MSK Flashcards
What are the Xray findings in RA?
SOLD Soft tissue swelling Osteopenia Loss of joint space Deformity/erosions - marginal
Give the deformities you might see in the hands of someone with bad RA?
- Ulnar deviation
- Swan neck
- Boutonniere
- Z shaped thumb
- MCP subluxation
What are some of the extra-articular manifestations of RA?
systems
Lung - ILD, nodules (plural effusions) Caplans (coal workers)
Haem - anaemia
Heart - pericartitis + HTN
Eyes - episcleritis and scleritis
What serum markers can you look for in RA?
- Anti cyclic citrullinated peptide abs
- Rheumatoid factor
What is RF?
It is the ab against the FC portion of IgG
What are the treatment steps for RA?
1) Analgesia = NSAIDs
2) Steroids = low dose pred for flares
3) DMARS = methotrexate + sulphasalazine/hydroxychloroquine
4) Biologics = infliximab
When would you consider biologics in RA?
Failure to respond to 2 DMARDS
2x 6m trials
How does methotrexate work?
Its a cytotoxic folate inhibitor that prevents cellular/DNA replicating
It has anti-inflammatory and immunosuppressive effects by inhibiting IL6, IL8 and TNFa
What are the SE of methotrexate?
Mucosal damage - sore mouth and GI upset
BM suppression - neutropenia and infection risk
LT = hepatic cirrhosis + pulmonary fibrosis
Give examples of the Anti-TNF drugs
Infliximab
Adalimumab
Etancercept
Give an example of a monoclonal ab against the CD20 portion on B cells
Rituximab
What are the crystals in Gout?
Monosodium urate
What investigations would you do if you suspected gout and what would you see?
Joint aspiration:
Long needle shaped crystals which are -ve bifringent
XR - soft tissue swelling with punched out lesions
How does allopurinol work?
It is a xanthine oxidase inhibitor
It reduces uric acid formation and may inhibit purine synthesis
What are the crystals in pseudo gout and what would you see in XR?
- Calcium pyrophosphate
- Linear opacification of the articular cartilage (mineralisation of the fibrocartilage)
What would you seen on an XR in the spine of a person with untreated Ank Spond?
BESS
- Bamboo spine is these are ossified
- Erosions
- Vertebral squaring
- Syndesmophyte formation
What are the extra-articular manifestations of Ank Spond?
- Anterior uveitis
- AR
- Amyloidosis
- Apical fibrosis
What are the treatment steps for Ank Spond?
1) Analgesia = NSAIDs
2) Intra-articular steroid injections
3) Biologics = Anti-TNFa = adalimumab, etanercept
What is the Xray deformity seen in psoriatic arthritis?
Pencil in cup
What are the extra-articular manifestations of reactive arthritis?
Conjunctivitis Skin: erythema nodosum Nais: onchyolysis/pitting GI: adbo pain, D CV: aortitis +/- AR
What are the organisms involved in septic arthritis?
Staph aureus
Neisseria gonorhroea
How do you manage septic arthritis?
Surgical drainage and lavage
IV abx
- Vancomycin + ceftriaxone then tailor to the culture results
Staph - flucloxacillin
What conditions pre-dispose you to osteomyelitis?
- DM
- Sickle cell anaemia
- IVDU
- immunosuppression/HIV
- alcohol excess
What investigations do you do if you suspect osteomyelitis?
Bloods: FBC, ESR + CRP
Cultures
Imaging: MRI
What is fibromyalgia?
It is a syndrome characterised by widespread pain throughout the body with tender points at specific anatomical sites
? altered pain perception and somatisation
What are some of the features of fibromyalgia?
Chronic pain 'all over pain' Lethargy Cognitive impairment - fibre-fog Sleep disturbance, headache, depression/anxiety, irritable bladder, IBS 11/18 tender points
How would you manage someone with fibromyalgia?
S: Patient education
C: aerobic exercise
P: CBT
B: Amitriptyline
What are the red flags of back pain?
TUNA FISH
- Trauma
- Unexplained weight loss/anorexia
- Neuro - bladder/bowel issues
- Age >50 or <20
- Fever/night sweats
- IVDU/Immunosuppression
- Steroid use
- Hx of malignancy
What do you need to have to Dx SLE?
