Musc1 Flashcards
Arthritides/Rheum
What is septic arthritis?
Infection of one or more joints caused by pathogenic bacteria
What is the aetiology of septic arthritis?
Direct bacterial inoculation
Haematogenous spread
Usually Staph aureus, or Neisseria gonorrhoea
History usually <2 weeks duration
What are the risk factors of septic arthritis?
Re-existing joint disease (RA)
Immunosuppression (DM, iatrogenic)
Prosthetic joints
IVDU
What are the signs and symptoms of septic arthritis?
Acutely inflamed tender swollen joint
Decreased range of motion
Systemically unwell
Knee most commonly affected
What are the investigations for septic arthritis?
Urgent joint aspiration -Gram stain and culture -WCC Bloods -ESR/CRP, WCC, cultures Imaging -XR, MRI
What is the management for septic arthritis?
IV ABx after aspiration
Analgesia
Consider joint washout under GA
What is gout?
Acute monoarthropathy with severe joint inflammation, secondary to deposition of monosodium urate crystals
What is the aetiology of gout?
Raised uric acid
- under excretion
- over production
What are the risk factors of gout?
Male High cell turnover rate (tumour lysis syndrome, lymphoma, psoriasis) Drugs (diuretics, aspirin, cytotoxics) Alcohol excess Purine rich diet (meat, seafood) Renal impairment
What are the symptoms of gout?
Rapid-onset severe pain- worst ever
Decreased range of motion
Most commonly affects joints in feet
First metatarsaophalangeal joint (podagra)
What are the signs of gout?
Acute swollen joint Tophi over extensor joint surfaces (elbow/knee), ear helix Can present with uric acid stones -renal tract obstruction -interstitial nephritis -radiolucent on imaging
What are the investigations of gout?
Blood
-serum uric acid (may be normal in acute attack)
Synovial fluid
-polarised light microscopy
-negatively birefringent needle-shaped crystals
XR
-soft tissue swelling and joint effusion (early)
-juxta-articular ‘punched-out’ erosions
What is the management for gout?
Acute: NSAIDs, colchicine
Chronic: Conservative and allopurinol
Why should you not give allopurinol in an acute attack of gout?
Can prolong/precipitate the attack
What is pseudogout?
Inflammation of a joint, secondary to deposition of calcium pyrophosphate crystals
What are the risk factors for pseudogout?
Elderly
Hyperparathyroidism
Haemochromatosis
Osteoarthritis
What are the symptoms and signs of pseudogout?
Very similar to gout
Commonly wrist or knee
What are the investigations for pseudogout?
Synovial fluid
-polarised light microscopy
-positively birefringent rhomboid-shaped crystals
XR
-chondrocalcinosis (eg. Ca deposition in knee cartilage)
What is reactive arthritis?
A sterile arthritis, typically affecting the lower limb 1-4 weeks after urethritis/dysentery
What is the aetiology of reactive arthritis?
Post-infectious joint inflammation Chlamydia Salmonella Campylobacter Shigella Yersinia
What are the risk factors for reactive arthritis?
Male 9:1
HLA-B27 serotype
Preceding infection
What are the symptoms of reactive arthritis?
Asymmetrical oligoarthritis
Worse in the morning
Knee most commonly affected
What are the signs of reactive arthritis?
Enthesitis (Achille's tendonitis) Conjunctivitis Mouth ulcers Circinate balanitis (ring shaped dermatitis of glans penis) Keratoderma blenorragica
What is Reiter’s syndrome?
Arthritis
Urethritis
Conjunctivitis
(Can’t see, pee, or climb a tree)
What are the investigations for reactive arthritis?
Diagnosed by process of elimination
Eg. CRP, ESR, ANA, urogenital/stool culture, arthrocentesis
What is osteoarthritis?
Mechanical degradation of cartilage and underlying bone, causing inflammation and osteophyte formation
What are the risk factors for osteoarthritis?
Age >50 Female Obese Physical/manual occupation FHx of OA
Which joints are affected in osteoarthritis?
DIP PIP Thumb CMC Knees Hips
What are the symptoms of osteoarthritis?
Pain worse on movement
Worse at the end of the day
Stiff, esp after rest
Reduced range of movement
What are the signs of osteoarthritis?
Bouchard's nodes- PIP Heberden's nodes- DIP Thumb sparing Fixed flexion deformity Crepitus Antalgic gait
What are the investigations for osteoarthritis?
Joint XR
What are the typical findings of a joint XR in a Pt with osetoarthritis?
(LOSS)
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
What is rheumatoid arthritis?
Chronic systemic inflammatory disease characterised by symmetrical deforming, peripheral polyarthritis
What is the cause of rheumatoid arthritis?
