Multi-system Autoimmune Disease Flashcards
1
Q
… are forms of arthritis that usually strike the bones in your spine and nearby joints.
A
Spondyloarthropathies are forms of arthritis that usually strike the bones in your spine and nearby joints.
2
Q
Spondyloarthropathies types
- … spondylitis
- Psoriatic Arthropathy
- … Arthropathy
- Intestinal Arthropathy
- … Ankylosing Spondylitis
- Hallmark ocular involvement is UVEITIS
A
- Ankylosing spondylitis
- Psoriatic Arthropathy
- Reactive Arthropathy
- Intestinal Arthropathy
-
Juvenile Ankylosing Spondylitis
- Hallmark ocular involvement is UVEITIS
3
Q
Spondyloarthropathies types
- Ankylosing spondylitis
- … Arthropathy
- Reactive Arthropathy
- … Arthropathy
- Juvenile Ankylosing Spondylitis
- Hallmark ocular involvement is …
A
- Ankylosing spondylitis
- Psoriatic Arthropathy
- Reactive Arthropathy
- Intestinal Arthropathy
- Juvenile Ankylosing Spondylitis
- Hallmark ocular involvement is UVEITIS
4
Q
Spondyloarthropathies types
- … spondylitis
- … Arthropathy
- … Arthropathy
- Intestinal Arthropathy
- Juvenile Ankylosing Spondylitis
- Hallmark … involvement is UVEITIS
A
- Ankylosing spondylitis
- Psoriatic Arthropathy
- Reactive Arthropathy
- Intestinal Arthropathy
- Juvenile Ankylosing Spondylitis
- Hallmark ocular involvement is UVEITIS
5
Q
CLINICAL CHARACTERISTICS OF SPONDYLOARTHROPATHIES
- Pattern of peripheral arthritis: predominantly … limb, asymmetric
- E..
- Tendency to radiographic sacroiliitis
- Absence of rheumatoid factor / anti CCP
- Extra-articular features characteristic of the group (such as anterior uveitis)
- Significant … aggregation
- Association with HLA-…
A
- Pattern of peripheral arthritis: predominantly lower limb, asymmetric
- Enthesitis
- Tendency to radiographic sacroiliitis
- Absence of rheumatoid factor / anti CCP
- Extra-articular features characteristic of the group (such as anterior uveitis)
- Significant familial aggregation
- Association with HLA-B27
6
Q
CLINICAL CHARACTERISTICS OF SPONDYLOARTHROPATHIES
- Pattern of peripheral arthritis: predominantly lower limb, …
- Enthesitis
- Tendency to radiographic …
- Absence of … factor / anti …
- Extra-articular features characteristic of the group (such as anterior …)
- Significant familial aggregation
- Association with …-B27
A
- Pattern of peripheral arthritis: predominantly lower limb, asymmetric
- Enthesitis
- Tendency to radiographic sacroiliitis
- Absence of rheumatoid factor / anti CCP
- Extra-articular features characteristic of the group (such as anterior uveitis)
- Significant familial aggregation
- Association with HLA-B27
7
Q
… is inflammation of the …, the sites where tendons or ligaments insert into the bone
A
Enthesitis is inflammation of the entheses, the sites where tendons or ligaments insert into the bone
8
Q
Ankylosing Spondylitis - Disease Probability
- Chronic back pain - ‘inflammatory’ (requires the presence of at least four of the following)
- Age at onset less than … years
- … onset
- Improvement with …
- No improvement with …
- … pain with improvement upon getting up
- Enthesitis
- family history
- Uveitis
- Asymmetic arthritis
- Response to NSAIDs
A
- Chronic back pain - ‘inflammatory’ (requires the presence of at least four of the following)
- Age at onset less than 40 years
- Insidious onset
- Improvement with exercise
- No improvement with rest
- Night pain with improvement upon getting up
- Enthesitis
- family history
- Uveitis
- Asymmetic arthritis
- Response to NSAIDs
9
Q
Ankylosing Spondylitis - Disease Probability
- Chronic back pain - ‘inflammatory’ (requires the presence of at least four of the following)
- Age at onset less than 40 years
- … onset
- Improvement with exercise
- No improvement with rest
- Night pain with improvement upon getting up
- E…
- … history
- Uveitis
- … arthritis
- Response to …
A
- Chronic back pain - ‘inflammatory’ (requires the presence of at least four of the following)
- Age at onset less than 40 years
- Insidious onset
- Improvement with exercise
- No improvement with rest
- Night pain with improvement upon getting up
