disease, Cord disease
3 As = Anaemia (normocytic), Amyloidosis, Arteritis
3 Ps = Pericarditis, Pleural disease, Pulmonary disease eg. Bronchiectasis)
3 Ss = Sjogren’s, Scleritis, Splenomegaly
Raynaud’s
Risk factors: Female, 30-50 years old
Investigations: Anti-CCP, RF, FBC for anaemia of chronic disease, CRP, X-ray
X-ray features: LESS: Loss of joint space Erosions (bony erosions, periarticular/marginal) Subluxation Soft tissue inflammation
Management: Methotrexate 12 weeks, do DAS-28 score, evaluate whether to add Sulfasalazine or Hydroxychloroquine Prednisolone acutely (with Adcal), Infliximab
Complications: Methotrexate is hepato and reno toxic, can cause ILD, all are teratogenic
What is DAS-28 and what is used to measure it?
RA disease activity score
28 joints evaluated for swelling and tenderness, ESR and CRP measured, patient questionnaire
What are the main differences between RA and OA?
- Anti-CCP and RF
- Morning stiffness for >30 minutes, vs evening stiffness in OA - gets better with use in RA, worse with OA
- Bilateral
- Warm joints in RA
- Older age in OA, 30-50 in RA
- Crepitus in OA
Sjogren's Syndrome Pathophysiology: Associated with what diseases? Symptoms: Risk factors: Investigations: Management:
Pathophysiology: Autoimmune attack of the lacrimal and salivary glands
Associated with: SLE and RA
Symptoms: Madfred:
- Myalgia
- Arthralgia
- Dry mouth
- Fatigue
- Raynaud’s
- Enlarged parotids
- Dry eyes
Risk factors: 80% female, RA/SLE
Investigations: Anti-Rho, Anti-La - can affect foetus, Schirmer’s tear volume test, salivary gland biopsy
Management: No steroids or DMARDs, avoid dry/smoky atmospheres, artificial tears/saliva, skin emollients and vaginal lubricants
Osteoarthritis Pathophysiology: Symptoms: Deformities: Signs: Risk factors: Investigations: X-ray signs of OA: Management:
Pathophysiology: Progressive loss of articular cartilage (through loss of elasticity, strength and proteoglycan composition, due to active response of chondrocytes), leading to remodelling of underlying bone
Symptoms: Commonly affects small joints of hands/feet, L5, C7, Hip and Knee - worsened with activity, relieved by rest, worst in the evening, can get inactivity-gelling
Deformities: Heberden’s (DIPJ), Bouchard’s (PIPJ)
Risk factors: >65 years old, Obesity, Female, Trauma, Manual job
Investigations: Clinical diagnosis, can do X-ray and blood tests
X-ray signs: LOSS
- Loss of joint space
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts
Management:
Conservative: Weight loss, strengthening, local heat, physio, paracetamol, topical NSAIDs, corticosteroid injections, osteotomy/joint fusion/arthroplasty
Systemic Lupus Erythematosus Pathophysiology: Symptoms: Risk factors: Investigations: Management:
Pathophysiology: Inadequate T cell suppression and increased B cell activity - Type 3 hypersensitivity reaction to soluble antigens, causing deposition.
Symptoms: SOAP BRAIN
- Serositis - Pleurisy
- Oral ulcers
- Arthritis
- Photosensitive rashes eg. discoid/malar
- Blood - low WCC, thrombocytopenia
- Renal involvement - glomerulonephritis
- ANA positive
- I - (immunological antibodies)
- Neurological disorders eg. seizures/psychosis
- Raynaud’s
- Oedema
- Systolic murmur
Risk factors: Young women
Investigations: Anti-dsDNA, Anti-phospholipid, ANA-positive, Anti-ro/Anti-la, Urine dip for proteinuria, FBCs for neuropenia/thrombocytopenia etc.