Autoimmune destruction of joints
What are the risk factors for rheumatoid arthritis?
50-60yrs Female 2:1 Smoker History of rheumatoid arthritis HLA-DR4/DR1 linked
Which joints are affected in rheumatoid arthritis?
MCPs
PIPs
No DIP involvement
What are the early signs of rheumatoid arthritis?
Joint inflammation
MCP/PIP/wrist/MTP affected
What are the late signs of rheumatoid arthritis?
Swan neck deformity Boutonniere deformity Z thumb Ulnar deviation of fingers Trigger finger
What are the extra-articular signs of rheumatoid arthritis?
Scleritis/episcleritis
Anaemia
Rheumatoid nodules
Amyloidosis
What are the investigations for rheumatoid arthritis?
Bloods
- raised CRP and ESR
- Rheumatoid factor: present in 70%
- anti-cyclic citrullinated peptide antibodies (more specific)
Imaging
-joint XR: soft tissue swelling, osteoporosis
What is amyloidosis?
A group of disorders characterised by deposition of amyloid fibrils
What are the two types of amyloidosis?
AL amyloidosis (primary) AA amyloidosis (secondary)
What is the aetiology of AL amyloidosis?
Proliferation of plasma cell clones
Monoclonal immunoglobulin formation
Fibrillar protein deposition
What are the risk factors for AL amyloidosis?
Monoclonal gammopathy of undetermined significance
Multiple myeloma
Lymphoma
What is MGUS?
A pre-multiple myeloma state, with raised paraprotein but no myeloma
What are the complications of AL amyloidosis?
Restrictive cardiomyopathy
Peripheral neuropathy
Depends on the organ affected, lots of overlap with AA amyloidosis
What is the aetiology of AA amyloidosis?
Chronic inflammation
Elevation of serum amyloid A
Fibrillar protein deposision
What are the risk factors for AA amyloidosis?
Rheumatoid arthritis
IBD
Chronic infection (TB, bronchiectasis, osteomyelitis)
What are the complications of AA amyloidosis?
Nephrotic syndrome
Hepatomegaly
Splenomegaly
Depends on the organ affected, lots of overlap with AA amyloidosis
What is the investigation for amyloidosis?
Histological biopsy of affected organ
What are spondyloarthritides?
Group of inflammatory arthritides affecting the spine and peripheral joints without production of RhF, and associated with the HLA-B27 allele
What are some common immunological features of the spondyloarthritides?
RhF negative
HLA B27 association
What are some common clinical features of the spondyloarthritides?
Axial arthritis (spine/sacroiliac involvement) Enthesitis (Achilles tendonitis/plantar fasciitis/costochondritis) Dactylitis Anterior uveitis Psoriaform rashes Oral ulcers Aortic regurgitation IBD
What are the 4 spondyloarthritides?
Ankylosing spondylitis
Psoriatic arthritis
Reactivie arthritis
Enteropathic arthropathy
What are the types of psoriatic arthritis?
Symmetrical polyarthritis Assymetrical oligoarthritis DIP predominant Spondylitis Arthritis multilans
What is the characteristic of symmetrical polyarthritis?
Rheumatoid-like
What is the characteristic of assymetrical oligoarthritis?
Typically hands and feet
What is the characteristic of DIP predominant?
High incidence of nail changes
What is the characteristic of spondylitis?
Spine and sacroiliac involvement
What is the characteristic of arthritis multilans?
Severe deformity
Telescoping fingers
What are the common nail changes seen in psoriatic arthritis?
Pitting
Onycholysis
Subungal hyperkeratosis
What is ankylosing spondylitis?
Chronic progressive inflammatory arthropathy of the spine and sacroiliac joints
What are the risk factors for ankylosing spondylitis?
Male 2.5:1
Age <30yrs
FHx of AnkSpon
HLA-B27 +ve
What are the symptoms of ankylosing spondylitis?
Midline back pain
Worse in the morning
Better with exercise
Insidious onset >3 months
What are the signs of ankylosing spondylitis?
Progressive loss of spinal movement
Sacroiliac tenderness
What test can you do to identify ankylosing spondylitis?
Schober’s test
Mark two points on the spine
The distance between the two should be >5cm upon leaning forwards
What are the investigations for ankylosing spondylitis?
Pelvic XR Sacroiliitis Vertebral body sparing Syndesmophytes Bamboo sign MRI- more sensitive and better at detecting early disease
A 25 year old female presents to A&E with a 2 day history of pain in right knee. She is an intravenous drug user, with no other significant past medical history.
On examination: Red, hot and swollen right knee with a reduced range of movement. The patient is febrile (38.5 ͦ C).
