MSK Flashcards
Spondyloarthropathies
Group of chronic rheumatic inflammatory conditions, associated with tissue type HLA-B27
AS, ReA, PsA, enteropathic arthritis (joint problems related to IBD)
Ankylosing spondylitis
chronic inflammatory disease of the spine and sacroiliac joints (axial skeleton)
AS Patho
- Enthesitis (inflammation at site of ligament, tendon and capsule insertion into bone) - lesions heal by fibrosis/ossification - formation of syndesmophytes (new bone) and bony fusion (ankylosis) of joints
Eg bamboo spine (fusion of spinous processes)
Extra-articular features - the As
- anterior uveitis
- amyloidosis
- apical lung fibrosis
- aortic regurgitation
- AV node block
- achilles tendonitis - due to enthesitis
HLA-B27 - positive doesn’t mean you have it, but most with AS are positive
AS Px
Arthritis in axial skeleton
Typically young man, lower back pain, stiffness
Pain at night, improves on getting up
Pain radiates from sacroiliac joints to hips
Progression to kyphotic position
Flare ups
Peripheral arthritis - 1/2 joints, asymmetrical
Peripheral enthesitis
Features of spondyloarthropathies
SPINEACHE
Sausage digit (dactylitis) Psoriasis Inflammatory back pain NSAID good response Enthesitis (heel) Arthritis Crohn's/colitis/elevated CRP (but can be normal) HLA-B27 Eye (uveitis)
AS lx
Bloods - ERS/CRP raised, anaemia, HLA-B27 positive (not dx - some negative but still have AS)
Spirometry - may show restriction - fibrosis, kyphosis
X-ray - changes later in disease (eg joint fusion)
MR
AS Mx
Exercise/physio NSAID - eg diclofenac DMARD - eg methotrexate anti-TNF - infliximab, etanercept Local steroid injections Surgery - straighten spine, replace hip
AS Cx
Increased CVD, osteoporosis risk
Spinal fusion - resp problems
Blindness from recurrent uveitis
Bone tumours
Primary rare
Secondary - metastases from breast, prostate, kidney, lung, thyroid
Can be benign (may cause pain)
Bone tumours patho
benign
osteochondroma (in metaphysis of long bones)
giant cell tumour (in epiphysis of long bones)
osteoblastomas and osteoid osteomas (from osteoblasts)
malignant osteosarcomas fibrosarcomas chrondrosarcomas (cartilage) Ewing's tumour
metastases are osteolytic (prostate often osteosclerotic too - increased bone density on xray)
Bone tumours Px
signs
tender
fatigue
anaemia
symptoms pain, unremitting, worse at night wt loss malaise pyrexia aches, pains, (maybe related to hypercalcaemia)
Bone tumours Ix
skeletal isotope scan X rays MRI Serum ALP from bone raised Hypercalcaemia PSA raised with prostatic metastases
Bone tumours Mx
Analgesics, anti-inflammatory drugs Radiotherapy Chemo Hormonal therapy Bisphosphonates - alendronate Surgery
Gout
Arthritis due to deposition of monosodium urate (MSU) crystals within joints
A crystal arthritis
Gout patho
Renal, drugs, diet -> excessive urate -> urate crystals -> phagocyte activation -> inflammation
Acute inflammation - gout attack
Long-term deposition - tophaceous gout
causes - underexcretion/overproduction
alcohol, diet, drugs, HTN, renal impairment, metabolic syndrome, obesity, diabetes, excess meat, shellfish, offal, hyperuricaemia
Gout Px
hot, swollen joints shiny red, taut pain inflammation, fever, malaise tophi - long-term (large crystal deposits)
Gout DDx
septic arthritis, pseudogout, reactive arthritis, OA, RA
Gout Ix
X-ray - BETS Bony hooks (from erosions) Erosions - punched out Tophi - more opaque Space intact (no loss of joint space)
Polarised light microscopy of aspirated synovial fluid - negative birefringent needles
U+E - serum uric acid, urea, creatinine
USS/CT/MRI
Gout Mx
NSAIDs, colchicine (inhibits phagocyte activation, inflammation), intra-articular steroids, rest, ice
Lose weight, reduce diet factors
