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Phase 4 Medicine > MSK/Rheumatology > Flashcards

MSK/Rheumatology Flashcards

1
Q

Define crystal arthropathies and name 2

A

Gout and Psuedogout

Describes acute intermittent episodes of joint inflammation caused by accumulation of urate crystals within synovial joints.

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2
Q

What type of crystals are found in gout and describe their structure and appearance (3)

A

Monosodium Urate Crystals

Needle-shaped

Negatively Bifringent under polarized light

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3
Q

What type of crystals are found in pseudogout and describe their structure and appearance (3)

A

Calcium pyrophosphate crystals

Small rhomboid brick shaped

Positively bifringent under polarized light.

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4
Q

Where does gout most commonly affect? (2)

A

1st metatarsophalangeal joint (big toe = podagra)

Osteoarthritic joints (ankle, foot, hand, wrist, elbow or knee)

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5
Q

What is the principle driver of gout?

A

Hyperuricaemia (high uric acid levels)

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6
Q

Describe the pathophysiology of gout (3)

A

Purines > Hypoxanthine > Xanthine > Uric acid

Uric acid precipitates, forming monosodium urate crystals.

Urate crystals trigger acute inflammatory response (recruitment of neutrophils) causing neutrophilic synovitis.

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7
Q

What enzyme catalyses the conversion of xanthine to uric acid?

A

Xanthine oxidase

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8
Q

What foods/drinks contain purines? (3)

A

Fizzy drinks

Alcohol

Red meats

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9
Q

Name 1 xanthine oxidase inhibitor

A

Allopurinol

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10
Q

Where is uric acid predominantly excreted from?

A

Kidneys

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11
Q

Give 5 risk factors for gout that result from reduced urate excretion

A

Elderly

Male

Impaired renal function

Post-menopausal women

Drugs (Aspirin, Indapamide, Tacrolimus, Pyrazinamide)

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12
Q

What drug is it important to stop in patients with hypertension presenting with gout? What should be given instead?

A

STOP Diuretics (indapamide)

Switch to ARB (losartan) as promotes uric acid excretion

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13
Q

Name 4 drugs associated with gout

A

Aspirin (high dose)

Indapamide (diuretic)

Tacrolimus (for severe eczema)

Pyrazinamide (TB)

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14
Q

Give 4 clinical features of gout

A

Acute monoarthritis (rapid onset - severe pain - big toe)

Urate deposits (tophi in pinna, tendons or extensor surfaces)

Joint stiffness, swelling, effusion

Renal disease (hyperuricaemia > CDK = radiolucent stones/interstitial nephritis)

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15
Q

Give 4 differentials for gout

A

Septic arthritis (consider in any monoarthropathy)

Pseudogout

Reactive arthritis

Haemarthrosis (bleeding into joints - haemophilia)

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16
Q

What investigation is used to definitively diagnose gout?

A

Joint aspiration (arthrocentesis) with synovial fluid analysis.

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17
Q

What additional investigations is it important to conduct when investigating ? gout(4)

A

Synovial Fluid Culture - To exclude septic arthritis

WBC - High neutrophils

Serum urate - Raised

X-ray (shows punched out erosions in juxta-articular bone and joint space narrowing)

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18
Q

What drugs can be used to manage acute gout? (4)

A

NSAIDs - Naproxen/Ibuprofen (contraindicated in CKD)

Corticosteroids - Prednisolone

Colchicine

IL-1 inhibitors - Anakinra or Canakinumab

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19
Q

What drugs are used to treat recurrent episodes of gout? (2-3 weeks post acute episode) (3)

A

Allopurinol (xanthine oxidase inhibitor)

Probenecid (inhibits uric acid reabsorption = increased uric acid excfretion in urine)

Rasburicase (recombinant urate oxidase)

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20
Q

Give 3 side effects of Colchicine

A

Diarrhoea

Nausea

Abdominal pain

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21
Q

What dietary change can help reduce the risk of developing gout in the future?