- Enthesitis
- family history
- Uveitis
- Asymmetic arthritis
- Response to NSAIDs
10
Q
Ankylosing Spondylitis - Disease Probability
- Chronic back pain - ‘inflammatory’ (requires the presence of at least … of the following)
- Age at onset less than 40 years
- Insidious onset
- Improvement with exercise
- No improvement with rest
- Night pain with improvement upon getting up
- E…
- family history
- U…
- Asymmetic arthritis
- Response to …
A
- Chronic back pain - ‘inflammatory’ (requires the presence of at least four of the following)
- Age at onset less than 40 years
- Insidious onset
- Improvement with exercise
- No improvement with rest
- Night pain with improvement upon getting up
- Enthesitis
- family history
- Uveitis
- Asymmetic arthritis
- Response to NSAIDs
11
Q
Ankylosing Spondylitis - Disease Probability
- Chronic back pain - ‘inflammatory’ (requires the presence of at least four of the following)
- Age at onset less than … years
- Insidious onset
- Improvement with …
- No improvement with …
- Night pain with … upon getting up
- Enthesitis
- family history
- Uveitis
- Asymmetic arthritis
- Response to NSAIDs
A
- Chronic back pain - ‘inflammatory’ (requires the presence of at least four of the following)
- Age at onset less than 40 years
- Insidious onset
- Improvement with exercise
- No improvement with rest
- Night pain with improvement upon getting up
- Enthesitis
- family history
- Uveitis
- Asymmetic arthritis
- Response to NSAIDs
12
Q
Imaging for Ankylosing Spondylitis diagnosis
A
Sacroiliac joint X-ray, if normal or equivocal, then CT or MRI, or HLA-B27 test
13
Q
In patients with over … months back pain, with/without peripheral manifestations and age at onset 1 SpA feature or HLA-… + plus >2 other SpA features
A
In patients with over 3 months back pain, with/without peripheral manifestations and age at onset <45 years - Sacroiliitis on imaging plus >1 SpA feature or HLA-B27 + plus >2 other SpA features
14
Q
Ankylosing Spondylitis
- Greek ‘ankylos‘- bent/crooked (fused) - ‘spondylos‘-a spinal vertebra
- Characteristically affects … adults
- Peak onset between …-… yrs
- Male:female - approximately 3:1*
A
- Greek ‘ankylos‘- bent/crooked (fused) - ‘spondylos‘-a spinal vertebra
- Characteristically affects young adults
- Peak onset between 20-30 yrs
- Male:female - approximately 3:1*
15
Q
Ankylosing Spondylitis
- Greek ‘ankylos‘- bent/crooked (fused) - ‘spondylos‘-a spinal vertebra
- Characteristically affects young adults
- Peak onset between 20-30 yrs
- Male:female - approximately ..-..*
A
- Greek ‘ankylos‘- bent/crooked (fused) - ‘spondylos‘-a spinal vertebra
- Characteristically affects young adults
- Peak onset between 20-30 yrs
- Male:female - approximately 3:1*
16
Q
Examining tenderness over sacroiliac joint
A
17
Q
… test is classically used to determine if there is a decrease in lumbar spine range of motion (flexion), most commonly as a result of ankylosing spondylitis.
A
Schober’s test is classically used to determine if there is a decrease in lumbar spine range of motion (flexion), most commonly as a result of ankylosing spondylitis.
For both versions of the test, an increase of less than 5cm is a positive test and may indicate ankylosing spondylitis (AS).
18
Q
Positive Schober’s Test
A
Less than 5cm increase in length with forward flexion: Decreased lumbar spine range of motion, ankylosing spondylitis
19
Q
The … to Wall Distance is a routine clinical test for thoracic kyphosis that has been in use for many years
A
The Occiput to Wall Distance is a routine clinical test for thoracic kyphosis that has been in use for many years
20
Q
Ankylosis of spine
A
on right
21
Q
Ankylosed sacroiliac joints
A
22
Q
Ankylosing Spondylitis - Clinical features
- Low back pain - Often the first symptom (in ~ …%).
- … pain - indicative of SI involvement. Often poorly localised and may be referred to the posterior thigh.
- Limited spinal …
- Hip and Shoulder pain- … arthritis
- Peripheral arthritis -Acute monoarthritis or oligoarthritis Mostly non-erosive and non-destructive.
- Enthesitis.