Allopurinol / febuxostat (inhibits purine conversion into uric acid by xanthine oxidase)
Pseudogout
deposition of calcium pyrophosphate crystals (CPP) on joint surface
Pseudogout patho
CPP crystal deposition, inflammation
Knee > wrist > shoulder > ankle > elbow
Acute attack triggers - trauma, illness, surgery, blood transfusion…
Pseudogout Px
Monoarthritic
severe pain, stiffness, swelling
fever
synovitis
Pseudogout Ix
X ray - chondrocalcinosis - linear calcification parallel to articular surfaces
Polarised light microscopy - positively birefringent rhomboids
FBC
Pseudogout Mx
Reduce food with high purine content
NSAIDs, analgesia, aspiration, joint injection, physio, rest
Anti-rheumatics - methotrexate, hydroxychloroquine
Surgery, synovectomy
Fibromyalgia
Chronic unexplained widespread pain, with soft-tissue tenderness on examination
Fibromyalgia Px
soft tissue tenderness, multiple sites widespread pain, poor analgesic response fatigue sleep disturbance poor concentration headache paraesthesia anxiety/depression altered bowel habit
Fibromyalgia Ix
clinical dx, Ix to rule out other dx
Fibromyalgia Mx
Educate, physio, exercise CBT TCA - amitriptyline anticonvulsant - pregabalin, gabapentin Dual reuptake inhibitors (antidepressant that inhibits reuptake of serotonin and NAd)- duloxetine
Fractures
Break in bone/cartilage (there is break in surface continuity)
Various patterns of fracture
Healing
Haematoma, fibrocartilaginous callus, bony callus, replaced by trabecular bone, remodelled into lamellar bone
RFs - osteoporosis, osteomalacia, Paget’s, infiltration
Mx - analgesia, examination (neurovascular, before and after stabilising break), reduce, immobilise, rehabilitate
Cx - damage to surrounding structures, infection, compartment syndrome, various systemic cx
NOF fracture
Intracapsular/extracapsular
Blood supply cut off to femur head
Px externally rotated leg and short fall groin pain can't weight bear
Mx
analgesia - morphine, nerve block
surgery - hip replacement (intra), DHS (extra)
Ankle fracture
Types - Weber classification
Dislocation - bone pressure on skin from underneath, relocate asap
Sprain - tender over joint line, RICE, get moving asap
Open fractures
Tetanus, infection risk - ABs
straight to theatre
Checking pulse, sensation - damage to nerves and vessels
Compartment syndrome
Fluid in compartment formed by fascia - pressure on veins, nerves, arteries, ischaemia (6 Ps)
Mx - fasciotomy
ACL injury
ACL limits anterior translation of tibia, rotational stability
Px - swelling, pain, knee giving way
Ix - Positive Lachman’s, anterior draw test, MRI
Mx - RICE, physio, surgical
Shoulder dislocation
Most commonly anterior dislocation
Struggle to lift arm, pain
Check neurovascular supply (axillary nerve)
Pop back in, get moving asap
Rotator cuff injury
Acute/chronic, partial/full thickness tears
Analgesia, physio, activity modification, corticosteroid injection, surgery
Mechanical lower back pain
Back pain common, watch out for red flags:
TUNAFISH (some of them) Trauma, TB Unexplained wt loss, night sweats Neurological deficits, bowel/bladder incontinence Age <20, >55 Fever IDVU Steroid use, immunocompromised History of cancer
Ix - clinical exam, find cause, x ray, MRI
Mx - neuro referral if neurological deficit, education, analgesia, exercise, physio
Spondylolisthesis
One vertebra slips forward/backwards
Pain, marked limitation of straight leg raising
Spinal stenosis
Narrowing of spinal canal, can cause neurogenic claudication
Pain worse walking downhill, relieved leaning forward
Osteoarthritis
Degenerative disease - joint pain and functional limitation / stiffness
OA patho
commonly affects peripheral joints - knees, hips, small joints of hands