A

Switching to a high dairy diet

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22
Q

Define pseudogout

A

Crystal arthropathy characterised by the deposition of calcium pyrophosphate crystals within joints.

Can be acute or chronic

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23
Q

How may acute pseudogout present?(2)

A

Presents with acute monoarthropathy (usually of larger joints in the elderly).

Usually occurs spontaneously and can be provoked by illness, trauma or surgery.

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24
Q

How may chronic pseudogout present?

A

Presents as an inflammatory RA-like (symmetrical) polyarthritis and synovitis (>5 joints)

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25
Q

What triad of pathology is typically seen in osteoarthritis?

A

Cartilage erosion and thickening of subchondral bone

Disordered bone repair (formation of osteophytes)

Synovial inflammation

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26
Q

Define osteoarthritis

A

Describes a degenerative joint disorder characterised by the progressive loss of hyaline cartilage, particularly of synovial joints.

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27
Q

Give 5 risk factors for pseudogout

A

Hyperparathyroidism

Haemochromatosis

Hypothyroidism

Age

Hypophosphataemia (may be 2nd to hyperparathyroidism)

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28
Q

Describe the clinical presentation of pseudogout

A

Osteoarthritis/RA live involvement of joints (wrists, shoulders, knee ect)

Symptoms of gout (swelling, effusion, pain ect)

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29
Q

What may be seen on an x-ray of a patient with pseudogout?

A

Chondrocalcinosis (soft tissue Ca deposits)

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30
Q

Other than joint aspiration (atherocentesis) what additional investigations are important to conduct in a patient with pseudogout? (2)

A

Serum calcium levels (to exclude hyperparathyroidism - low)

Serum parathyroid hormone (to exclude hyperparathyroidism - low)

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31
Q

How does osteoarthritis typically present (4)

A

Joint pain, Stiffness, Deformity and loss off function.

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32
Q

Where anatomically is the most common presentation of osteoarthritis?

A

OA of the knee

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33
Q

What cells produce cartilage? And from what substance makes cartilage resistant to compression?

A

Chondrocytes

Chondroitin sulfate

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34
Q

Name 3 types of cartilage and give examples of where they are found.

A

Hyaline cartilage (most widespread types - articular surfaces of long bones, rib tips, rings of trachea)

Fibrous cartilage (pubic symphysis, intervertebral discs, menisci)

Elastic cartilage (Epiglottis and pinnae of ear)

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35
Q

What are the main components of fibrous cartilage?

A

Type I and Type II collagen

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36
Q

What are the main components of elastic cartilage?

A

Elastin and Type II collagen

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37
Q

What type of cartilage is found in the pubic symphysis, intervertebral discs and menisci?

A

Fibrous cartilage

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38
Q

What type of cartilage is the most widespread cartilage found on the articular surfaces of long bones, rib tips and rings of the trachea?

A

Hyaline cartilage

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39
Q

What ultimately drives the progression of osteoarthritis? name 3 factors that influence this.

A

Reduced formation and increased breakdown of articular hyaline cartilage;

Metalloproteinase over production (enzymes catalyse collagen)

Production of IL-1 and TNF-a (stimulates chondrocytes to produce metalloproteinases)

Production of NO (NO activates metalloproteinases)

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40
Q

Give 3 clinical features of osteoarthritis

A

Pain (Worse with prolonged activity)

Joint stiffness (<30mins morning stiffness - improves through the day)

Bouchard’s (PIP) and Heberden’s (DIP) Nodes

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41
Q

What is the primary investigation for osteoarthritis? What would it likely show?

A

X-Ray of affected joint

LOSS;
- Loss of joint space (joint space narrowing)
- Osteophyte formation
- Subchondral sclerosis
- Subchondral cysts

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42
Q

What blood tests would be conducted when investigating osteoarthritis? (4)

A

CRP (Normal)
ESR (Normal)
Rheumatoid Factor (Negative)
Anti-CCP (Negative)

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43
Q

What investigation can be used to assess osteoarthritic damage to the knee?