- Constitutional features- fatigue and malaise. Disturbed sleep, caused by back or joint pain at night, may contribute to fatigue
A
- Low back pain - Often the first symptom (in ~ 75%).
- Buttock pain - indicative of SI involvement. Often poorly localised and may be referred to the posterior thigh.
- Limited spinal mobility
- Hip and Shoulder pain- girdle arthritis
- Peripheral arthritis -Acute monoarthritis or oligoarthritis Mostly non-erosive and non-destructive.
- Enthesitis.
- Constitutional features- fatigue and malaise. Disturbed sleep, caused by back or joint pain at night, may contribute to fatigue
23
Q
Ankylosing Spondylitis - Clinical features
- … … pain - Often the first symptom (in ~ 75%).
- Buttock pain - indicative of SI involvement. Often poorly localised and may be referred to the posterior …
- Limited spinal mobility
- … and … pain- girdle arthritis
- Peripheral arthritis -Acute monoarthritis or oligoarthritis Mostly non-erosive and non-destructive.
- Enthesitis.
- Constitutional features- fatigue and malaise. Disturbed sleep, caused by back or joint pain at night, may contribute to fatigue
A
- Low back pain - Often the first symptom (in ~ 75%).
- Buttock pain - indicative of SI involvement. Often poorly localised and may be referred to the posterior thigh.
- Limited spinal mobility
- Hip and Shoulder pain- girdle arthritis
- Peripheral arthritis -Acute monoarthritis or oligoarthritis Mostly non-erosive and non-destructive.
- Enthesitis.
- Constitutional features- fatigue and malaise. Disturbed sleep, caused by back or joint pain at night, may contribute to fatigue
24
Q
Ankylosing Spondylitis - Clinical features
- Low back pain - Often the first symptom (in ~ 75%).
- Buttock pain - indicative of SI involvement. Often poorly localised and may be referred to the posterior thigh.
- Limited … mobility
- Hip and Shoulder pain- girdle arthritis
- Peripheral arthritis -Acute monoarthritis or oligoarthritis Mostly non-erosive and non-destructive.
- E…
- Constitutional features- … and …. Disturbed …, caused by back or joint pain at …, may contribute to …
A
- Low back pain - Often the first symptom (in ~ 75%).
- Buttock pain - indicative of SI involvement. Often poorly localised and may be referred to the posterior thigh.
- Limited spinal mobility
- Hip and Shoulder pain- girdle arthritis
- Peripheral arthritis -Acute monoarthritis or oligoarthritis Mostly non-erosive and non-destructive.
- Enthesitis.
- Constitutional features- fatigue and malaise. Disturbed sleep, caused by back or joint pain at night, may contribute to fatigue
25
Q
Ankylosing Spondylitis - Clinical features
- Low back pain - Often the first symptom (in ~ ….%).
- Buttock pain - indicative of SI involvement. Often poorly localised and may be referred to the … …
- Limited spinal mobility
- Hip and Shoulder pain- girdle arthritis
- Peripheral … -Acute … or … Mostly non-erosive and non-destructive.
- Enthesitis.
- Constitutional features- fatigue and malaise. Disturbed sleep, caused by back or joint pain at night, may contribute to fatigue
A
- Low back pain - Often the first symptom (in ~ 75%).
- Buttock pain - indicative of SI involvement. Often poorly localised and may be referred to the posterior thigh.
- Limited spinal mobility
- Hip and Shoulder pain- girdle arthritis
- Peripheral arthritis -Acute monoarthritis or oligoarthritis Mostly non-erosive and non-destructive.
- Enthesitis.
- Constitutional features- fatigue and malaise. Disturbed sleep, caused by back or joint pain at night, may contribute to fatigue
26
Q
Other organ involvement - Ankylosing Spondylitis
- Anterior … (iritis) – 40%
- … tendonitis (enthesitis)
- Aortic … (4%)
- Apical lung … (1.5%)
- A-V conduction defects (rare)
- Amyloidosis (rare)
A
- Anterior uveitis (iritis) – 40%
- Achillies tendonitis (enthesitis)
- Aortic regurgitation (4%)
- Apical lung fibrosis (1.5%)
- A-V conduction defects (rare)
- Amyloidosis (rare)
27
Q
Other organ involvement - Ankylosing Spondylitis
- … uveitis (iritis) – 40%
- Achillies … (enthesitis)
- … regurgitation (4%)
- Apical lung fibrosis (1.5%)
- A-V … defects (rare)
- …dosis (rare)
A
- Anterior uveitis (iritis) – 40%
- Achillies tendonitis (enthesitis)
- Aortic regurgitation (4%)
- Apical lung fibrosis (1.5%)
- A-V conduction defects (rare)
- Amyloidosis (rare)
28
Q
Association of HLA-B27 and Spondyloarthropathies
A
general healthy can be positive for HLA-B27 - note
29
Q
How is it diagnosed? - Ankylosing Spondylitis
- History
- Clinical examination
- Blood test (not diagnostic): ESR, …, Anaemia, HLA …
- Radiological:
- …- pelvis (SI joints and hips) and spine
- …- more sensitive and picks up changes early
- GOALS OF THERAPY:
- Symptomatic relief -Eliminate/reduce pain and stiffness.
