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1
Q

What is ankylosing spondylitis?

A

A chronic progressive inflammatory arthropathy.

It involves radiological changes in the spine and sacroiliac joints, mainly affecting the axial skeleton.

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2
Q

What is the pathophysiology of ankylosing spondylitis?

A
  • Inflammation
  • Cartilage erosion
  • Ossification
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3
Q

What are the risk factors for ankylosing spondylitis?

A
  • Genetics
  • Family history
  • Male sex
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4
Q

What are the signs and symptoms of ankylosing spondylitis?

A
  • Gradual onset back pain
  • Progressive loss of spinal movement
  • Question mark posture
  • Enthesitis
  • Costochondritis
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5
Q

What are the extra-articular manifestations of ankylosing spondylitis?

A
  • Osteoporosis
  • Acute iritis (anterior uveitis)
  • Aortic valve incompetence
  • Apical pulmonary fibrosis
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6
Q

What investigations should be ordered for ankylosing spondylitis?

A
  • Pelvic X-ray (sacroiliitis)
  • Diagnosis made clinically due to late X-ray changes
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7
Q

What are the differentials for ankylosing spondylitis?

A
  • Osteoarthritis
  • Diffuse idiopathic skeletal hyperostosis
  • Psoriatic arthritis
  • Reactive arthritis
  • Infection
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8
Q

What is the aim of treatment for ankylosing spondylitis?

A
  • Prevent disease progression
  • Maximising quality of life
  • Manage symptoms and inflammation
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9
Q

What is the management of ankylosing spondylitis?

A
  • Physio and exercise
  • NSAIDs
  • Anti-TNF (if severe)
  • Bisphosphonates
  • Hip replacement
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10
Q

What are the complications of ankylosing spondylitis?

A
  • Osteoporosis
  • Iritis
  • Cardiac involvement
  • Hip involvement
  • Pulmonary involvement
  • Neurological involvement
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11
Q

What is psoriatic arthritis?

A

A chronic inflammatory condition associated with psoriasis.

Seronegative inflammatory arthritis differentiated from RA by severe clinical features.

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12
Q

What is the pathophysiology of psoriatic arthritis?

A
  • CD8 T-cells play a primary role
  • Angiogenic growth factors are over-expressed
  • Vascular changes and bone changes
  • Cytokines cause activation and proliferation of osteoclasts (erosion and osteolysis)
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13
Q

What are the risk factors for psoriatic arthritis?

A
  • Psoriasis
  • Family history
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14
Q

What is the clinical presentation of psoriatic arthritis?

A
  • Joint pain and stiffness (inc morning stiffness)
  • Peripheral arthritis
  • Dactylitis
  • Pain at sight of tendon attachment
  • Spinal stiffness
  • Reduction of cervical mobility
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15
Q

What are the investigations for psoriatic arthritis?

A

X-ray hands and feet (distal interphalangeal joint erosion)

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16
Q

What are the differentials for psoriatic arthritis?

A
  • Rheumatoid arthritis
  • Gout
  • Erosive osteoarthritis
  • Reactive arthritis
  • Mycobacterial tenosynovitis
  • Sarcoid dactylitis
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17
Q

What is the management of psoriatic arthritis?

A
  • NSAIDs
  • Sulfasalazine, methotrexate etc
  • Anti-TNF
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18
Q

What are the complications of psoriatic arthritis?

A

Cardiovascular disease

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19
Q

What is reactive arthritis?

A

Inflammatory arthritis which occurs after exposure to some GU and GI infections

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20
Q

What is the pathophysiology of reactive arthritis?

A

Immune-mediated syndrome triggered by recent infection:
- T cells attack synovium and other self-antigens through molecular mimicry

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21
Q

What are the causes of reactive arthritis?

A
  • Chlamydia
  • Salmonella
  • Shigella
  • Campylobacter
  • C.diff
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22
Q

What are the risk factors for reactive arthritis?

A
  • Male sex
  • HLA-B27 genotype
  • 20-40 years old
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23
Q

What are the signs and symptoms of reactive arthritis?