A

Arthroscopy

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44
Q

How is osteoarthritis managed? (3)

A

Exercise (improve muscle strength) (weight loss if overweight)

Patient Education

Analgesia (Oral/Topical)

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45
Q

Describe the 1th to 4th line analgesic treatments for osteoarthritis (5)

A

1st - Topical analgesia (Diclofenac/Ibuprofen gel/Capsaicin)

2nd - Paracetamol + Topical Analgesia

3rd - NSAID + Paracetamol + Topical Analgesia

4th - Opioid (codeine) + Paracetamol + Topical Analgesia

Adjunct - Intra-articular steroid injections (Methylprednisolone acetate)

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46
Q

Describe 3 surgical methods of treating osteoarthritis

A

Arthroscopy

Osteotomy (removing bone)

Arthroplasty (joint replacement)

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47
Q

Give 3 indications for conducting an arthroplasty in a case of osteoarthritis

A

Uncontrolled pain (particularly at night)

Significant limitation of function

Patient age

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48
Q

Define Rheumatoid Arthritis and describe how it is characterised.

A

Describes a chronic systemic inflammatory disease primarily affecting synovial joints of the hands and feet.

Characterised by symmetrical, deforming peripheral polyarthritis (>5 joints).

49
Q

What is Rheumatoid Arthritis associated with and why?

A

An increased risk of cardiovascular and cerebrovascular disease as atherosclerosis is accelerated

50
Q

Give 3 risk factors for rheumatoid arthritis

A

Smoking

Genetics - HLA-DR1/DR4

Female

51
Q

What is the main driver of rheumatoid arthritis? What factors drive this? (3)

A

Synovial inflammation (synovitis)

Driven by; TNF, IL-1 and IL-6

52
Q

What 4 processes occur during the development of Rheumatoid Arthritis?

A

Recruitment of inflammatory Cells (T-cells, B-cells, Macrophages)

Synovial Hyperplasia

Increased angiogenesis

Joint effusion (swelling from excess synovial fluid)

53
Q

What joints are primarily affected in Rheumatoid Arthritis? How does this differ to Osteoarthritis?

A

RA = MCP and PIP Joints of the hands and feet

OA = PIP and DIP joints (not MCP)

54
Q

Give 3 clinical features of rheumatoid arthritis

A

Symmetrical Arthritic of MCP and POP joints lasting >6 weeks

Pain/stiffness worse in the morning (relieved with exercise)

Systemic illness (fatigue, weightloss, carpal tunnel syndrome)

55
Q

Give 5 systemic, extra articular symptoms of rheumatoid arthritis

A

Carpal Tunnel Syndrome/Frozen Shoulder/Quervains tenosynovitis

Fatigue/Weight loss

Heart - Pericarditis/Pericardial effusion

Eyes - Sceleritis/Uveitis

Lungs - Pleural effusions/Fibrosing alveolitis

56
Q

Name and describe 1 rare complication of rheumatoid arthritis

A

Felty’s syndrome

SANTA;
- Splenomegaly
- Anaemia
- Neutropenia
- Thrombocytopenia
- Arthritis (rheumatoid)

57
Q

What clinical signs may be seen in rheumatoid arthritis? (4)

A

Boutonniere’s/Swan Neck Deformities

Ulnar deviation and subluxation

Raynauds

Signs of inflammation (hot, red, swelling, pain, loss of function)

58
Q

What blood tests may be ordered to investigate rheumatoid arthritis?

A

ESR/CRP (Raised)

Rheumatoid Factor (Positive)

Anti-CCP (Positive - Useful if RF is negative)

59
Q

What imaging investigation is useful to use to investigate rheumatoid arthritis? What may it show?

A

X-ray

Shows periarticular erosions at joint margins. May later progress to joint space narrowing.