Loss of cartilage, disordered bone repair (osteophytes - calcified cartilaginous growths at joint margins), inflammation
Exposed subchondral bone becomes sclerotic
wear and tear essentially
OA Px
signs reduced range of movt pain on movt joint swelling, instability tenderness crepitus absence of systemic features (fever, rash) bone swelling and deformity from osteophytes (Herbedens - DIP, Bouchards - PIP) Asymmetrical joint involvement
symptoms pain exacerbated by exercise, relieved by rest reduced function worsens with prolonged activity stiffness in morning <30min/none
OA Ix
X-ray - LOSS Loss of joint space Osteophyte formation Subchondral sclerosis Subchondral cysts
FBC - CRP maybe raised
MRI
Joint aspiration - exclude septic arthritis, gout
OA Mx
Exercise, wt loss Physio/occ therapy, walking aids Analgesia Joint steroid injections Surgery - joint replacement / fusion
Osteomalacia
Normal amount of bone but mineral content low - excess uncalcified osteoid and cartilage
Rickets in children
Osteomalacia causes
Vit d deficiency
Hypophosphataemia (due to xs PTH release in response to low Ca absorption, so decreased phosphate absorption in kidneys, more excretion)
Renal disease - cannot produce active vit D
Drug induced
Liver disease
Tumour induced
Osteomalacia Px
muscle weakness - waddling gait, difficulty climbing stairs
widespread bone pain, tenderness
fractures, esp femoral neck
Rickets Px
growth retardation, hypotonia
knock knees, bowed legs
widened epiphyses at wrist
features of hypocalcaemia (tetany - severe)
Osteomalacia Ix
Bloods
Low Ca, phosphate, raised ALP, PTH, low 25-OH vit D
Biopsy - shows incomplete mineralisation
X-ray - defective mineralisation, Looser’s zones - low density bands
Osteomalacia Mx
Vit d replacement:
Dietary insufficiency - calcium D3 forte tablet
Malabsorption - oral ergocalciferol/calcitriol
Renal - alfacalcidol/calcitriol
Osteomyelitis
infection of bone marrow
OM Patho
results in inflammatory destruction of bone, abscess formation, ischaemia, necrosis
acute/chronic (necrosis)
Can form from direct inoculation (via trauma/surgery), contagious spread (from adjacent soft tissues), haematogenous seeding (blood flow)
Commonly S.aureus
OM Px
signs
systemic - fevers, rigors, sweats, malaise
Acute, local - tenderness, warmth, erythema, swelling
Chronic - as above, non-healing ulcers/fractures
symptoms
onset over several days
dull pain
may be aggravated by movt
OM Ix
Increased WCC, ESR, CRP X-ray MRI/CT Nuclear bone scan Bone biopsy Blood cultures
OM Mx
Surgical - debridement, hardware replacement
ABs
Osteoporosis
Low bone mass, microarchitectural deterioration of bone tissue -> bones are fragile, susceptible to fracture
Osteoporosis patho
Bone mass decreases in old age - increased fracture risk
Common fractures - hip, vertebral, Colles (radius/wrist)
Postmenopause - higher bone turnover with lower oestrogen, osteoporosis risk
Osteoporosis RFs
SHATTERED
Steroid use
Hyperparathyroidism, hyperthyroidism, hypercalciuria
Alcohol, tobacco
Thin (underweight BMI)
Testosterone use
Early menopause
Renal, liver failure
Erosive/inflammatory bone disease (myeloma, RA)
Dietary decreased Ca/malabsorption / T1DM
Osteoporosis Px
Asymptomatic
More fractures
Osteoporosis Ix
FRAX - assess risk of fracture
DEXA scan - measures bone mineral density - T score given (std deviation compared with peak bone mass), osteopenia before osteoporosis
X-ray - normally in hindsight after fracture
Osteoporosis Mx
Stop smoking, reduce alcohol, weight bearing exercises, calcium and vit d rich diet, home fall prevention
Anti-resorptive - decrease osteoclast activity, bone turnover
Bisphosphonates - alendronate
HRT - oestrogen
