Monoarthropathies Flashcards
GOUT EPIDEMIOLOGY/SYMPTOMS
i) what is M:F? name three RFs
ii) name two things that it is characterised by? name three things that can contribute to this
iii) what crystals are depos in joints/synovium
iv) name three main symptoms? what joint is usually first affected?
v) what is it caused by?
i) M:F 5:1
RFs - male, overweight, medication, dietary
ii) high urate production and decreased renal urate excretion - due to drugs eg thiazides, CKD, MPD/cytoxics increase urate
iii) monosodium urate crystal depos
iv) significant pain, swelling, erythema, 70% new px are in first MTP
v) chronic hyperuraicaemia
GOUT INVESTIGATIONS AND ACUTE TX
i) what does synovial fluid analysis entail?
ii) name four radiological features - what is an early sign? what is preserved until late? what is seen in RA but not in gout?
iii) which two drugs are given initially? name a side effect of one of these
iv) what is given if one of these drugs is contraindicated?
v) what other therapy can be given
i) synovial fluid analysis = needle shaped negatively bifringent monosodium urate crystals under polarised light
ii) early sign = joint effusion
joint space is preserved until late disease
eccentric erosions
no periarticular osteopenia (like RA)
soft tissue tophi
iii) give NSAIDs and colchicine (diarrhoea)
give max dose until 2 days after symptoms have settled
PPI for gastroprotection
iv) if NSAIDs or colch are CI then give steroid (prednisolone)
v) can also give intra articular steroid injection
LONG TERM THERAPY FOR GOUT
i) what drug is offered to patients after first gout attack? what is given as cover tx when this is started?
ii) name four indications for the long term tx to be reccomended?
iii) name four lifestyle mods that can be suggested?
iv) name a ppt drug that should be stopped? what vitamin decreases uric acid levels? whcih BP drug can decrease uric acid levels?
v) what range does urate need to be in for gout to resolve?
vi) when may colchicine be contra inidicated
i) allopurinol - give colchicine cover when starting
ii) >2 attacks in 12 months, tophi, renal disease, uric acid renal stones, diuretic use
iii) decrease ETOH, weight loss, avoid purine rich foods (seafood, oily fish, yeast products)
iv) stop thiazides and increase vitamin C intake
losartan can also decrease serum uric acid levels
v) urate <0.36
vI) CI colchicine in severe renal disease
PSEUDOGOUT
i) what is it aka? who does it commonly present with and what with?
ii) what needs to be excluded in the first instance? how is this done?
iii) what is used diagnostically? name three things that are seen?
iv) what is the classic xray appearance that is diagnostic? name three four other xray features? LOSS
i) calcium pyrophosphate dihydrate crystal deposition in synovium
commonly px in older adults with hot swollen stiff painful knee
ii) exclude septic arthritis with synovial aspirate
iii) synovial aspirate > no bacterial growth, calcium pyrophosphate crystals, rhomboid shaped crystals, positive bifringement rods in polarised light
iv) classic xray appearnce is chrondrocalcinosis - thin white line in joint space (ca deposition)
loss of joint space, osteophytes, subarticular sclerosis and subchondral cysts
MX OF PSEUDOGOUT
i) what should be given if there is x ray change but no symptoms?
ii) how long do symptoms usually respond in?
iii) name four txs that can be given
i) no tx
ii) usually resolve over weeks
iii) NSAIDs, colchicine, joint aspiration, steroid injection or oral
SEPTIC ARTHRITIS
i) what is the most common causative agent? what is most common in young sexually active?
ii) name three presenting feautres?
iii) what investigation must be done? name two other investigations
iv) what is tx mainstay? give two examples of drugs given? how long for? name two other treatments that may be given
i) staph aureus
neiseria gonnorea
ii) acute hot swollen joint (usually knee), restricted movement and fever
iii) must do a synovial fluid sample (ideally before abx start)
also do blood cultures and joint imaging
iv) IV abx for gram positive cocci - fluclox or clindamycin if allergic for 4-6weeks (oral switch after 2 weeks)
need aspiration to decompress joint
arthroscopic lavage
PSORIATIC ARTHRITIS
i) what % of patients with psoriasis does it occur in? does it usually happen before or after skin manifestations?
