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(msk) rheumatology diagnostics Flashcards

1
Q

what are diagnostics?

A

laboratory tests and imaging studies

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2
Q

what are the three categories of rheumatology diagnostics?

A

1) blood tests
2) joint (synovial) fluid analysis
3) imaging tests (mainly x-rays but also ultrasound, CT, MRI)

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3
Q

which imaging is used most commonly in rheumatology?

A

mainly x-rays but also ultrasound, CT, MRI

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4
Q

how do you go about ordering blood tests for a rheumatological patient?

A
  • ask yourself: do you even need any blood tests? = diagnosis may be clear from history and examination alone (e.g. osteoarthritis of the knee)
  • start with the basic blood tests before ordering ‘fancy’ tests
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5
Q

what are the basic, baseline rheumatology blood tests?

A 
FBC (full blood count)
U&E (urea & electrolytes)
LFT (liver function tests)
bone profile
ESR (erythrocyte sedimentation rate)
CRP (C-reactive protein)
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6
Q

define arthritis

A

pain and swelling (inflammation) in the joint

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7
Q

what are the three broad divisions of arthritis?

A

osteoarthritis (degenerative) = cartilage is worn out (non-inflammatory)

inflammatory = inflammation usually caused by autoimmune disease; most common is rheumatoid arthritis

septic = infection in joint, inflammation arises secondary to that

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8
Q

what would the full blood count result for a patient with inflammatory arthritis be?
(refer to Hb, MCV, WBCC, platelets)

A

Hb = normal or reduced (anaemia of chronic inflammation, ACD)

MCV = normal (ACD is usually normocytic)

WBC = normal

platelets = normal or elevated (ACD can cause reactive increase in platelets)

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9
Q

explain how chronic inflammation can lead to anaemia

A

long-standing, uncontrolled inflammation suppresses the bone marrow
= less production of RBCs (normocytic anaemia)

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10
Q

what type of anaemia is usually present in inflammatory arthritis?

A

normocytic anaemia

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11
Q

what would the full blood count result for a patient with osteoarthritis be?
(refer to Hb, MCV, WBCC, platelets)

A

Hb = normal

MCV = normal

WBC = normal

platelets = normal

(non-inflammatory so likely to have normal FBC)

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12
Q

what would the full blood count result for a patient with septic arthritis be?
(refer to Hb, MCV, WBCC, platelets)

A

Hb = normal

MCV = normal

WBC = normal or elevated (leukocytosis - due to elevated neutrophils as a result of bacterial infection)

platelets = normal or elevated

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13
Q

what is assessed as part of a U&E blood test?

A

urea
creatinine
sodium
potassium

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14
Q

why is plasma creatinine an important blood test?

A

higher creatinine

= worse renal clearance (indicating kidney problem secondary to rheumatic disease)

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15
Q

what is assessed as part of a U&E blood test?

A

urea
creatinine
sodium
potassium

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16
Q

give examples of the systemic manifestations of rheumatic disease that affect the kidney

A

1) systemic lupus erythematous (SLE) = lupus nephritis (kidney inflammation)
2) vasculitis = nephritis (e.g. glomerularnephritis)
3) amyloidosis = chronic inflammation in poorly controlled inflammatory disease -> high levels of serum amyloid A (SAA) protein -> SAA deposits in organs (AA amyloidosis)

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17
Q

when does amyloidosis occur?

A

when chronic inflammation is poorly controlled, as part of the acute phase response in the liver, serum amyloid A protein is produced (SAA)

serum levels of SAA elevated so deposition occurs in the organs forming amyloid plaques = amyloidosis

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18
Q

which drug is commonly associated with kidney damage?

A

non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. ibuprofen) can cause kidney impairment

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19
Q

what is assessed as part of an LFT blood test?

A

bilirubin
alanine aminotransferase (ALT)
alkaline phosphatase (ALP)
albumin

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20
Q

why is it important to do LFTs in a rheumatic patient?