Denosumab - Mab to RANK ligand
Anabolic - increase osteoblast activity and bone formation
Teriparatide - PTH analogue
Osteoporosis Cx
Death, permanent disability, unable to walk independently, reduced ADL
Paget’s disease
focal disorder of bone remodelling
Unknown cause. Increased osteoclast bone resorption, formation of weaker new bone, increased bone blood flow, fibrosis - deformity and increased fracture risk
Paget’s Px
Common sites - pelvis, spine, femur, skull, tibia
60-80% asym
signs
deformities - bowed tibia, skull changes
symptoms bone pain joint pain neurological cx - nerve compression - deafness (CN8), paraparesis (partial paralysis of lower limbs) Hydrocephalus
Rarely - high-output cardiac failure, heart hypertrophy due to increased bone blood flow, osteosarcoma
Paget’s Ix
Increased serum ALP, normal Ca and phosphate - increased bone turnover
Urinary hydroxyproline excretion raised - marker of disease activity
X-ray localised deformity sclerotic changes osteolytic areas (reduced density)
Isotope bone scans
Paget’s Mx
Orthotics, sticks, walkers
Bisphosphonates - alendronate
NSAIDs - ibuprofen
Surgery to correct problems
Psoriatic arthritis
inflammatory arthritis associated with psoriasis, a spondyloarthropathy
PsA Px
Psoriatic arthritis mutilans - finger deformity Nail changes - pitting, onycholysis Psoriatic rash - knees, elbows, hidden sites (behind ear, scalp...) Dactylitis (finger swelling) Joint stiffness, pain, swelling Tender tendons, enthesitis DIP joint disease Sacroilitis
PsA Ix
Bloods - RF negative, ESR, CRP often elevated
X-ray
DIP predominantly affected (rather than MCPJ and PIP as in RA)
Erosions central in joint
Pencil-in-cup deformity
Synovial fluid aspirate - no crystals, WCC high
PsA Mx
NSAIDs DMARDs - sulfasalazine, methotrexate Joint steroid injections Anti-TNF - etanercept Surgery, physio, exercise, heat tx
Reactive arthritis
Arthritis occurring as an autoimmune response to infection elsewhere
a spondyloarthropathy (HLA-B27 associated)
Main causes - GI infections, sexually acquired
ReA Px
Asymmetrical joint pain / arthritis - warm, red, sudden onset Malaise, fatigue, fever Dactylitis Mouth ulcers Nail dystrophy
Reiter’s syndrome - can’t see, can’t pee, can’t climb a tree
conjunctivitis, anterior uveitis
urethritis - pain on urination
enthesitis
Skin - circinate balanitis, keratoderma, blennorrhagia
Sacroiliitis, spondylitis
ReA Ix
Bloods - ESR/CRP raised Culture stool if diarrhoea GUM referral Aspirate synovial fluid - sterile, high neutrophil count Xray - may show enthesitis
ReA Mx
Splint joint NSAIDs, local steroid injections ABs DMARDs - sulfasalazine, methotrexate TNF-alpha blockers - etanercept/golimumab
Rheumatoid arthritis
Chronic autoimmune disease - inflammation of synovial joints
RA Px
signs
inflammation - red, hot, pain, swelling
symmetrical, polyarthropathy of smaller joints (MCP, PIP, wrist, MTP joints)
loss of function
deformity (swan neck, boutonniere, z-thumb, ulnar deviation, subluxation)
extra-articular involvement (see cx)
symptoms
pain worse in morning, stiffness >30min
fatigue, malaise
pain progressively gets worse
RA DDx
OA, septic arthritis (single joint), ReA, spondyloarthropathies, PsA, SLE
RA Ix
Bloods - anaemia, high ESR/CRP
RF - positive in 60-70%
anti-CCP
X-ray - LESS loss of joint space erosions (focal) soft tissue swelling soft bones (osteopenia)
RA Mx
Physio/occ therapy, podiatry, surgery, stop smoking
DMARDs - methotrexate, sulfasalazine, hydroxychloroquine
Biological agents - TNF inhibitors, B-cell depletion
Prednisolone
NSAIDs - ibuprofen, naproxen, diclofenac
Analgesics - paracetamol, codeine
RA Cx
Eyes - scleritis, secondary Sjogren’s
Skin - ulcers, rashes, nail fold infarcts, vasculitis