- Restore/preserve function
- Prevent … damage
- Prevent … … - to maintain spinal mobility, and prevent development of spinal deformities
- Minimise extra-spinal and extra-articular manifestation
A
- History
- Clinical examination
- Blood test (not diagnostic): ESR, CRP, Anaemia, HLA B27
- Radiological:
- X-rays- pelvis (SI joints and hips) and spine
- MRI- more sensitive and picks up changes early
- GOALS OF THERAPY:
- Symptomatic relief -Eliminate/reduce pain and stiffness.
- Restore/preserve function
- Prevent joint damage
- Prevent spinal fusion - to maintain spinal mobility, and prevent development of spinal deformities
- Minimise extra-spinal and extra-articular manifestation
30
Q
How is it diagnosed? - Ankylosing Spondylitis
- …
- Clinical …
- Blood test (not diagnostic): …, CRP, …, HLA B27
- Radiological:
- X-rays- pelvis (SI joints and hips) and spine
- MRI- more sensitive and picks up changes early
- GOALS OF THERAPY:
- Symptomatic relief -Eliminate/reduce pain and …
- Restore/preserve …
- Prevent joint damage
- Prevent spinal fusion - to maintain spinal …, and prevent development of spinal …
- Minimise extra-spinal and extra-articular manifestation
A
- History
- Clinical examination
- Blood test (not diagnostic): ESR, CRP, Anaemia, HLA B27
- Radiological:
- X-rays- pelvis (SI joints and hips) and spine
- MRI- more sensitive and picks up changes early
- GOALS OF THERAPY:
- Symptomatic relief -Eliminate/reduce pain and stiffness.
- Restore/preserve function
- Prevent joint damage
- Prevent spinal fusion - to maintain spinal mobility, and prevent development of spinal deformities
- Minimise extra-spinal and extra-articular manifestation
31
Q
Treatment - Ankylosing Spondylitis
- … & …
- Pain relief: simple analgesics & Anti-inflammatory (NSAIDs)
- … (if peripheral joints affected)
- Steroids-oral/intra-muscular/intra-venous
- Anti-… agents
- Surgery e.g. hip replacement
- …-Osteoporosis prophylaxis
- Osteopathy, Chiropractic (any form of spinal manipulation) is not recommended.
A
- Physiotherapy & exercise
- Pain relief: simple analgesics & Anti-inflammatory (NSAIDs)
- DMARDs (if peripheral joints affected)
- Steroids-oral/intra-muscular/intra-venous
- Anti-TNF agents
- Surgery e.g. hip replacement
- DEXA-Osteoporosis prophylaxis
- Osteopathy, Chiropractic (any form of spinal manipulation) is not recommended.
32
Q
Treatment - Ankylosing Spondylitis
- Physiotherapy & exercise
- Pain relief: simple analgesics & Anti-inflammatory (…)
- DMARDs (if peripheral joints affected)
- …-oral/intra-muscular/intra-venous
- Anti-TNF agents
- Surgery e.g. … replacement
- DEXA-Osteoporosis …
- Osteopathy, Chiropractic (any form of spinal manipulation) is not recommended.
A
- Physiotherapy & exercise
- Pain relief: simple analgesics & Anti-inflammatory (NSAIDs)
- DMARDs (if peripheral joints affected)
- Steroids-oral/intra-muscular/intra-venous
- Anti-TNF agents
- Surgery e.g. hip replacement
- DEXA-Osteoporosis prophylaxis
- Osteopathy, Chiropractic (any form of spinal manipulation) is not recommended.
33
Q
NICE Guidance on use of Anti-TNF alpha agents in AS
- The patient’s disease satisfies the modified New York criteria for diagnosis of Ankylosing Spondylitis.
- A score of ≥… units on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
- and
- ≥… cm on the 0 to 10 cm spinal pain visual analogue scale (VAS).