A

disease-modifying anti-rheumatic drugs (DMARDs) = treatment
= (e.g. methotrexate) can cause liver damage

SO patients on methotrexate have to have regular blood tests (e.g. every 8 weeks)

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21
Q

what is assessed as part of a LFT blood test?

A

bilirubin
alanine aminotransferase (ALT)
alkaline phosphatase (ALP)
albumin

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22
Q

what are the two possible interpretations of a low albumin level?

A

can either reflect a problem of synthesis (in liver)

or a problem of leakage from kidney due to reduced oncotic pressure (e.g. in lupus nephritis)

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23
Q

what is assessed as part of bone profile?

A

calcium
phosphate (PO4)
alkaline phosphatase (ALP)

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24
Q

why is ALP part of the liver function tests and bone profile as well?

A

the source of ALP can be bone OR liver

i.e. production in the bone OR liver

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25
what is Paget's disease of bone?
disrupts the normal cycle of bone renewal, causing bones to become weakened and possibly deformed (disease caused by abnormality of high bone turnover)
26
what ALP levels are expected in Paget's disease of bone?
very elevated ALP levels
27
what are the clinical features of Paget's disease of bone?
bone pain, excessive pain growth, fracture through area of abnormal bone
28
why is ALP elevated in Paget's?
ALP is formed by the bone-forming osteoblasts in Paget's, osteoclast malfunction results in a much faster rate of bone resorption so as a compensatory mechanism, osteoblast activity is significantly increased (new bone is larger and weaker than normal tho) side effect of increased osteoblast activity is increased ALP production
29
what bone profile is expected in Paget's disease? | refer to calcium, phosphate and ALP
very elevated ALP
30
what bone profile is expected in osteomalacia? | refer to calcium, phosphate and ALP
ALP normal or ↑, Ca and PO4 normal or ↓
31
what bone profile is expected in osteoporosis? | refer to calcium, phosphate and ALP
calcium, PO4 and ALP normal usually
32
how is osteoporosis diagnosed?
DEXA scan
33
what are the two markers of inflammation in a blood test?
CRP and ESR
34
which is the preferred marker of inflammation: CRP or ESR - and why?
usually, CRP is the more specific one of the two as ESR can be elevated for many other reasons (elevated immunoglobulin level, paraprotein (myeloma), anaemia, tends to rise with age)
35
what are possible reasons why ESR can be elevated, besides inflammation?
elevated immunoglobulin level paraprotein (myeloma) anaemia tends to rise with age
36
what are CRP and ESR levels like in SLE?
ESR is usually high but CRP normal
37
when is CRP elevated in SLE?
if there is significant synovitis or there is an inflammatory pleural or pericardial effusion
38
when is CRP elevated in SLE?
if there is significant synovitis or there is an inflammatory pleural or pericardial effusion BUT if CRP in lupus, have a low index of suspicion for infection = always suspect new infection first thing!
39
which two autoantibodies are found in the blood of patients with rheumatoid arthritis?
rheumatoid factor (RF) cyclic citrullinated peptides (CCP) antibodies
40
when would you think about carrying our specific, specialist rheumatological tests?
prolonged morning stiffness, over-stiffness on joint examination
41
what is rheumatoid factor?
antibodies that recognize the Fc portion of IgG as their target antigen + are typically IgM (pentameric) antibodies themselves i.e. IgM anti-IgG antibody
42
how common is rheumatoid factor in RA patients?
positive in 70% at disease onset and further 10-15% become positive over the first 2 years of diagnosis
43
which antibody is more specific to rheumatoid arthritis: RF or anti-CCP?
testing for the CCP is more specific to RA patients + the presence of CCP antibodies is associated with a worse prognosis (more aggressive disease)
44
if anti-CCP is present, what can be concluded about the type of RA?
presence of anti-CCP antibodies is associated with a worse prognosis (more aggressive disease)
45