4/11 features
DOPAMIN RASH
Discoid, oral ulcers, photosensitivity, ANA, malar rash, immunological (ds DNA, smith) neuro (siezures/psychosis)
Renal, arthritis, serositis (pleuritis, pericarditis) Haem (anaemia, leukopenia, thrombocytopenia)
What ix would you do if you suspected SLE?
Raised ESR - normal CRP
Complement: low C3 and C4
Auto abs: ANA, Anti-ds DNA, Anti-smith
Antiphospholipid abs
How do you treat mild SLE?
IA CS injections
PO pred if a flare up
Hydroxychloroquine
How do you treat mod SLE
Hydroxychloroquine + immunosuppressants
- High dose CS
- Azathioprine, cyclophosphamide
- Ciclosporin, tracolimus
How do you treat refractory SLE
Rituximab (Monoclonal ab against B cells)
- when 2 immunosuppressants have failed
How do you treat anti-phospholipid syndrome?
Warfarin
What is sjogrens?
Immunologically mediated destruction of the epithelial exoglands - mainly the lacrimal and salivary glands
What HLA is Sjogrens associated with?
HLA DR3
What investigations can you do in Sjogrens?
- Schirmer test (paper strip into eye <10mm wetting)
- Auto abs: Anti-Ro + anti-La
- Sialography: Looking at function of salivary gland
- Biopsy of salivary gland: mononuclear infiltrate
How do you treat sjogrens?
Artificial tears + saliva
Pilocarpine
Systemic: NSAIDs, hydroxychloroquine and steroids
What are the SE of steroids?
SHIP DOC Syndromes - cushings HTN Infections (immunosuppressive) Psychosis DM + weight gain Osteoporosis Cataracts
How are the small vessel vasculitis divided up?
Give examples in each group
ANCA + ve = granulomatosis with polyangiitis + Esinophilic granulomatosis with polyangiitis (chrug-strauss
ANCE -ve = Henoch-schonlien purpura (immune complex mediated)
What is ANCA?
Anti-neutrophil cytoplasm Abs = auto-abs
They bind to 2 proteins in neutrophil cytoplasm (PR3 + MPO)
The binding of ANCA to neutrophils causes a toxic release of substances - inflam to the vessels - N migrate through vessel wall and release pro-inflammatory cytokines
How can you test for ANCA?
ELISA
Indirect Immunofluorescence
What is Wegener’s - granulomatosis polyangiitis?
ELK
It is a necrotising granuloma of the upper and lower airways with focal glomerulonephritis
ENT - Lungs - Kidneys
How might someone present with granulomatosis polyangiitis?
URT - otorrhoea, sinus pain, nasal d/c LRT - SOB, CP, haemoptysis, cough Renal - oedema, HTN, haematuria \+ Eyes - periorbital oedema MSK - myalgia and arthralgia Neuro - numbness and weakness
How would you induce remission in someone with graulomatosis polyangiitis if it was:
a) Non-lifethreatening
b) Life threatening
a) Non-lifethreatening = IV methylpred + methotrexate
b) Life threatening = IV methylpred + cyclophosphamide
What is the triad of Churg-stauss?
1) Vasculitis
2) Asthmas
3) Esinophilia
Vasculitis in a person with atopy
What is Goodpastures?
Anti-GMB disease - pulmonary renal disease
Auto-abs to the alpha 3 chain of type 3 collagen in BM of alveoli and glomeruli
How do you treat Goodpstures?
Immunosuppression (PO pred + cyclophosphamide)
Plasmapharesis
What is polyarteritis nodosa?
Necrotising arteritis with formation of micro aneurysms, thrombus and infarction
Spares the lungs and the kidneys
Due to the deposition of complement –> inflammation
What is the sign in polyarteritis nodosa that is due to micro aneurysms and focal narrowing?
Rosary sign
Describe polymyalgia Rheumatica
Pain and stiffness in the shoulders, neck and pelvic girdle >2weeks with systemic symptoms at onset - malaise, fever, fatigue