- A score of ≥… units on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
- Conventional treatment with two or more non-steroidal anti-inflammatory drugs taken sequentially at maximum tolerated or recommended dosage for 4 weeks has failed to control symptoms.
A
- The patient’s disease satisfies the modified New York criteria for diagnosis of Ankylosing Spondylitis.•
- A score of ≥4 units on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
- and
- ≥4 cm on the 0 to 10 cm spinal pain visual analogue scale (VAS).
- A score of ≥4 units on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
- Conventional treatment with two or more non-steroidal anti-inflammatory drugs taken sequentially at maximum tolerated or recommended dosage for 4 weeks has failed to control symptoms.
34
Q
NICE Guidance on use of Anti-TNF alpha agents in AS
- The patient’s disease satisfies the modified New York criteria for diagnosis of Ankylosing Spondylitis.•
- A score of ≥4 units on the … Ankylosing Spondylitis Disease Activity Index (BASDAI)
- and
- ≥4 cm on the 0 to 10 cm spinal pain … … scale (VAS).
- A score of ≥4 units on the … Ankylosing Spondylitis Disease Activity Index (BASDAI)
- Conventional treatment with … or more non-steroidal anti-inflammatory drugs taken sequentially at maximum tolerated or recommended dosage for … weeks has failed to control symptoms.
A
- The patient’s disease satisfies the modified New York criteria for diagnosis of Ankylosing Spondylitis.•
- A score of ≥4 units on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
- and
- ≥4 cm on the 0 to 10 cm spinal pain visual analogue scale (VAS).
- A score of ≥4 units on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
- Conventional treatment with two or more non-steroidal anti-inflammatory drugs taken sequentially at maximum tolerated or recommended dosage for 4 weeks has failed to control symptoms.
35
Q
Reactive Arthritis Triad
- Common organisms:
- Chlamydia / Gonorrhoea, Shigella / Salmonella / Yersinia / Campylobacter / C.Difficile, Flu
- Cant see, cant pee, cant climb a tree…
A
- Common organisms:
- Chlamydia / Gonorrhoea, Shigella / Salmonella / Yersinia / Campylobacter / C.Difficile, Flu
- Conjunctivitis: discharge, erythema, burning, photophobia
- Urethritis: dysuria, urgency, frequency, discharge
- Arthritis: Knees, ankles, feet
36
Q
Reactive Arthritis Triad
- Common organisms:
- … / Gonorrhoea, Shigella / Salmonella / Yersinia / Campylobacter / C.Difficile, Flu
- …: discharge, erythema, burning, photophobia
- …: dysuria, urgency, frequency, discharge
- …: Knees, ankles, feet
A
- Common organisms:
- Chlamydia / Gonorrhoea, Shigella / Salmonella / Yersinia / Campylobacter / C.Difficile, Flu
- Conjunctivitis: discharge, erythema, burning, photophobia
- Urethritis: dysuria, urgency, frequency, discharge
- Arthritis: Knees, ankles, feetul
37
Q
Most common organism causing reactive arthritis
A
Chlamydia (but can be Gonorrhoea, Shigella / Salmonella / Yersinia / Campylobacter / C.Difficile, Flu)
38
Q
triad for…
A
- reactive arthritis:
- Conjunctivitis: discharge, erythema, burning, photophobia
- Urethritis: dysuria, urgency, frequency, discharge
- Arthritis: Knees, ankles, feet
39
Q
Reactive arthritis images
A
40
Q
Investigations for Reactive Arthritis
- ESR, …-… protein, FBC, Liver and Renal function, RF
- … analysis, … of affected joints
- … examination if … symptoms present
- Joint fluid Aspiration-Cell count, crystals, Gram stain & culture
- Bacterial culture of:
- Feces, Urine or urethral swab, Cervical sample, Throat
- … culture (not always necessary)
- Treatment
- Rest
- … if infection is still present
- NSAIDs
- Intra-articular/Systemic corticosteroids
- Disease modifying anti-rheumatic drugs in some cases
A
- ESR, C-Reactive protein, FBC, Liver and Renal function, RF
- Urine analysis, Radiograph of affected joints
- Ophthalmologic examination if eye symptoms present
- Joint fluid Aspiration-Cell count, crystals, Gram stain & culture
- Bacterial culture of:
- Feces, Urine or urethral swab, Cervical sample, Throat
- Blood culture (not always necessary)
- Treatment
- Rest
- Antibiotics if infection is still present
- NSAIDs
- Intra-articular/Systemic corticosteroids
- Disease modifying anti-rheumatic drugs in some cases
41
Q
Investigations for Reactive Arthritis
- …, C-Reactive protein, FBC, Liver and Renal function, RF
- Urine analysis, Radiograph of affected joints
- Ophthalmologic examination if eye symptoms present
- Joint fluid …-Cell count, crystals, Gram stain & culture
- Bacterial culture of:
- …, Urine or … swab, Cervical sample, Throat
- Blood culture (not always necessary)
- Treatment
- R…
- Antibiotics if infection is still present
- N..