Soft tissues - nodules, bursitis
Rheumatoid nodules
Neuropathies
Haem - anaemia, Fe-deficiency, splenomegaly
Resp - pleural effusion, rheumatoid nodules
CV - increased MI risk
Kidneys - amyloidosis, nephropathy
Liver
Depression
Antiphospholipid syndrome
autoimmune disorder characterised by arterial, venous thrombosis, adverse pregnancy outcomes, raised levels of antiphospholipid (aPL) ABs
associated with SLE, RA, systemic sclerosis, GCA
Perhaps aPL ABs -> hypercoagulable
APS Px
CLOT
Coagulation issue
Livedo reticularis - purple skin
Obstetric issues - pregnancy loss, pre-eclampsia, intrauterine growth restriction (IUGR)
Thrombosis/thrombocytopenia - DVT, stroke, MI, PE, organ infarction, haemolytic anaemia
APS Ix
screen for aPL ABs (<50 with ischaemic stroke, women with 3+ miscarriages)
lupus anticoagulant test, anticardiolipin test, anti-B2-glycoprotein test, - positive
FBC - thrombocytopenia, haemolytic anaemia
Clotting screen
CT/MRI/ECHO (heart)
Doppler USS - DVT
APS Mx
Healthy lifestyle to prevent CVD
Acute thrombosis - heparin
Prophylactic - warfarin, aspirin
Clopidogrel
Sjogren’s syndrome
autoimmune destruction of exocrine glands, esp lacrimal, salivary
Primary/secondary (RA, SLE, systemic sclerosis)
Lymphocytic infiltration and fibrosis of glands
Sjogren’s Px
Decreased tear production - dry eyes, blurring, itching, redness
Decreased salivation - dry mouth, caries, cracks, difficulty tasting/swallowing
Parotid swelling
Ulceration of nasal sputum
Vaginal dryness, dry cough, painful intercourse
Systemic signs - polyarthritis, Raynaud’s, lymphadenopathy, fatigue,
Sjogren’s Ix
Schirmer's test Rose Bengal staining may show keratitis Anti-RO (SS-A), anti-LA (SS-B) ABs RF +ve in 38% USS salivary glands
Sjogren’s Mx
Sicca (dryness) - hypromellose (artificial tears), frequent drinks
NSAIDs, hydroxychloroquine for arthralgia
Myositis
autoimmune disorder - inflammation of muscles, also necrosis
Myositis patho
Polymyositis - muscles affected
Dermatomyositis - immune system attacks muscle and skin
Can also affect other body parts - joints, oesophagus, lungs, heart
Causes - virus, genetics
Myositis Px
Polymyositis
symmetrical, progressive muscle weakness, wasting - affects large proximal muscles (shoulders, hips)
difficulty squatting, going upstairs, rising from chair, raising hands above head
involvement of pharyngeal, laryngeal, resp muscles - dysphagia, dysphonia, resp failure
fatigue, myalgia, muscle cramps
fine motor movts affected later
dermatomyositis
same as above
heliotrope - purple discolouration of eyelids
Gottron’s sign - scaly erythematous plaques over knuckles
GI ulcers/infections
Fever, arthralgia, Raynauds, interstitial lung fibrosis
Myositis Ix
EMG (electromyography) - detect muscle changes
ABs - Jo-1, PM-SCl, Mi-2, ANA
Muscle/skin biopsy
Muscle enzymes - raised creatinine kinase, aldolase, AST, LDH
CXR, PFTs, HRCT, MRI
Myositis Mx
Use sun block Exercise therapy Prednisolone Immunosuppression - azathioprine Hydroxychloroquine/topical tacrolimus for skin rashes
Systemic sclerosis
multisystem autoimmune disease - increased fibroblast activity, abnormal growth of connective tissue, vascular damage, fibrosis
Scleroderma - the skin component
SSc patho
Limited - more common, face, forearms, lower legs, CREST
Diffuse - more skin involved, mortality higher
3 cardinal features of SSC
- excessive collagen production, deposition
- vascular damage
- immune system activation via auto-AB production, cell-mediated
Causes - genetics, infectious agents, chemicals, drugs, silica dust exposure…
SSC Px
limited - CREST
Calcinosis - calcium deposits in skin
Raynaud’s phenomenon
Esophageal dysfunction, acid reflux, decrease in motility
