MSK/Rheumatology Flashcards
describe the disease process behind osteoarthritis
general wear and tear, a chronic degenerative disease.
loss of articular cartilage - exposed bone becomes sclerotic.
attempts at repair produces osteophytes (nodules).
describe the usual onset of osteoarthritis
> 50yrs, slow and gradual
describe the pattern of joint involvement of osteoarthritis
asymmetrical.
finger joints, thumbs + weight bearing joints (hip/knee)
what hand changes are common to osteoarthritis?
Heberden’s (DIP) + Bouchard’s (PIP) nodes.
NO swelling.
what systemic features are present in osteoarthritis?
NONE
describe the character of the pain from osteoarthritis
increases with movement, worse at the end of the day.
what would the lab findings be in osteoarthrits?
RhF -ve, ANA -ve, raised CRP, normal ESR
what would be the radiological findings in osteoarthritis?
LOSS.
Loss of joint space, Osteophytes, Subchondral cysts, Sclerosis.
what main features would you use to differentiate between rheumatoid and osteoarthritis?
pattern of joint involvement.
absence of systemic features of OA.
RA has marked early morning stiffness lasting >60mins.
how would you treat osteoarthritis?
exercise for local muscle strength/aerobic fitness.
analgesia - paracetamol ± topical NSAIDs.
codeine/short-term oral NSAID (+PPI).
intra-articular steroid injections.
joint replacement surgery.
describe the disease process behind rheumatoid arthritis
chronic systemic inflammatory, autoimmune disease.
production of cytokines (IL-1,2,4,6,8 + TNFalpha) by T cells = inflammation.
local rheumatoid factor production.
synovitis => pannus formation => pannus destroys articular cartilage and subchondral bone.
describe the usual onset of rheumatoid arthritis
aged 30-50. rapid, within a year.
describe the pattern of joints affected by rheumatoid arthritis
symmetrical.
small and large joints on both sides.
>3 affected, hands usually involved.
what hand changes are common to rheumatoid arthritis?
swan neck deformity, Boutonniere’s deformity, Z thumb, ulnar deviation, hot swollen joints.
what systemic features are present in rheumatoid arthritis?
elbow and lung nodules, vasculitis, pericarditis, carpal tunnel, Sjorgen’s, Raynaud’s, lymphadenopathy, fever, fatigue
describe the character of the pain from rheumatoid arthritis
morning stiffness >60 mins.
pain is accompanied by stiffness.
what would the lab findings be in rheumatoid arthritis?
RhF +ve, anti-CCP +ve (highly specific for RA), raised CRP, raised ESR
what would be the radiological findings in rheumatoid arthritis?
LESS.
Loss of joint space, Erosions, Soft bone, Swelling of soft tissue.
how would you treat rheumatoid arthritis?
DMARDs - sulfasalazine, methotrexate.
Biological agents - infliximab, rituximab, tocilizumab etc.
NSAIDs - diclofenac, ibuprofen.
Steroids for flare ups (IM methylprednisolone).
what is the diagnostic criteria for rheumatoid arthritis?
need 4 out of 7:
morning stiffness >1h.
3+ joints affected.
arthritis in hand joints.
symmetrical.
rheumatoid nodules.
RhF+ve.
radiological changes.
what rheumatoid arthritis treatment requires regular pregnancy tests in women of child-bearing age and why?
methotrexate - it’s a folic acid antagonist, risk of neural tube defects is high.
what disease lowers your risk of developing osteoarthritis?
osteoporosis
define osteoporosis, in general terms
low bone mass and micro-architectural deterioration leading to bone fragility and increased fracture risk
give 5 risk factors for osteoporosis
age, parental history, alcohol (>4units/day), RA, BMI less than 19, steroids (5mg/d prednisolone).
Hyperthyroidism, hyperparathyroidism, hypercalciuria.
Alcohol and tobacco use.
Thin (BMI less than 19)
what fractures might alert you that a patient could have osteoporosis?
thoracic and lumbar vertebrae.
proximal femur.
distal radius (Colles’ fracture).
what is the gold standard investigation for osteoporosis?
DEXA bone scan.
what lifestyle measures should an osteoporosis patient take?
smoking cessation, low alcohol intake, weight bearing exercises, calcium and vit D rich diet, home help.
how would you medically treat osteoporosis?
bisphophonates e.g. alendronate, zolendronate
calcium + vit D.
strontium ranelate - if intolerant to bisphosphonates.