60
Q

Describe the management of rheumatoid arthritis

A

1st line;
DMARDs - Methotrexate/Sulfasalazine (Pregnancy)
Analgesia - NSAIDs/Aspirin
Corticosteroids - Prednisolone

2nd line
Anti-TNF medications - Infliximab (if unresponsive to DMARD)

3rd line
Rituximab (If unresponsive to Anti-TNF)

61
Q

Give 4 possible side effects of methotrexate

A

Hepatotoxicity

Anaemia (Macrocytic)

Pulmonary fibrosis

Pancytopenia

62
Q

Describe spondyloarthropathies

A

A group of chronic inflammatory conditions affecting the spine and peripheral joints

63
Q

Spondyloarthropathies are associated with what allele?

A

HLA-B27

64
Q

Name 4 types of seronegative spondyloarthropathies

A

Ankylosing spondylitis

Psoriatic arthritis

Reactive arthritis

Enteric arthropathy

65
Q

What common clinical features are seen in seronegative spondyloarthropathies? (SPINEACHE)

A

S - Sausage Digit (Dactylitis)
P - Psoriasis
I - Inflammatory back pain
N - NSAID good response
E - Enthesitis (achilies tendon, costochondritis)
A - Arthritis (axial - spine/sacroiliac joints)
C - Crohn’s /Colitis/Raised CRP
H - HLA-B27
E - Eye (Uveitis)

66
Q

How do spondyloarthropathies tend to present? (3)

A

Asymmetrical

Large joint oligoarthritis (<5 joints) or monoarthritis

Seronegative (RF negative)

67
Q

Define ankylosing spondylitis

A

Chronic inflammatory disease characterized by stiffening and inflammation of the spine and sacroiliac joints

68
Q

How does ankylosing spondylitis differ to rheumatoid arthritis?

A

In contrast to RA, where inflammation and erosion are the only pathological processes present, AS also involves subsequent repair (ossification).

Inflammation in AS patients is dominated by inflammatory cells and an increased number of osteoclasts.

69
Q

Give 3 epidemiological features of ankylosing spondylitis

A

More common in men

Early presentation (late teens/early 20s)

Gradual onset lower back pain

70
Q

Describe the typical presentation of ankylosing spondylitis. (5)

A

Typical presentation is a man <30 yrs with gradual onset of lower back pain, worse in the morning relieved with exercise.

Asymmetrical involvement
Morning stiffness/pain relieved by exercise
Iritisis/uveitis
Enthesitis
Kyphosis/Lumbar lordosis

71
Q

What may an pelvic x-ray show in a patient with ankylosing spondylitis? (3)

A

Sacroiliitis (erosions, irregularities, sclerosis)

Syndesmophytes (bony proliferations)

Bamboo spine (fusion of spinal joints)

72
Q

How is ankylosing spondylitis managed? (5)

A

Exercise

Analgesia - NSAIDs/Paracetamol

Intra-articular corticosteroid injections - Hydrocortisone (if peripheral joint involvement)

DMARDs - Sulfasalazine/Methotrexate

Surgery (hip replacement)

73
Q

Describe psoriatic arthritis

A

Describes an chronic inflammatory joint disease associated with psoriasis.

74
Q

What joint is commonly affected in psoriatic arthritis?

A

Distal Interphalangeal Joint (DIP)

75
Q

What deformities may be seen on an x-ray of a patient with psoriatic arthritis? (3)

A

Pencil cup deformity (Erosion of DIP joint)

Fluffy periostitis (peri-articular new bone formation)

Osteolysis

76
Q

Give 4 clinical features of psoriatic arthritis

A

Psoriatic skin symptoms (Psoriasic plaques on scalp/legs, onycholysis - detachment of nail from nail bed)

Prolonged morning stiffness/pain (>30 mins) that improves with use

DIP joint involvement

Dactylitis

77
Q

Describe reactive arthritis

A

Reactive arthritis describes an inflammatory arthritis that occurs after exposure to certain gastrointestinal (dysentery) or genitourinary infections (urethritis).