- Intra-articular/Systemic …
- Disease modifying .. … drugs in some cases
A
- ESR, C-Reactive protein, FBC, Liver and Renal function, RF
- Urine analysis, Radiograph of affected joints
- Ophthalmologic examination if eye symptoms present
- Joint fluid Aspiration-Cell count, crystals, Gram stain & culture
- Bacterial culture of:
- Feces, Urine or urethral swab, Cervical sample, Throat
- Blood culture (not always necessary)
-
Treatment
- Rest
- Antibiotics if infection is still present
- NSAIDs
- Intra-articular/Systemic corticosteroids
- Disease modifying anti-rheumatic drugs in some cases
42
Q
Psoriatic Arthritis
- Arthritis may precede the onset of psoriasis / can also be … degree relative with …
- Prevalence 0.04%-0.1%
- … … is equal
- … changes have the strongest association with arthritis
- Spondyloarthropathy seen in about 5%
- Sacroiliac joint involvement can be symmetric or asymmetric
A
- Arthritis may precede the onset of psoriasis / can also be first degree relative with psoriasis
- Prevalence 0.04%-0.1%
- Sex distribution is equal
- Nail changes have the strongest association with arthritis
- Spondyloarthropathy seen in about 5%
- Sacroiliac joint involvement can be symmetric or asymmetric
43
Q
Psoriatic Arthritis
- Arthritis may … the onset of psoriasis / can also be first degree relative with psoriasis
- Prevalence …%
- Sex distribution is equal
- Nail changes have the strongest association with arthritis
- Spondyloarthropathy seen in about …%
- … joint involvement can be symmetric or asymmetric
A
- Arthritis may precede the onset of psoriasis / can also be first degree relative with psoriasis
- Prevalence 0.04%-0.1%
- Sex distribution is equal
- Nail changes have the strongest association with arthritis
- Spondyloarthropathy seen in about 5%
- Sacroiliac joint involvement can be symmetric or asymmetric
44
Q
THE MOLL AND WRIGHT CLASSIFICATION OF PSORIATIC ARTHRITIS
- Arthritis with … joint involvement predominant
- Arthritis M…
- Symmetric polyarthritis – indistinguishable from RA
- Asymmetric oligoarticular arthritis
- … spondylitis
A
- Arthritis with DIP joint involvement predominant
- Arthritis mutilans
- Symmetric polyarthritis – indistinguishable from RA
- Asymmetric oligoarticular arthritis
- Predominant spondylitis
45
Q
THE MOLL AND WRIGHT CLASSIFICATION OF PSORIATIC ARTHRITIS
- Arthritis with DIP joint involvement predominant
- Arthritis mutilans
- … polyarthritis – indistinguishable from RA
- … oligoarticular arthritis
- Predominant spondylitis
A
- Arthritis with DIP joint involvement predominant
- Arthritis mutilans
- Symmetric polyarthritis – indistinguishable from RA
- Asymmetric oligoarticular arthritis
- Predominant spondylitis
47
Q
X-ray shows what?
A
Classic ‘pencil in cup’ erosive changes - Psoriatic Arthritis
48
Q
Anti-TNF in Psoriatic Arthritis
A
49
Q
Seronegative Spondyloarthropathy Summary
A
50
Q
Which joints are diseased?
A
PIPs / DIPs
51
Q
Name the radiological appearance seen on the x-ray
A
Pencil in cup - psoriatic arthritis
52
Q
Name the pathology
A
Dactylitis
53
Q
What is vasculitis?
A
Vasculitis means inflammation of the blood vessels.
54
Q
Vasculitis Presentations
A
55
Q
Vasculitis Classification
A
56
Q
Vasculitis - Classification tree
A
57
Q
Vasculitis Case 1:
- A 64 year old man complains of general malaise and has lost 6kg in weight over six months
- Haemoptysis 9 days ago
- Purpuric rash on his legs
- BP is 165/90.