HRT is preventative, but not used to treat.
explain the pathophysiology of SLE
apoptotic cells and cell fragments aren’t cleared efficiently by phagocytes - taken to lymph nodes, taken up by APCs.
APCs present self-antigens from these fragments to T cells, activating B cell proliferation and production of autoantibodies.
Leads to antibody formation, immune complex deposition, complement activation and influx of neutrophils = clinical manifestations.
what 3 genes is SLE associated with?
HLA-B8, DR2, DR3
what are the WHO diagnostic criteria for SLE?
need 4 out of 11 - SOAP BRAIN MD
Serositis
Oral ulcers
ANA +ve
Photosensitivity
Blood disorders
Renal disorder
Arthritis
Immunological disorder
Neurological disorder
Malar rash
Discoid rash
what autoantibodies might you find in a patient with SLE?
ANA, anti-Ro, anti-dsDNA, anti-La
what histological features might you see on investigation of a patient with SLE?
deposition of IgG and complement in kidneys and skin
give 6 symptoms of SLE
Raynaud’s, chest pain, dyspnoea, depression, fatigue, dry eyes/mouth, abdominal pain, joint pain, muscle pain, polyneuropathy/sensory loss
give 6 signs of SLE
malar rash, discoid rash, photosensitivity rash, purpura, weight loss, lymphadenopathy, oral/nasal ulcers, bruising, proteinuria, fever, pallor due to anaemia
how might you monitor SLE activity?
anti-dsDNA antibody titres.
complement - low C3/C4.
ESR.
what ESR/CRP results would make you think of SLE?
multisystem disorder with raised ESR but normal CRP
how would you manage a severe flare of SLE?
IV cyclophosphamide and high-dose prednisolone.
how would you manage the cutaneous symptoms of SLE?
topical steroids, strong sunblock/avoid sun exposure
describe maintenance treatment for SLE
NSAIDs, hydroxychloroquine, low-dose steroids, azathioprine/methotrexate or mycophenolate
how would lupus nephritis be managed?
needs more intense immunosuppression than SLE:
cyclophosphamide/mycophenolate
what are the 4 characteristic clinical features of anti-phospholipid syndrome?
coagulation defect, livedo reticularis (blue/pink mottling), obstetric problems (miscarriages), thrombocytopenia (bleeding)
what is antiphospholipid syndrome?
associated with SLE, or a primary disease.
there are antiphospholipid antibodies causing CLOTS - leads to the features of miscarriages, livedo reticularis etc
what are the 3 diagnostic investigations to be carried out in antiphospholipid syndrome?
lupus anticoagulation test, anti-beta2 glycoprotein test, anticardiolipin test.
indicate +ve blood test for antiphospholipid antibodies.
how would you manage a patient with antiphospholipid syndrome?
warfarin, if there’s recurrent thrombosis.
if high IgG but asymptomatic, then give aspirin/clopidogrel as prophylaxis.
what 2 genes are associated with Sjogren’s syndrome?
HLA-B8/DR3
give 2 secondary causes of Sjogren’s
SLE, RA, scleroderma
what is the characteristic feature of Sjogren’s and where is it seen?
dryness - eyes, mouth (vagina) - and parotid enlargement.
what tests would you do to diagnose Sjogren’s?
Schirmer’s test - filter paper on inside of eyelid for 5 mins, if less than 5mm moistened - positive for Sjogrens
how would you treat Sjogrens?
artificial tears and saliva replacement.
NSAIDs and hydroxycholoroquine for arthralgia.
explain the pathophysiology behind systemic sclerosis
autoimmune dysfunction causes overproduction of collagen.
T cells accumulate in skin and secrete cytokines which stimulate collagen deposition and stimulate fibroblasts.
scleroderma (skin fibrosis) + vascular disease.
what are the features of CREST syndrome?
Calcinosis of subcutaneous tissue.
Raynaud’s.
oEsophageal and gut dysmotility.
Sclerodactyly - swollen, tight digits.
Telangiectasia (spider veins).
what parts of the body is skin involvement limited to in CREST syndrome?
hands, feet and face
what parts of the body are affected by diffuse systemic sclerosis?
diffuse skin involvement.
heart, lungs, GI tract and kidneys all involved.
what antibodies might you find on investigation of a patient with systemic sclerosis?
ANA, RhF, ACA, anti-topoisomerase, anti-RNA polymerase
how would you treat systemic sclerosis?
IV cyclophosphamide.
ACEi/ARBs reduce risk of renal problems.