Sclerodactyly - thickening, tightening of skin on fingers and hands
Telangiectasias - dilation of capillaries causing red marks on skin (spider veins)
is limited to hands, face, feet, forearms
diffuse more rapid, widespread skin changes GI - dilatation, loss of strength Renal - disease Lung - fibrosis Myocardial fibrosis, arrhythmias
SSc Ix
Bloods - anaemia, raised ESR, auto-ABs (anticentromere (limited), anti-topoisomerase-1 and anti-RNA (diffuse), RF, ANA)
Urinalysis - raised urea, creatinine in AKI, proteinuria
Imaging - CXR, hand xray, barium swallow, HRCT
SSC Mx
No cure, steroids, immunosuppressants
Raynauds - hand-warmers, vasodilators (CCB nifedipine, bosentan, iloprost, sildenafil), fluoxetine (SSRI)
GORD - PPI
Prevent renal crisis - ramipril
Pulmonary fibrosis - cyclophosphamide
Septic arthritis
Infection in joint, produces inflammation
Septic arthritis patho
S.aureus most commonly
Neisseria gonorrhoea - consider in sexually active
Staph epidermidis
consider Lyme disease if own a dog/in high risk area
H.influenzae in children
G- bacteria, eg E.coli,
Septic arthritis RFs
Prosthetic joints, DM, immunosuppression, pre-existing joint disease, low SES, young and v old, IVDU, osteomyelitis
Septic arthritis Px
hip, knee, shoulder common
signs
red, hot, swollen joint, non-weight bearing
tachycardia, fever, rash, malaise, anorexia
symptoms
painful joint, loss of function
Septic arthritis Ix
FBC - raised WCC
Blood culture
Joint aspiration - before ABs, fluid opaque/pus
STI screen, HIV, skin wound swabs, sputum, throat
Septic arthritis Tx
IV ABs
flucloxacillin - most G+, eg S.aureus
erythromycin/clindamycin if allergic to penicillin
cefotaxime for G-/gonococcal
vancomycin for MRSA
if immunocompromised - fluclox + gentamicin
Double prednisolone dose if already on prednisolone
Needle aspiration to decompress joint
Arthroscopic lavage
Systemic lupus erythematosus
chronic, inflammatory multisystem autoimmune disease, characterised by auto-ABs to nuclear material
abnormal immune function - T/B cell dysfunction, complement dysfunction, aberrant apoptosis, impaired immune complex clearance
SLE RFs
sun exposure, FHx, smoking, drugs, EBV
SLE Px
Factors that can trigger flare up - sunlight, oestrogen contraception, pregnancy, drugs, infection, stress
signs
Raynaud’s
Jaccoud’s arthropathy - reversible joint deformities, eg ulnar deviation, swan neck
symptoms fatigue, malaise, fever, wt loss arthralgia - polyarticular myalgia, myositis butterfly rash on nose and cheeks (malar rash) secondary fibromyalgia
SLE - MD SOAP BRAIN
Malar rash Discoid rash Serositis Oral ulcers Arthritis, like RA Photosensivity Blood - all low (anaemia, leukopenia, thrombocytopenia) Renal disease - proteinuria ANA positive Immunological disorder - anti-dsDNA Neurological disorder - seizures, cerebrovascular disease, myasthenia gravis
SLE Ix
Bloods - auto-ABs - anti-RO, anti-LA, anti-dsDNA, ANA
certain MHC antigens (HLA-DR2/3) confer increased susceptibility
SLE Mx
Sun block
Hydroxychloroquine
Glucocorticosteroids
Immunosuppressants - azathioprine, cyclophosphamide, methotrexate
Vasculitis
Inflammation of vessel wall
Seen in many diseases - RA, SLE, myositis, some drug reactions, scleroderma, Goodpasture’s, IBD
Patho
Inflammation, necrosis of vessel wall, impaired blood flow, results in - vessel wall destruction, endothelial injury
Large-vessel - GCA, polymyalgia rheumatica, Takayasu’s arteritis
Medium-vessel - polyarteritis nodosa, Kawasaki’s disease
Small-vessel - ANCA associated (microscopic polyangiitis, granulomatosis with polyangiitis), ANCA negative
All associated with anaemia, raised ESR, can be primary/secondary
Polymyalgia rheumatica
Inflammatory condition of unknown cause, often coexists with GCA, kind of a large vessel vasculitis