Diagnosed off 4 symptoms, including Anti-DNA, anti-phospholipid, ANA
Management: Lifestyle changes (sun-screen, healthy eating, avoid smoking), DMARDs - hydroxychloroquine/azathioprine, with mycophenolate mofetil if bad (eg. lupus nephritis)
Corticosteroids given in flare ups
Spondyloarthropathies
Name 4:
Name 3 key features:
- Ankylosing Spondylitis
- Enteropathic Arthritis
- Reactive Arthritis
- Psoriatic Arthritis
3 key features:
- Sacroiliac disease
- Arthropathy
- Enthesis (inflammation of the tendons)
Ankylosing Spondylitis Pathophysiology: Symptoms: Extra-articular manifestations of Ankylosing Spondylitis: Risk factors: Investigations: Management: Complications:
Pathophysiology: Inflammatory arthritis of the back, mainly SI joint
Symptoms: Bilateral buttock/back pain, young, lumbar lordosis/kyphosis with reduced chest expansion
Extra-articular manifestations: Uveitis, Lung fibrosis, Amyloidosis, Aortic Incompetence, AV node block
Risk factors: Young male, HLA-B27 (a MHC class 1)
Investigations: Schober’s test - measures ability to bend lower back, MRI spine/SI joints, Dexascan
Management: NSAIDs, Physio, TNF-a blockers eg. infliximab
Complications: Kyphosis and lordosis, uveitis, anaemia, prostatitis
Psoriatic Arthritis Pathophysiology: Symptoms: Investigations: Management:
Pathophysiology: Psoriasis causing arthritis
Symptoms: Sausage digits, oligo-arthritis, severe deformities
Investigations: CRP, X-ray (“pencil in cup” appearance)
Management: NSAIDs, DMARDs, TNF-a inhibitors
Reactive Arthritis Pathophysiology: Bacteria associated with: Symptoms: Investigations: Management:
Pathophysiology: Transient, sterile synovitis
Associated with: Chlamydia trachomatis, shigella, campylobacter, salmonella
Symptoms: Asymmetrical lower limb arthritis, conjunctivitis/uveitis, urethritis
Investigations: STI test/microbiology, joint aspirate to rule out septic
Management: NSAIDs, manage infection, joint injections, may take up to 2 years to clear
Enteropathic Arthritis
Cause:
Types:
Management:
Cause: IBD
Types: Peripheral (oligoarticular, associated with flares) and axial
Management: DMARDs or TNF-a inhibitors (not NSAIDs, as they flare up IBD)
Gout Pathophysiology: Symptoms: Risk factors: Investigations: Management: Complications:
Pathophysiology: Hyperuricaemia, leading to monosodium urate crystal deposition. Can deposit in soft tissues, leading to tophi, or cause calculi.
Symptoms: Painful, swollen 1st metatarsophalangeal joint
Risk factors: Middle aged (>40), male, alcoholism, thiazide diuretics, pyrazinamide, CKD, psoriasis, large meat intake, obesity, smoking
Investigations: Joint aspiration and microscopy to see crystals
Management: NSAIDs + steroids (acutely), Allopurinol (xanthine oxidase inhibitor), maintain optimal weight, modify diet to remove purine-rich food, reduce alcohol, stop smoking
Complications: Higher CVD risk
Differences between Gout and Pseudogout?
Pseudogout = calcium pyrophosphate crystals which are positively birefringent and rhomboid, commonly affecting the knee
Osteoporosis Pathophysiology: Symptoms: Risk factors: Investigations: Management:
Pathophysiology: Low bone mass, leading to low bone strength and fracture risk
Symptoms: Decreased height over time, back pain due to spinal fractures, hunched back
Risk factors: Age >65, premature menopause, female, low BMI, low Vitamin D, cigarette smoking, steroids, alcohol, fractures, coeliac disease
Investigations: Dexascan (z-score determined from the average, >2.5 = osteoporosis)
Management: Vitamin D and Calcium, Alendronic acid (bisphosphonate) - only given for 3 years at a time, must sit for 30 mins after and drink 1L of water to prevent oesophageal irritation
Fibromyalgia Pathophysiology: Symptoms: Investigations: Management:
Pathophysiology: Central pain processing system disorder - also presents with allodynia, increased pain response to stimuli. Usually due to sleep deprivation/disturbance.