A
  • Asymmetrical lower limb oligoarthritis
  • Iritis/conjunctivitis
  • Plaques on soles/palms
  • Painless penile ulceration
  • Enthesitis
  • Mouth ulcers
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24
Q

What investigations are ordered for reactive arthritis?

A
  • X-rays:
  • Sacroiliitis
  • Enthesopathy
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25
What are the differentials for reactive arthritis?
- Ankylosing spondylitis - Psoriatic arthritis - Rheumatoid arthritis - Disseminated gonococcal disease - Gout - Septic arthritis
26
What is the management of reactive arthritis?
- NSAID - Local steroids - Sulfasalazine/methotrexate for relapse
27
What is osteoarthritis?
A degenerative joint disorder: - Prevalence increases with age - Degeneration of hyaline cartilage
28
What is the pathophysiology of osteoarthritis?
- Failure of homeostatic balance of cartilage matrix synthesis and degradation - Involvement of other joint structures (eg. bone marrow lesions of subchondral bone)
29
What are the risk factors for osteoarthritis?
- Age - Obesity - Local trauma - Female sex - Genetic predisposition - Occupation - Inflammatory arthritis
30
What are the symptoms of osteoarthritis?
1. Pain - Often the reason patients seek medical advice - May not be present 2. Functional impairment - Walking - Activities of daily living
31
What are the signs of osteoarthritis?
- Alteration in gait - Joint swelling (eg. bony enlargement, synovitis) - Limited range of movement - Deformities
32
How is osteoarthritis diagnosed?
X-ray LOSS: - Loss of joint space - Osteophytes - Subchondral sclerosis - Subchondral cysts May additionally be changes to bone contour.
33
What are the differentials for osteoarthritis?
- Bursitis - Gout - Pseudogout - Rheumatoid arthritis - Psoriatic arthritis - Avascular necrosis - Meniscal tears
34
What is the conservative management of osteoarthritis?
- Weight loss - Less sport, more rest - Physio - Walking aids and home modifications
35
What is the medical management of osteoarthritis?
- Analgesia (paracetamol and NSAIDs) - Joint injection (local anaesthetic and steroids)
36
What is the surgical management of osteoarthritis?
- Arthroscopy - Arthroplasty - Osteotomy - Fusion
37
What is gout?
A syndrome categorised by hyperuricaemia and deposition of urate crystals causing an attack of acute inflammatory arthritis. Can affect any joint.
38
What is the epidemiology of gout?
- More common in males - Increasing age
39
What is the pathophysiology of gout?
- Inability to metabolise uric acid - Urate reabsorbed in kidneys - High urate levels → crystal formation → gout
40
What are the risk factors for gout?
- Age - Male - Menopause - Meat, seafood and beer - Diuretics - Drugs (aspirin, ciclosporin etc) - Genetic disposition
41
What are the signs and symptoms of gout?
- Rapid-onset severe pain - Joint stiffness - Few affected joints - Cardinal symptoms of inflammation - Malaise and systemic symptoms
42
What investigations are ordered for gout?
- Arthrocentesis synovial fluid analysis (High WCC and crystals) - Polarised light microscopy - Serum uric acid (decreases) - X-rays
43
What are the differentials for gout?
- Pseudogout - Septic arthritis - Trauma - Rheumatoid arthritis - Reactive arthritis - Psoriatic arthritis
44
How are acute attacks of gout managed?
- NSAIDs or COX-2 inhibitors (avoid NSAIDs in patients with CKD) - Colchicine - Prednisolone
45
What is the conservative management of gout?
- Rest - Ice - Stay hydrated - Continue urate lowering therapy
46
How is gout prevented?
- Urate lowering therapy - Dietary modification - CV risk assessment and treatment
47
What are the complications of gout?
- Acute uric acid nephropathy - Nephrolithiasis
48
What is osteoporosis?
Low bone density and micro-architectural defects in bone tissue. Results in increased bone fragility and susceptibility to fracture.
49
What is the pathophysiology of osteoporosis?