78
Q

Give 3 gastro-intestinal causes of reactive arthritis

A

Salmonella
Shigella
Yersinia enterocolitica

79
Q

Give 1 genitourinary cause of reactive arthritis

A

Chlamydia

80
Q

Describe Systemic Lupus Erythematosus

A

Describes a multisystemic autoimmune disease characterized by the generation of antibodies against autoantigens (such as Anti-Nuclear Antibody -ANA) which form immune complexes.

81
Q

What type of hypersensitivity reaction is SLE? and why?

A

Type 3 hypersensitivity reaction

Forms immune complexes

82
Q

Give 3 epidemiological factors of SLE

A

Female

Afro-caribbean/asian

Genetics - HLA-B8, DR2 and DR3/Compliment deficiency (C3/C4)

83
Q

Give 5 clinical features of SLE

A

Malar rash (butterfly rash)

Photosensitive rash (after sunlight exposure)

Discoid rash (keratotic rash - chronic SLE)

Arthralgia/arthritis (presents similar to RA)

Organ specific features (kidney, eyes, CS, GI, Heart)

84
Q

What immunological tests should be performed when investigating SLE? (4)

A

ANA (Most sensitive - useful rule out test)

dsDNA antibody (Most specific)

Anti-Smith

Low Cs and C4

85
Q

Give 3 additional tests (non-immunological) to perform when investigating SLE

A

ESR/CRP (ESR elevated due to systemic inflammation, CRP normal as condition is chronic)

Urinalysis (Assess renal involvement)

Coombs test (order if pt has features of anaemia)

86
Q

Describe the management of SLE (3)

A

Analgesia - NSAIDs

Suncream

Hydroxychloroquine

87
Q

Give 2 potential musculoskeletal features of SLE

A

Arthralgia

Non-erosive arthritis

88
Q

Give 2 potential cardiovascular features of SLE

A

Pericarditis (most common cardiac symptom)

Myocarditis

89
Q

Give 2 potential respiratory features of SLE

A

Pleurisy

Fibrosing alveolitis

90
Q

Give 2 potential renal features of SLE

A

Proteinuria

Glomerulonephritis (diffuse proliferative glomerulonephritis is most common)

91
Q

How is diffuse proliferative glomerulonephritis (caused by SLE) treated? (2)

A

Treat hypertension

Glucocorticoids (prednisolone) with Mycophenolate/Cyclophosphamide

92
Q

Give 2 potential neuropsychiatric features of SLE

A

Anxiety/Depression

Seizures

93
Q

Describe osteoporosis

A

Osteoporosis is a systemic skeletal disease characterized by low bone mass and structural deterioration in bone microarchitecture.

Making bones more susceptible to fracture

94
Q

What is a fragility fracture?

A

Describes an osteoporotic fracture that occurs as a result of increased bone fragility due to osteoporosis.

Typically occurring from the patient falling from a standing height or less.

95
Q

Name 3 common sites for fragility fractures to occur

A

Wrist, Hip, Spine

96
Q

What cell type drives bone resorption?

A

Osteoclasts

97
Q

What cell type drives bone formation?

A

Osteoblasts

98
Q

How does osteoporosis occur?

A

Occurs as a consequence of imbalances in bone resorption (osteoclasts) and bone formation (osteoblasts), in which bone resorption is favoured, resulting in a net loss of bone density.

99
Q

Name 3 biochemical factors involved in regulating bone remodelling

A

Parathyroid hormone (increases blood Ca levels by promoting bone resportion)

1,25 dihydroxy vitamin D (Calcitriol) (increases blood Ca levels by promoting bone resorption and renal phosphate resorption)

Calcitonin (opposes PTH) (Acts to decrease blood calcium levels by inhibiting bone resorption)

100
Q

Give risk factors for osteoporosis (SHATTERED)

A

S - Steroid use (>5mg/d prednisolone)
H - Hyperthyroidism, hyperparathyroidism, hypercalciuria
A -Alcohol and smoking
T - Thin (<18.5 BMI)
T - Testosterone reduction
E - Early Menopause
R - Renal or Liver failure (Chronic Kidney Disease associated w/ tertiary hyperparathyroidism)
E -Erosive/inflammatory bone disease (myeloma/RA)
D - Dietary (reduced calcium intake, malabsorption, diabetes mellitus type 1)

101
Q

What is the gold standard investigation for osteoporosis?