Symptoms: Pain, joint stiffness, fatigue, numbness, headaches, IBS, depression, “fibrofog” - poor memory and concentration
Investigations: No physical abnormalities
Management: Sleep improvements, low-dose amitriptyline, CBT
Polymyalgia Rheumatica Pathophysiology: Causes: Symptoms: Signs: Risk factors: Investigations: Management: Complications:
Pathophysiology: Pain and stiffness in the shoulders, hips and neck - RA-like morning stiffness and raised inflammatory markers
Causes:
Symptoms: Proximal limb pain and stiffness, difficulty rising from a chair or combing hair, night-time pain, fatigue, weight loss, normal muscle strength
Signs:
Risk factors: >70 and GCA
Investigations: ESR/CRP (raised)
Management: Prednisolone PO, reduced gradually over 18 months - can use methotrexate as a steroid-sparing agent
Complications:
Dermatomyositis and Polymyositis Pathophysiology: Symptoms: Risk factors: Investigations: Management: Complications:
Pathophysiology: Idiopathic striated muscle inflammation and skin changes
Symptoms: Insidious, painless symmetrical proximal muscle weakness, violet skin rash around eyelids and periorbital oedema, Gottron’s papules (photosensitive rash on joints eg. fingers)
Risk factors: SLE/Scleroderma
Investigations: Raised serum muscle enzyme levels eg. creatinine, ANA +ve, MRI, EMG of the muscles
Management: High dose corticosteroids, methotrexate, sun protection
Complications: Can affect oesophagus (dysphagia) and diaphragm (respiratory failure)
Giant Cell Arteritis Pathophysiology: Symptoms: Signs: Risk factors: Investigations: Management: Complications:
Pathophysiology: Chronic vasculitis of the large and medium vessels - occurs in those 50-70+ usually aka temporal arteritis - causes inflammation of the arteries originating from the arch of the aorta
Symptoms: Headache, unilateral, localised over the temple, jaw claudication (can cause claudication of the jaw muscles), visual findings eg. amarosis fugax/diplopia are an ophthalmic emergency, scalp tenderness over temporal artery
Risk factors: Age 50+, Female, White, Polymyalgia Rheumatica, HLA-DR4
Investigations: Raised ESR/CRP, check for temporal artery tenderness, assess vision, can do artery biopsy
Management: Oral prednisolone
Methylprednisolone IV pulse therapy for 1-3 days if visual symptoms, aspirin to reduce thrombosis risk
Complications: Occlusive arteritis is an ophthalmic - emergency - ischaemic optic neuropathy
Raynaud's Phenomenon Pathophysiology: Associated conditions: Management: Complications:
Pathophysiology: Vasospasm of the digits, causing pain and colour change - white = reduced blood flow, blue = venous stasis, red = re-warming hyperaemia
Associated conditions: If presents over 30 years old: SLE, Scleroderma, Dermatomyositis, Sjogren’s, Beta blockers
Management: Advise patients to keep warm and avoid smoking
Calcium channel blockers, nail fold-capillaroscopy to evaluate microvasculature
Complications: Digital ulcers, digital ischaemia, infection
Systemic Sclerosis/Scleroderma Pathophysiology: Types: Investigations: Management: Complications:
Pathophysiology: Increased fibroblast activity, leading to abnormal growth of connective tissue, leading to vascular damage or fibrosis
Types: Limited and diffuse. Limited = common one. CREST syndrome:
- Calcinosis
- Raynaud’s (always)
- Oesophageal dysmotility
- Sclerodactyly
- Telangiectasia
Investigations: Normal inflammatory markers, will see calcinosis in the hands on X-ray, ANA +ve with anti-centromere antibodies
Management: No cure, will need psychological support, calcium channel blocker for Raynaud’s, methotrexate can reduce skin thickening, ACE to prevent hypertensive crisis, prednisolone for flares
Complications: Scleroderma renal crisis, causing massive hypertension
Vasculitis Pathophysiology: Symptoms: Types: Investigations: Management:
Pathophysiology: Inflammatory blood vessel disorders, leading to blood vessel wall damage with subsequent thrombosis, ischaemia, bleeding
Symptoms: Fever, weight loss, malaise, diminished appetite, sweating, Raynaud’s, headaches, arthralgia, pericarditis, neuropathy
Types: Granulomatosis with polyangitis (small vessel), Kawasaki, GCA
Investigations: Dipstick, as glomerulonephritis common
Management: Corticosteroids -> methotrexate