The mismatch between osteoclastic bone resorption and osteoblastic bone formation. Genetic factors have the biggest influence on peak bone mass.
50
What are the risk factors for osteoporosis?
- Prior fragility fracture - Female sex - White - Increasing age - Low BMI - FHx of maternal hip fracture - Post-menopause
51
What are the signs and symptoms of osteoporosis?
- Back pain - Kyphosis - Impaired vision and gait - Imbalance - Vertebral tenderness
52
What investigstiond should be ordered for osteoporosis?
Dual-energy X-ray absorptiometry (DEXA) T-score < -2.5 = osteoporosis (T-score is standard deviation compared with gender-matched young adult average peak bone mass)
53
What are the differentials for osteoporosis?
- Multiple myeloma - Osteomalacia - Primary hyperparathyroidism - Metastatic bone malignancy - Vertebral deformities
54
What is the management of osteoporosis?
- Diet and lifestyle - Antiresorptive drugs (bisphosphonates, HRT, denosumab) - Anabolic drugs (teriparatide)
55
How do anti-resorptive drugs work?
Decrease osteoclast activity and bone turnover.
56
How do anabolic drugs work?
Increase osteoblast activity and bone formation.
57
What are the complications of osteoporosis?
- Hip/rib/wrist fractures - Chronic pain syndrome
58
What is pseudogout?
Calcium pyrophosphate arthritis - Caused by calcium deposition of calcium pyrophosphate crystals - Associated with both acute and chronic arthritis
59
What is the pathophysiology of pseudogout?
- CPP crystals are shed from the cartilage into articular space - Unknown how inflammation occurs
60
What are the risk factors for pseudogout?
- Age - Injury - Hyperparathyroidism - Haemochromatosis - Family history
61
What are the signs and symptoms of pseudogout?
- Cardinal signs of inflammation - Osteoarthritis-like involvement of joints (wrists, shoulders) - Sudden worsening - Joint effusion
62
What investigations are ordered for the diagnosis of pseudogout?
- Arthrocentesis with synovial fluid analysis (presence of rod-shaped crystals) - X-ray of affected joints
63
What are the differentials for pseudogout?
- Acute gouty arthritis - Acute septic arthritis - Milwaukee shoulder syndrome - Osteoarthritis - Rheumatoid arthritis
64
What is the management of pseudogout?
- Intra-articular corticosteroids - NSAIDs for pain
65
What is rheumatoid arthritis?
A chronic inflammatory condition primarily affecting small joints of the hands and feet.
66
What is the pathophysiology of rheumatoid arthritis?
Inflamed synovium showing angiogenesis, cellular hyperplasia, and influx of inflammatory cells.
67
What are the signs and symptoms of rheumatoid arthritis?
- Asymmetrical arthritis - Cardinal signs of inflammation - Morning stiffness (>30 mins) - Stiffness improves with exercise - Symmetrical pain/stiffness
68
What are the hand deformities associated with rheumatoid arthritis?
- Ulnar deviation - Swan neck/Z-thumb - Boutonniere deformity
69
What are the extra-articular manifestations of rheumatoid arthritis in the lungs?
- Pleural effusion - Fibrosing alveolitis - Interstitial lung disease
70
What are the extra-articular manifestations of rheumatoid arthritis in the heart?
- Pericarditis - Pericardial rub - Raynaud's - Pericardial effusion
71
What are the extra-articular manifestations of rheumatoid arthritis in the eyes?
- Dry eyes - Episcleritis/scleritis
72
What are the extra-articular manifestations of rheumatoid arthritis in the nervous system?
- Peripheral sensory neuropathy - Compression/entrapment neuropathies - Cord compression
73
What are the extra-articular manifestations of rheumatoid arthritis in the kidneys?
- Amyloidosis - Nephrotic syndrome - CKD
74
What are the extra-articular manifestations of rheumatoid arthritis in the skin?
Subcutaneous nodules
75
What investigations are ordered for the diagnosis of rheumatoid arthritis?
- Rheumatoid factor - Anti-cyclic citrullinated peptide (anti-CCP) antibody - Radiographs (erosions) - US (synovitis) - X-ray