- Dipstick urinalysis showed +++blood and ++protein.
- Creatinine is 320, Hb 95 and platelets 210.
- Serology: ANCA, Anti GBM abs, Anti phospholipid screen, ANA/ENA, dsDNA / Complement, Anti streptococcal abs, RF / Anti CCP
- If the ANCA is +, what could he have?
A
- A 64 year old man complains of general malaise and has lost 6kg in weight over six months
- Haemoptysis 9 days ago
- Purpuric rash on his legs
- BP is 165/90.
- Dipstick urinalysis showed +++blood and ++protein.
- Creatinine is 320, Hb 95 and platelets 210.
- Serology: ANCA, Anti GBM abs, Anti phospholipid screen, ANA/ENA, dsDNA / Complement, Anti streptococcal abs, RF / Anti CCP
- If the ANCA is +, what could he have?
- Most likely to be GPA
BUT screen for -
- Infections: Hep B/C, N. Meningitidis
- Drug: Cocaine, Amphetamines
- Medications: NSAIDs, Abx, Thiazide Diuretics, Warfarin
- Malignancy: Lymphomas, Myeloma
- Inflammatory: RA / SLE
58
Q
Vasculitis is classified into 3 groups, which are…
A
Small, medium and large
60
Q
Examination Features - GCA
- Abnormal … Temporal Artery
- Tender
- Thickened
- Reduced/ Absent …
- … Tenderness
- Cranial Nerve …
- Vascular …
- … Pulses
A
-
Abnormal Superficial Temporal Artery
- Tender
- Thickened
- Reduced/ Absent Pulsation
- Scalp Tenderness
- Cranial Nerve Palsies
- Vascular Bruits
- Asymmetric Pulses
63
Q
ANCA positive Vasculitis Treatment
A
68
Q
Case 2 - Vasculitis
- 55 year old lady
- Proximal myalgia
- Complaining of pain and difficulty turning over in bed and combing her hair
- ESR 60
- CRP 45
- Diagnosis?
- What other diagnosis is associated with this?
- … cell …
A
- 55 year old lady
- Proximal myalgia
- Complaining of pain and difficulty turning over in bed and combing her hair
- ESR 60
- CRP 45
- What other diagnosis is associated with Polymyalgia Rheumatica?
- Giant cell arteritis
71
Q
Examination Features - GCA
- Abnormal Superficial Temporal Artery
- …
- …
- …/ … Pulsation
- Scalp …
- … Nerve Palsies
- … Bruits
- Asymmetric …
A
-
Abnormal Superficial Temporal Artery
- Tender
- Thickened
- Reduced/ Absent Pulsation
- Scalp Tenderness
- Cranial Nerve Palsies
- Vascular Bruits
- Asymmetric Pulses
72
Q
Visual Loss - GCA
- … Defect
- Afferent … Defect
- Anterior Ischaemic Optic Neuritis
- Central Retinal Artery …
- …
- Early … Review
A
- Field Defect
- Afferent Pupillary Defect
- Anterior Ischaemic Optic Neuritis
- Central Retinal Artery Occlusion
-
Diplopia
- Early Opthalmology Review
73
Q
Giant cell arteritis - May cause abnormal findings on fundoscopy:
- Central retinal artery occlusion may cause a …-spot
- Anterior ischaemic optic neuropathy may cause a … disc … (caused by inflammatory occlusion of posterior ciliary arteries and subsequent ischaemia of optic nerve)
A
- Central retinal artery occlusion may cause a cherry-spot
- Anterior ischaemic optic neuropathy may cause a Pallid disc oedema (caused by inflammatory occlusion of posterior ciliary arteries and subsequent ischaemia of optic nerve)
74
Q
Giant cell arteritis - May cause abnormal findings on fundoscopy:
- …. … artery occlusion may cause a cherry-spot
- … … optic neuropathy may cause a Pallid disc oedema (caused by inflammatory occlusion of posterior ciliary arteries and subsequent ischaemia of optic nerve)
A
- Central retinal artery occlusion may cause a cherry-spot
- Anterior ischaemic optic neuropathy may cause a Pallid disc oedema (caused by inflammatory occlusion of posterior ciliary arteries and subsequent ischaemia of optic nerve)
79
Q
This is a Temporal Biopsy sample showing ….
A
Immune cell infiltration
84
Q
PMR diagnostic criteria (Polymyalgia rheumatica)
Also - PMR is associated with …: 1/50 with … get PMR but 1/10 PMR get ….