what are anti-nuclear antibodies?
antibodies directed at the nuclear component of the cell
46
explain how anti-nuclear antibodies are non-specific
- relatively common in the normal, healthy population at low titre (level) - prevalence of ANA increases with age in the general population - sometimes transiently positive following infection
47
when are ANAs useful in rheumatology?
high titre ANA together with the correct clinical features may indicate one of the autoimmune connective tissue diseases (eg SLE, Sjogren’s syndrome, scleroderma)
48
why must you cautiously order ANA blood tests in rheumatology?
as they are non-specific, will show up positive in most healthy individuals as well - so must order judiciously! = to prevent it leading to anxiety and unnecessary referral to hospital and further investigation (!!) SO = only order if you suspect autoimmune connective tissue disease clinically (!!)
49
name four autoimmune connective tissue diseases
systemic lupus erythematosus scleroderma Sjogren's syndrome polymyositis
50
what are the clinical features of systemic lupus erythematosus?
arthritis skin rash mouth ulcers kidney disease haematological pleural effusion pericardial effusion
51
what are the clinical features of Sjogren's syndrone?
dry eyes dry mouth extra-articular features
52
what are the clinical features of Sjogren's syndrome?
dry eyes dry mouth extra-articular features
53
what are the clinical features of scleroderma?
vasculopathy (esp. Raynaud’s phenomenon) skin thickening organ fibrosis
54
how is an ANA result reported?
either negative for ANA (no ANA) or positive with a dilution ratio
55
what is the ANA dilution ratio?
the way to report the strength of ANA = maximal dilution at which it is still detectable e.g. 1:80 (weak), 1:320, 1:640, 1:1280 (strong)
56
which ANA dilution is stronger: 1:80 or 1:1280?
1:1280 as after 1280 dilutions, ANA are still at detectable levels whereas with 1:80, ANA is only detectable up until 80 dilutions
57
what does a negative ANA mean?
exclude the diagnosis of SLE
58
what does a negative ANA mean in terms of SLE?
can exclude the diagnosis of SLE
59
what does a positive ANA mean in terms of SLE?
does not necessarily mean SLE but can be suggestive of SLE if there are clinical and lab features to support the diagnosis of SLE stronger test = more clinically significant
60
which tests are ordered if an ANA comes back positive for SLE?
1) ENA (extractable nuclear antigens) = a panel of 5 autoantibodies tested for 2) dsDNA 3) complement levels C3 and C4
61
what is tested in an ENA?
the presence of Ro, La, RNP, Smith and Jo-1 antibodies
62
why is an ENA test carried out after an ANA comes back positive?
positive ANA + clinical features = suggests SLE so need to narrow down and find out which antibody is causing the specific positive result
63
what are Ro antibodies a sign of?
lupus or Sjogren's syndrome
64
what are La antibodies a sign of?
lupus or Sjogren's syndrome
65
what are RNP antibodies a sign of?
lupus or mixed connective tissue disease
66
what are Smith antibodies a sign of?
lupus
67
what are Jo-1 antibodies a sign of?
polymyositis
68
why are dsDNA antibodies tested for in patients with suspected lupus?
highly specific for lupus, associated with renal involvement, useful for tracking lupus activity over time
69
why are complement C3 and C4 tested for in patients with suspected lupus?
may be decreased in active lupus
70
summarise the blood tests carried out for a patient with suspected SLE
basic = FBC, U&E, ESR, CRP, LFT, bone profile specific antibodies = RF, CCP antibodies, ANA super-specific = ENA, dsDNA, C3 & C4
71
how is synovial fluid obtained for analysis?
obtained by aspirating fluid from a joint
72
what are the indications for joint aspiration?
diagnostic: to obtain synovial fluid for analysis therapeutic: to relieve symptoms (+/- concurrent steroid injection)
73
what are the two main diagnostic uses for aspiration?
suspected septic arthritis diagnosing crystal arthritis (e.g. gout, pseudogout)
74
how is suspected septic arthritis diagnosed?
gold stand for diagnosis is synovial fluid aspiration and analysis send for microbial culture and sensitivities = causative organism can be identified and sensitivities can guide the antibiotic choice