PMR patho
inflammatory disorder causes pain in limb girdles
Muscles actually spared, pain comes from bursae/tendons - referred pain
PMR Px
sub acute onset <2wks sudden onset severe pain, stiffness of shoulders, neck, hips, lumbar spine (limb girdle pattern) symptoms worse in morning mild polyarthritis of peripheral joints fatigue, fever, wt loss, depression
PMR DDx
RA, spondyloarthropathies, SLE, myositis, OA, malignancy, fibromyalgia
PMR Ix
Clinical history ESR/CRP raised ANCA negative serum ALP raised Mild anaemia (normocytic, normochromic) Temporal artery biopsy - GCA Creatinine kinase normal - distinguish from myopathies
PMR Mx
Prednisolone long-term
lansoprazole and alendronate to prevent osteoporosis and GI upset
Giant cell arteritis
Inflammatory granulomatous arteritis of large cerebral arteries, other large vessels, eg aorta
occurs in association with PMR (50%)
GCA Px
signs
tenderness, swelling of temporal/occipital arteries
Sudden painless vision loss - arteritis anterior ischaemic optic neuropathy - emergency
symptoms severe headache (temporal pulsating) scalp tender jaw claudication (when eating) malaise, lethargy, fever limb claudication, polymyalgia
GCA DDx
migraine, tension headache, trigeminal neuralgia, polyarteritis nodosa
GCA Ix
anaemia ANCA negative ESR/CRP high serum ALP may be raised temporal artery biopsy USS, PET/CT scan temporal artery tenderness
GCA Mx
prednisolone, lansoprazole, alendronate
visual changes - methylprednisolone
DMARDs if failure to wean steroids - methotrexate, tocilizumab
Polyarteritis nodosa
Medium-vessel necrotising vasculitis, causes aneurysms, thrombosis, leading to organ infarction
PAN Px
fever, malaise, wt loss, myalgia, then features due to organ infarction:
Neurological - mononeuritis multiplex (due to arteritis of vessel supply to peripheral nerves)
Abdo - pain due to arterial involvement of abdo viscera
Renal - haematuria, proteinuria, HTN, kidney disease
Cardiac - coronary arteritis -> MI, HF
Skin - subcut haemorrhage, gangrene
PAN DDx
fever from infection, Crohn’s, SLE, RA, other vasculitis
PAN Ix
Bloods - anaemia, WCC ESR raised
ANCA negative
Biopsy - eg of kidney, check for damage
Angiography - microaneurysms
PAN Mx
Ramipril - control BP
Prednisolone
Immunosuppression - azathioprine/cyclophosphamide
ANCA-associated vasculitis
Granulomatosis with polyangiitis, microscopic polyangiitis - necrotising vasculitis of small vessels
patho
pathogenic anti-neutrophil cytoplasmic ABs (ANCA) - can activate neutrophils - drive inflammation - granulomatous
Px varies from limited to generalied multi-system disease epistaxis, crusts, stuffiness, hearing loss, stridor iritis, diplopia cough, SOB, haemoptysis rash numbness, tingling, wrist/foot drop joint pain, swelling saddle nose deformity
Ix
Confirm dx - H+E, ANCA testing, tissue biposy
Assess organ involvement - CT, tests ets
Assess disease activity - Birmingham vasculitis activity score, vasculitis damage index
Mx
cyclophosphamide/rituximab, corticosteroids, DMARDs, steroid taper
Acute disc disease
prolapse of intervertebral disc, results in acute back pain
older patients, sciatica more likely
Px
sudden onset severe back pain, often following strenuous activity
pain related to position, aggravated by movt
muscle spasm
pain radiation and clinical findings depend on disc affected
Ix
Xray, MRI (see notes for nerve root lesions)
Mx
analgesia, surgery, physio
Chronic disc disease
associated with degenerative changes in lower lumbar discs and facet joints
Px
pain, aggravated by movt
sciatic radiation may occur - pain in buttocks, radiating to posterior thigh
Mx
NSAIDs, physio, wt reduction, surgery (fusion)
