MSK week 2 Flashcards
Describe rheumatoid arthritis
A symmetrical inflammatory arthritis caused by inflammation of the synovial membrane.,
Where does RA usually affect?
Commonly affects the small joints of the hands and feet (MCP and PIPs)
Who does RA usually affect?
Women more commonly than men.
Which antibodies are you likely to see in association with RA?
Rheumatoid Factor
Anti CCP
Which antibody is most specific and relates to disease activity in RA?
Anti-CCP.
Pathogenesis of RA
An immune response is triggered against the synovium which lines some joints and tendons. An inflammatory panes forms which then attacks and denudes articular cartilage leading to joint destruction.
Tendon ruptures and soft tissue damage can occur leading to joint instability and subluxation.
How do you diagnose RA?
Based on clinical presentation, radiographic findings and serological analysis.
Early clinical presentation of RA
Symmetrical synovitis (doughy swelling)
Pain
Morning stiffness
Involvement of MCP and PIP but not DIP
Late clinical presentation of RA
Larger joints may become involved e.g. cervical spine. Atlanto-axial involvement may cause compression of the spinal cord.
Extra-articular features of RA
Rheumatoid nodules- most commonly found on the extensor surfaces or sites of frequent mechanical irritation.
Pleural effusion, interstitial fibrosis and pulmonary nodules
Increased risk of cardiovascular co-morbidities
Investigations into RA
Antibody testing (15-20% of patients don't have antibodies) CRP, plasma viscosity and ESR are also raised. In early disease X-rays will show no joint abnormality (due to early features being soft tissue swelling and bone thinning).
Treatment of RA
Goal- commence DMARD therapy within 3 months of onset of symptoms. Try DMARD one- methotrexate. If this fails add sulfasalazine If this fails add hydroxychloroquine Alongside these NSAIDs and aspirin.
If DMARD therapy fails- biologics may work. Anti-TNF alpha drugs given by injection.
To qualify for these must have high level of disease activity.
Disease activity monitoring in RA
DAS 28 Remission<2.6 Low disease activity 2.7-3.2 Moderate disease activity 3.3-5.1 High disease activity >5.1
Describe ankylosing spondylitis
Chronic inflammatory disease of the spine and sacroiliac joints which can lead to eventual fusion of the joints.
Who gets ankylosing spondylitis?
Young men (late adolescents- early adulthood)
Clinical presentation of ankylosing spondylitis
Spinal pain and stiffness
Spinal morning stiffness which improves with exercise
Over time- loss of spinal movement and a question mark spine.
What is a question mark spine?
Loss of lumbar lordosis-
Increased thoracic kyphosis.
How can you measure the affect of ankylosing spondylitis
Schobers test
Measure 5cm above the superior iliac crests and 10cm below.
Ask the patient to bend over and the space should exceed 20cm between the two marks (unless they have AS)
What will an Xray show of ankylosing spondylitis?
May show sclerosis and fusion of the sacroiliac joints Syndesmophytes (bony spurs from the vertebral bodies) Bamboo spine (intervertebral joints fuse together)
Treatment of ankylosing spondylitis?
Physiotherapy, NSAIDs, exercise
For more aggressive disease- anti-TNF alpha
What is reactive arthritis?
Arthritis that follows infection somewhere else in the body.
What organisms usually cause reactive arthritis?
GU- chlamydia, Neissena
GI- campylobacter, salmonella.
Presentation of reactive arthritis
Large, swollen red and hot joint 1-3 weeks after infection
What is Reiters syndrome?
Triad- urethritis, uveitis or conjunctivitis and arthritis.
Treatment of reactive arthritis?
Aimed at underlying cause or symptomatic relief.
Steroid IM or IA
What is psoriatic arthritis?
Occurs in up to 30% of patients with psoriasis. Asymmetrical oligoarthritis. May involve hands in a similar pattern to RA.
Triad of symptoms that can occur in psoriatic arthritis
Enthesitis
Spondylitis (inflammation of the vertebra)
Dactylitis (inflammation of the digits)
Treatment of psoriatic arthritis
Similar to RA- DMARDs 1st line- methotrexate
Anti-TNF therapy for those who do not respond.