A

DEXA bone densitometry

(T-score <-2.5 = osteoporosis)

102
Q

What assessment tool is used in osteoporosis? What does it estimate?

A

FRAX (Fracture risk assessment tool)

Estimates 10yr risk of osteoporotic fracture in untreated patients

103
Q

FRAX should be conducted in ALL patients before a DEXA except for? (3)

A

> 50 with hx of fragility fractures
<40 with major risk factor for fragility fractors
With vertebral or hip fractures

104
Q

What metabolite tests would be useful to perform on a patient with osteoporosis?

A

Calcium (hypocalcemia)

Phosphate (low - osteomalacia)

PTH

Vitamin D

TFTs

105
Q

Describe how T-scores used in a DEXA scan are used to assess severity (4)

A

> -1.0 = Normal
-1.0 to -2.5 = Osteopenia
< -2.5 = Osteoporosis
< -2.5 + fracture = Severe osteoporosis

106
Q

What does a T score of <-2.5 mean?

A

This means that the patient’s bone density is >2.5 standard deviations below the young adult mean value

107
Q

What does a Z-score compare your bone density to?

A

to the average values for a person of the same;
age, gender and ethnicity.

108
Q

Give 4 pieces of general management advice for managing osteoporosis

A

Reduce smoking and alcohol intake

Increase dietary intake of calcium and phosphate (dairy)

Encourage weight bearing or balancing exercises (Tai Chi)

Home based fall prevention

109
Q

Give 3 pharmacological managements for osteoporosis

A

1st line - Alendronic Acid (bisphosphonates)

Calcium + Vitamin D supplementation

Strontium Ranelate (stimulates bone formation)

110
Q

Give 4 drugs used in the secondary prevention of osteoporosis

A

Raloxifene (Selective oestrogen receptor modulator)

Teriparatide (PTH analogue)

Denosumab (RANK Ligand MAB)

HRT (Oestrogen)

111
Q

How is osteomalacia characterised?

A

Osteomalacia is characterised by a normal amount of bone but it has a decreased mineral content (as there is excess unmineralized osteoid and cartilage).

112
Q

What is the difference between rickets and osteomalacia?

A

Rickets occurs DURING the period of bone growth (before fusion of the epiphysis),this can result in growth retardation and skeletal deformities.

Osteomalacia is when this occurs AFTER fusion of the epiphysis.

113
Q

What is the primary cause of osteomalacia?

A

Vitamin D deficiency

114
Q

Give 4 causes of vitamin D deficiency

A

Sub-optimal exposure to UV-B (biggest factor)

Insufficient dietary intake

Insufficient absorption of vitamin D in the smal intestine

Liver/Renal failure

115
Q

What is the primary role of vitamin D and how does it achieve this? (3)

A

Primary role is to maintain blood calcium and phosphate levels.

Does this by;
Promoting calcium reabsorption in the distal tubule.

Promoting intestinal (duodenal) calcium and phosphate absorption.

Stimulating osteoclast activity (stimulates bone reabsorption)

116
Q

Give 3 clinical features of osteomalacia

A

Bone pain

Proximal muscle weakness (myopathy) and tenderness

Malabsorption syndromes (coeliac, chronic alcoholism, chronic pancreatitis)

117
Q

Give 4 clinical features of Rickets (children)

A

Bone pain

Growth retardation

Developmental delay

Bony deformities (pigeon chest, bowed legs)

118
Q

What metabolite levels would be seen in the blood of a patient with osteomalacia? (3)

A

Low calcium

Low Vitamin D

Low Phosphate

119
Q

How is osteomalacia treated? (2)

A

Calcium carbonate/citrate

Ergocalciferol (Vitamin D)

Phase 4 Medicine (15 decks)

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