75
what does crystal arthritis include?
gout, pseudogout
76
how is the diagnosis of crystal arthritis made?
by aspirating fluid from the affected joint and examining it under a microscope using polarized light
77
how do gout crystals appear under polarised light?
needle-shaped crystals with negative birefringence
78
how do pseudogout crystals appear under polarised light?
rhomboid-shaped crystals with positive birefringence Pseudogout = Positive
79
what are the key differences between septic arthritis and reactive arthritis?
synovial fluid culture - septic = positive - reactive = sterile antibiotic therapy - septic = yes - reactive = no joint lavage - septic = yes (larger joints) - reactive = no
80
what imaging modalities are used in rheumatology?
x-rays CT scans MRI ultrasound
81
which imaging modality is preferentially used in rheumatology and why?
x-rays = first-line, cheap, widely available
82
when would CT scans be used in rheumatology?
more detailed bony imaging
83
when would MRI scans be used in rheumatology?
best visualization of 1) soft tissue structures like tendons, ligaments 2) spinal imaging (can see spinal cord, exiting nerve roots and discs) BUT = expensive and time-consuming (so no usually used)
84
when would ultrasound scans be used in rheumatology?
best visualization of soft tissue structures - good for smaller joints, less good for larger hip/knee joints
85
what imaging modality is used to investigate osteoarthritis?
plain X-rays remain the most useful test in the diagnosis of osteoarthritis
86
what are the radiographic features of osteoarthritis?
joint space narrowing (bone on bone) osteophytes (extra bone growth; bone spurs) subchondral bony sclerosis (increased white space) subchondral cysts (cysts under cartilage)
87
what imaging modality is used to investigate rheumatoid arthritis?
1) x-rays 2) ultrasound 3) MRI
88
what are the radiographic features of rheumatoid arthritis on an X-ray?
soft tissue swelling peri-articular osteopenia bony erosions (sign of established disease - but want to treat EARLY before this stage is reached) (but info is limited to bony structures)
89
why is ultrasound sometimes better than an X-ray at detecting rheumatoid arthritis?
much better test for detecting synovitis
90
what are the radiographic features of rheumatoid arthritis on an ultrasound?
synovial hypertrophy (thickening) increased blood flow (seen as doppler signal) may detect erosions not seen on plain X-ray
91
what happens in an early arthritis clinic?
ultrasound (usually of hands and wrists) can be performed alongside clinical assessment in a dedicated early arthritis clinic = for earlier diagnosis and treatment
92
why is an MRI scan not usually used for rheumatoid arthritis?
time-consuming and expensive
93
compare the radiographic changes seen in rheumatoid arthritis and osteoarthritis
RA: - joint space narrowing - peri-articular osteopenia - bony erosions OA: - joint space narrowing - osteophytes - subchondral sclerosis
94
what does joint space narrowing indicate?
indicates articular cartilage loss = occurs in OA (primary abnormality) and RA (secondary to synovitis)
95
what are osteophytes at the distal interphalangeal joints called?
Heberden's nodes
96
what are osteophytes at the proximal interphalangeal joints called?
Bouchard's nodes
97
what is juxta-articular osteopenia a common sign of?
inflammatory arthritis
98
where do bony erosions occur in arthritis?
erosions occur initially at the margins of the joint where the synovium is in direct contact with bone (seen over time)
99
what do subchondral scleroses look like on a plain radigraph?
dense area of bone just under the cartilage in your joints, and it looks like abnormally white bone along the joint line
100
how does gout commonly present on a X-ray?
juxta-articular erosions | commonly at the MTPJ of the great toe
101
what is the term use to describe gout of the MTPJ of the big toe?
podagra | most commonly affected
102
how does psoriatic arthritis present on an X-ray?
asymmetry of joints involved bony erosions of IPJs, MCPJs not affected 'pencil and cup deformity'

brs (phase 1b) (71 decks)

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