What is enteropathic arthritis?
Inflammatory arthritis involving peripheral joints and sometimes the spine inpatients with IBD
Which joints tend to be affected by enteropathic arthritis?
Tends to be the large joints.
Treatment of enteropathic IBD
Treat underlying disease.
What is gout?
Uric acid depositation in the joints. Uric acid is made from the breakdown of purine bases (adenine and guanine) in DNA replication.
What is hyperuricaemia due to?
Renal under excretion (thiazide diuretics do this, so does renal failure)
Excessive alcohol, red meat and fish intake.
What triggers the crystals to precipitate in joints?
Dehydration
Trauma
Surgery
Which joints are affected by gout
The first MTP joint
The ankle and the knee
(however can be any)
How does gout present?
Intensely hot, painful, swollen joint. Symptoms last for 7-10 days if untreated.
What are gout tophi?
Painless white accumulations of uric acid in the soft tissues- they may erupt through the skin.
How to diagnose gout
Analyse a sample of synovial fluid with polarised microscopy
Needle shaped, negatively birefringent.
Treatment of an acute attack of gout
NSAIDs, corticosteroids and opioid analgesics
Treatment of chronic gout
After the acute attack has subsided- allopurinol is a uric acid decreaser.
What is calcium pyrophosphatase?
Psuedogout
Appearence of psuedogout
Rhomboid shaped, weakly positive birefringent.
What is chondrocalcinosis?
calcium pyrophosphatase deposits in cartilage and other soft tissues in the absence of acute inflammation.
What are seronegative inflammatory arthropathies?
No antibodies in serum.
What are connective tissue diseases?
Diseases which present with symptoms similar to lupus, scleroderma or polymyositis.
What is systemic lupus erythematous?
Chronic autoimmune condition which presentation is highly variable.
Pathogenesis of SLE
Defect in apoptosis meaning excessive cell death occurs and there is a change in immune tolerance.
The defective clearance of apoptotic cell debris leads to immune complex depostitation in some tissues (the basement membrane of the skin and kidneys) and increased circulating immune complexes.
Some of these immune complexes lodge in blood vessels which activates complement and therefore an inflammatory reaction occurs.
Who gets SLE?
Women of child bearing age are the ones most affected.
90% of overall is women.
Prognosis of SLE
10 year survival exceeds 90%
How would you diagnose SLE?
Based on 4 or more of the following (need at least one clinical and one lab finding) LAB Anti nuclear antibody Anti-sm antibody Anti double stranded DNA antibody Antiphospholipid antibody Low complement
Clinical -Acute cutaneous lupus Chronic cutaneous lupus Oral or nasal ulcers Non-scarring alopecia Arthritis Serositis Renal Neurologic Haemolytic anaemia Leukopenia Thrombocytopenia
Skin presentation of SLE
Malar/butterfly rash Discoid lupus Alopecia Oral/nasal ulceration Raynauds Photosensitivity
MSK presentation of SLE
Arthralgia, arthritis and myalgia. Arthritis isn’t erosive or deforming.
Renal presentation of SLE
Lupus nephritis
Respiratory presentation of SLE
Pleurisy Pulmonary hypertension Pulmonary emboli Pleural effusion Pneumonitis
Haematological presentation of SLE
Leukopenia, lymphopenia, thrombocytopenia, anaemia
Cardiac presentation of SLE
Pericarditis
Pericardial effusion
Endocarditis
Antibodies involved in SLE
Anti double stranded DNA antibody- most specific. Also correlates to disease activity
Anti- nuclear antibody- not very specific however positive in 95% of patients
Anti-Sm antibody- specific however low sensitivity
Anti Ro/Anti-la and anti-RNP- may be seen in SLE but can be seen in other autoimmune conditions.
What happens to complement in SLE
Complement goes down when disease activity is high.
What other investigations would you do into SLE?
Full blood count
Urinalysis- to look for glomerular nephritis
Imaging- look for organ involvement.
Management of SLE (generally)
Depends on manifestation of the disease.