ii) what is the most common manifestation? name three others
iii) name four signs? what two things may be seen in the nails?
iv) what unusual thing is seen on Xray? name the appearance seen? name another thing seen on xray?
v) what should be used to treat pain? name three other txs
vi) what is the most severe form of psoriatic arthritis? what is seen and why
i) 10-20% of patients with psoriasis
usually happens before skin manifest
ii) most common = symmetric polyarthritis
can also be assym oligoarthritis (aff hands and feet), sacroilitis or DIP disease
iii) psoriatic skin lesions, dactylitis (sausage fingers), enthesitis, tenosynovitis (ext tendons of hands)
nail change = pitting and oncholyisis
can also be assoc with ant uveitis and aortitis
iv) x ray see both erosion and new bone formation
pencil in cup appearance and periositis
v) give NSAIDs for pain/if mild
DMARDs (methotrexate, leflunomide, sulfasalazine)
Anti TNF (etanercept, adalim)
usetekinumab = if severe (to IL12/13)
vi) arthritis mutlilans
osteolysis > shortening of digits = telescopic finger
REACTIVE ARTHRITIS
i) what is it? what is the important DD? how does RA differ? which gene can it be linked to?
ii) name the two main triggers and an organism for each
iii) name the three common associations?
iv) how is it managed?
v) name four tx that may be given? how long does it usually take to resolve? what can be given if it does not resolve
i) synovitis in joints after an infective trigger
DD is septic arthritis but RA has no infection in joint
HLAB27
ii) two main triggers are post dysenteric shigella/salmonella (gastritis) or STI eg chlamid/gonnorea
iii) common assoc are bilateral conjunctivitis, anterior uveitis and balantitis
iv) do a synovial joint aspirate to rule out septic arth > send fpr gram stain, culture, sens, crystal exam and give abx until septic arth is excluded
v) NSAIDs, steroid infection, systemic steroids if multiple joints
most resolve in 6 months - if not then give DMARDs or anti TNF
ANKYLOSING SPONDYLITIS
i) what type of arthropathy is it? which gene is it associated with? who does it classically present in
ii) what is the hallmark clinical feature? when is pain worse? what does it improve with?
iii) on examination - which two movements are reduced? what test can be used for this?
iv) name five A’s that can be associated with it
v) which joints must be involved for a diagnosis? over how long do symptoms devleop
i) seronegative spondyloarthropathy (also psoriatic arthritis, IBD, reactive)
assoc with HLA B27
classically px in young male with HLAB27
ii) hallmark is inflammatory back pain (pain anf stiffness in lower back and SI joints/buttock)
pain is worse in the morning/at night and improves with exercise/moving (at least 30min)
iii) O/E - reduced lateral and forward flexion
schobers test - positive test with <5cm increase forward flexion
iv) Apical fibrosis, anterior uveitis, aortic regurg, achilles tendonitis, AV node block, amyloidosis
v) sacroiliac
symptoms develop over more than 3 months
ANKYLOSING SPONDYLITIS INVESTIGATIONS AND TX
i) which two blood markers may be raised? what gene is positive in 90% patients
ii) which scan is done first? what happens if this is negative but there is high clinical suspicion?
iii) name four things that may be seen on imaging characteristic of AS
iv) what is first line tx? what lifestyle measyre should be encouraged?
v) what should be given if there is any peripheral joint involvement? what is given if there is persistent disease?
i) ESR and CRP
HLAB27
ii) do Xray first and if high clin suspicion and xray normal do MRI of whole spine and SI joints
iii) see sacroilitis, squaring of lumbar vert, bamboo spine (late sign), syndesmophytes
iv) first line is NSAIDs
encourage regular exercise and physio
v) periph joints = give a DMARD eg sulfasalazine
give anti TNF if persistent disease