76
What is seen on an X-ray in rheumatoid arthritis?
LESS: - Loss of joint space - Erosion - Soft tissue swelling - Soft bones (osteopenia)
77
What are the differentials for rheumatoid arthritis?
- Psoriatic arthritis - Infectious arthritis - Gout - Systemic lupus erythematous - Osteoarthritis
78
What is the conservative management for rheumatoid arthritis?
- Smoking cessation - Reduce weight - Exercise
79
What is the medical treatment for rheumatoid arthritis?
- Analgesia (NSAIDs/Cox-inhibitors) - Corticosteroids - DMARDs (methotrexate) - Biological DMARDs
80
What is the surgical management for rheumatoid arthritis?
Synovectomy
81
What is septic arthritis?
The infection of one or more joints caused by pathogenic inoculation of microbes. It occurs either by direct inoculation or via haematogenous spread.
82
What are the risk factors for septic arthritis?
- Existing joint problems - Artificial joint - Medication for RA - Skin fragility - Immunocompromised - Joint trauma
83
What are the signs and symptoms of septic arthritis?
- Cardinal signs of inflammation - Acute presentation - Fever - Usually a single, large joint (may be prosthetic)
84
What are the investigations for septic arthritis?
- Synovial fluid aspirate (presence of micro-organisms) - Synovial fluid WCC
85
What are the differentials for septic arthritis?
- Other forms of arthritis - Gout and pseudogout - Haemarthrosis - Trauma - Cellulitis
86
What is the management of septic arthritis?
- Antibiotics - Therapeutic joint aspiration - Analgesia
87
What are the possible complications of septic arthritis?
- Osteomyelitis - Joint destruction
88
What is osteomyelitis?
An inflammatory condition usually caused by Staph aureus. Generally limited to one bone but can be at multiple sites, in periphery or axial skeleton.
89
What are the causes of osteomyelitis?
- S. aureus - Strep - Enterobacter spp - H. influenza - P. aeruginosa
90
What are the risk factors for osteomyelitis?
- Diabetes mellitus - Immunosuppression - Alcohol - Intravenous drug users
91
What is the clinical presentation of osteomyelitis?
- Reluctance to weight bear (limp) - Non-specific pain at site - Malaise - Systemic symptoms - Paravertebral muscle tenderness/spasm - Fever - Spinal cord nerve root compression
92
How is osteomyelitis diagnosed?
Culture from bone biopsy at debridement.
93
What are the differentials for osteomyelitis?
- Septic arthritis - Juvenile idiopathic arthritis - Reactive arthritis - Transient synovitis - Cellulitis - Necrotising fasciitis
94
What is the management of osteomyelitis?
- Antibiotics - Analgesia - Immobilise limb - Debridement/drainage of abscess
95
What is systemic lupus erythematous?
A chronic multi-system disorder commonly affecting women of reproductive age. Characterised by the presence of antinuclear antibodies and constitutional symptoms.
96
What is the pathophysiology of systemic lupus erythematous?
Antigen-driven immune-mediated disease. T cell dysregulation of B cells leads to auto-immune response.
97
What are the risk factors for SLE?
- Female sex - Age 15-45 - Drugs - FHx - Smoking
98
What are the signs and symptoms of SLE?
- Rash - Fatigue - Oral ulcers - Fibromyalgia - Raynaud's phenomenon - Chest pain - Thrombosis - Abdo pain (N+V)
99
What types of rash are seen in SLE?
- Malar (butterfly) rash - Photosensitive rash - Discoid rash
100
What are the differentials for systemic lupus erythematous?
- Rheumatoid arthritis - Antiphospholipid syndrome - Systemic sclerosis - Mixed connective tissue disease - HIV - Infectious mononucleosis
101
What is the management of SLE?
- NSAIDs - Hydroxychloroquine for fatigue - Steroid tablets, injections and creams for kidney inflammation and rashes
102
What are the complications of SLE?
- Anaemia - Leukopenia - Thrombocytopenia - Raynaud's phenomenon

Phase 2a (11 decks)

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