Skin disease and arthralgia in SLE management
Hyroxychloroquine (DMARD), topical steroids and NSAIDS
Inflammatory arthritis and organ involvement in SLE management
Immunosupression e.g. azathioprine
Corticosteroids at moderate doses.
Severe organ disease in SLE management
IV steroids and cyclophosphamide
Unresponsive cases of SLE management
IV immunoglobulin
Rituximab
How is SLE monitored?
Frequent FBC and urinalysis
Check anti-ds-dna antibody
BP and cholesterol (to stop cardiovascular morbidities)
Complement levels
What is sjogrens syndrome?
Autoimmune connective tissue disease that causes lymphatic infiltrates into exocrine glands.
Presentation of sjogrens syndrome?
Ocular dryness, oral dryness, vaginal dryness. Parotid gland swelling
Arthralgia and fatigue
How would you diagnose sjogrens
Need 4 or more of the following
Ocular symptoms- dry eyes (greater than 3months)
Oral symptoms- dry mouth, recurrent swollen salivary glands, need water to digest food
Ocular signs- Schirmers performed without anesthesia
Oral signs- abnormal salivary scintigraphy
Anti-Ro or anti-La antibodies
Management of sjogrens syndrome?
Mainly symptomatic- eye drops
Regular dental care
Pilocarpine can help saliva production (side effects are flushing)
Hydroxychloroquine can help with arthralgia and fatigue.
What is systemic sclerosis?
Systemic connective tissue disease characteristically including vasomotor disturbances (Raynauds), fibrosis, atrophy of the skin and subcutaneous tissues.
What causes skin and organ changes in systemic sclerosis
Collagen depositation in the skin and organs.
Minor features of systemic sclerosis
Sclerodactyly (thickening and tightness of the skin)
Atrophy of the fingertips
Bilateral lung fibrosis
Major features of systemic sclerosis
Centrally located skin sclerosis (hardening)- affects arms, face and neck.
Three phases of cutaneous involvement in systemic sclerosis
Oedematous, indurative and atrophic
Skin becomes thickened and hard
Calcinosis- deposits of calcium- may be seen in digits.
What can happen to the skin on the face in systemic sclerosis?
Pinching of the nose can cause a beak like appearance. Skin becomes tighter around the mouth.
What organ involvement can you get with systemic sclerosis?
Pulmonary hypertension and pulmonary fibrosis
GI- dysphagia, malabsorption and bacterial overgrowth.
Inflammatory arthritis and myositis may be seen.
What are the classifications of systemic sclerosis
Limited- skin involved is confined to the face, hands, forearms and feet. Organ involvement is later. Anti-centromere antibody.
Diffuse- skin changes develop more rapidly and on the trunk. Early significant organ involvement. Anti Scl 70 antibody.
Management of systemic sclerosis
No specific management- mostly symptomatic.
For Raynauds- calcium channel blockers
Renal involvement- ACE inhibitors
GI- PPI for reflux
ILD-immunosuppression- usually cyclophosphamide
What is mixed connective tissue disease?
Condition which features symptoms also seen in other connective tissue diseases.
What symptoms could you see in mixed connective tissue disease?
Raynauds Arthralgia/arthritis Myositis Sclerodactyly Pulmonary hypertension ILD
Treatment of mixed connective tissue disease?
Varies according to presentation
Calcium blockers for Raynauds
Significant muscle or lung disease-immunosuppression.
What is anti-phospholipid syndrome?
Manifests as recurrent arterial or venous thrombosis and/or fatal loss. May occur in relation to other autoimmune disorders
Presentation of antiphospholipid syndrome
Increased frequency of stroke or MI (especially in the young)
Recurrent pulmonary emboli or thrombosis
Pulmonary hypertension
Late spontaneous fetal loss (common- but can occur at any point during pregnancy)
Cutaneous feature- livedo reticularis.
Investigations into antiphospholipid syndrome?
Lupus anticoagulant
Anti-cardiolipid antibodies
Anti-beta 2 glycoprotein.
Management of anti-phospholipid syndrome
anticoagulation
Low molecular weight heparin if pregnant.