A
- PMR is associated with GCA: 1/50 with GCA get PMR but 1/10 PMR get GCA.
85
Q
PMR diagnostic criteria (Polymyalgia rheumatica)
A
86
Q
Systemic lupus erythematosus (SLE)
- Chronic, …, … disease
- Broad spectrum of clinical features involving almost all organs and tissues
- Prevalence in the UK: … per 100,000
- …:… = 10-20:1 (GENDER)
- Peak onset between 15- 40 years
- More common and severe in those of Afro-Caribbean, India, Hispanic and Chinese origin living in USA and Europe> …
A
- Chronic, relapsing, remitting disease
- Broad spectrum of clinical features involving almost all organs and tissues
- Prevalence in the UK: 97 per 100,000
- F:M= 10-20:1
- Peak onset between 15- 40 years
- More common and severe in those of Afro-Caribbean, India, Hispanic and Chinese origin living in USA and Europe> Caucasians
87
Q
Systemic lupus erythematosus (SLE)
- …, relapsing, remitting disease
- Broad spectrum of clinical features involving almost all organs and tissues
- Prevalence in the UK: 97 per 100,000
- F:M= 10-20:1
- Peak onset between …-… years
- … common and … in those of Afro-Caribbean, India, Hispanic and Chinese origin living in USA and Europe> Caucasians
A
- Chronic, relapsing, remitting disease
- Broad spectrum of clinical features involving almost all organs and tissues
- Prevalence in the UK: 97 per 100,000
- F:M= 10-20:1
- Peak onset between 15- 40 years
- More common and severe in those of Afro-Caribbean, India, Hispanic and Chinese origin living in USA and Europe> Caucasians
90
Q
SLE PATHOPHYSIOLOGY
A
91
Q
SLE PATHOPHYSIOLOGY
A
92
Q
SLE – 2019 classification criteria
- …. positive ≥1:80
- … clinical and ≥10 points (count highest in each criterion)
A
- ANA positive ≥1:80
- One clinical and ≥10 points (count highest in each criterion)
93
Q
SLE – 2019 classification criteria
- ANA positive ≥…
- One clinical and ≥… points (count highest in each criterion)
A
- ANA positive ≥1:80
- One clinical and ≥10 points (count highest in each criterion)
94
Q
SLE
A
98
Q
SLE Principals of management
- Nonpharmacological management (… protection; … cessation; … risk modification; … prevention)
A
- Nonpharmacological management (sun protection; smoking cessation; CVD risk modification; osteoporosis prevention)
101
Q
Sjogren’s Syndrome Diagnosis
- Need …/6 criteria including one of the red criterion
A
- Need 4/6 criteria including one of the red criterion
106
Q
Spot Diagnosis
- … syndrome:
- Reynaud’s (WHITE BLUE RED)
- Telangeictasia of lips
- Tight shiny skin on finger - scelrodactyly
- Calcinosis
- Oesophageal dismotility - reflux
A
-
Crest syndrome:
- Reynaud’s (WHITE BLUE RED)
- Telangeictasia of lips
- Tight shiny skin on finger - scelrodactyly
- Calcinosis
- Oesophageal dismotility - reflux
109
Q
Systemic Sclerosis Clinical Features
- Sclerodactyly
- … phenomenon
- Heartburn
- Abnormal nailfold …
- …iectasia
- Pulmonary arterial hypertension
- … lung disease
- Lower bowel: distension / diarrhea / constipation
- Renal failure / proteinuria
- … dysfunction
A
- Sclerodactyly
- Raynaud’s phenomenon
- Heartburn
- Abnormal nailfold capillaries
- Telangiectasia
- Pulmonary arterial hypertension
- Interstitial lung disease
- Lower bowel: distension / diarrhea / constipation
- Renal failure / proteinuria
- Erectile dysfunction
110
Q
Systemic Sclerosis Clinical Features
- Sclerodactyly
- Raynaud’s phenomenon
- …
- Abnormal … capillaries
- Telangiectasia
- Pulmonary arterial …
- Interstitial lung disease
- … bowel: distension / diarrhea / constipation
- … failure / proteinuria
- Erectile dysfunction
A
- Sclerodactyly
- Raynaud’s phenomenon
- Heartburn
- Abnormal nailfold capillaries
- Telangiectasia
- Pulmonary arterial hypertension
- Interstitial lung disease
- Lower bowel: distension / diarrhea / constipation
- Renal failure / proteinuria
- Erectile dysfunction