Blood tests have been sent and the patient is stable.
What is the next most appropriate course of action?
A. Request review by orthopaedic surgeon B. MRI knee C. X-ray of the knee D. Start broad-spectrum IV antibiotics E. Aspirate the joint effusion
E. Aspirate the joint effusion
Important to aspirate the joint before giving antibiotics in septic arthritis if patient stable to improve ability to grow and thus detect causative pathogen.
Ortho r/v should occur prior to aspiration in a patient with a prosthetic joint, as arthrocentesis should not occur outside of sterile environment.
MRI may show associated osteomyelitis, but not appropriate at this stage.
A 54 year old man presents to A&E with severe pain in his left foot. The pain started suddenly 45 minutes ago. He denies any trauma, and has only recently been discharged following treatment for pneumonia.
On examination: Red, hot and swollen metatarsophalangeal joint. His basic observations are normal.
Bloods: ↑WCC, ↑CRP, uric acid normal
Joint aspiration: Needle-shaped negatively birefringent crystals
What is the most likely diagnosis?
A. Gout B. Pseudogout C. Septic arthritis D. Reactive arthritis E. Osteomyelitis
A. Gout
“Worst pain I’ve ever had doctor”
Most likely to be gout, given the severity & rapid-onset of the pain, and the joint involvement pattern (MTP). Dehydration often predisposes to gout – in this case the recent pneumonia likely contributed to this.
A 21 year old man presents with a 3 week history of a painful, hot, swollen right knee. He denies trauma or fever. He also complains of pain in his left heel. He was treated for a chlamydia infection 6 weeks ago.
What is the most likely diagnosis?
A. Gout B. Pseudogout C. Septic arthritis D. Reactive arthritis E. Rheumatoid arthritis
D. Reactive arthritis
A 56 year old woman presents with pain and stiffness of her hands. This pain is particularly bad at the end of the day. She has occasionally dropped things, and thinks her grip has become worse. She is taking regular over the counter analgesia.
On examination you find Bouchard’s and Heberden’s nodes.
What is the most likely diagnosis?
A. Rheumatoid arthritis B. Osteoarthritis C. Reactive arthritis D. Psoriatic arthritis E. Systemic sclerosis
B. Osteoarthritis
Osteoarthritic hands – Heberden’s (Distal interphalangeal joints) and Bouchard’s nodes (proximal interphalangeal joints).
History of pain and stiffness in hands at the end of the day is classic for OA.
A 67 year old woman presents with pain, swelling and stiffness of her left knee. This pain is particularly bad after walking the dog.
On examination there is swelling of the left knee and a reduced range of movement. She has an antalgic gait.
What is the most likely diagnosis?
A. Rheumatoid arthritis B. Osteoarthritis C. Reactive arthritis D. Psoriatic arthritis E. Systemic sclerosis
B. Osteoarthritis
Antalgic gait develops as a way to avoid pain while walking (A shortened stance phase in painful limb)
Image is a weight bearing AP plain radiograph of knees. This shows a right-sided total knee replacement and features of osteoarthritis in the left knee. These can be remembered as LOSS:
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
A 55 year old woman presents with painful and swollen joints in her hands. Her hands are stiff for over an hour after waking every morning. She is taking regular over the counter analgesia.
On examination you note a swan neck deformity and Boutonniere deformity.
What test is the most specific for the likely diagnosis?
A. Erythrocyte sedimentation rate B. C-reactive protein C. Rheumatoid factor D. Anti-cyclic citrullinated peptide E. Anti-nuclear antibody
D. Anti-cyclic citrullinated peptide
Rheumatoid hands. Swan neck deformity of index finger. Boutonniere deformity of middle finger.
Anti-CCP is most specific test for RA. RF is a useful test in RA, though is less specific than anti-CCP. ANA is commonly associated with systemic lupus erythematosus. ESR and CRP are general markers of inflammation.
A 60 year old woman presents with painful and swollen joints in her hands. Her hands are stiff in the mornings and after periods of rest. The stiffness eases with activity.
On examination:you note DIP swelling in the right hand, alongside some onycholysis and pitting.
What is the most likely diagnosis?
A. Rheumatoid arthritis B. Osteoarthritis C. Reactive arthritis D. Psoriatic arthritis E. Systemic sclerosis
D. Psoriatic arthritis
Asymmetrical oligoarthropathy, with involvement of the distal interphalangeal joints. Nail changes are present (pitting & onycholysis). Around 10-20% percent of patients with skin lesions develop an arthropathy. Arthritis can present before skin changes.
A 29 year old man presents to the GP with lower back pain and stiffness for the last 3 months. His symptoms are worse in the morning and improve with exercise. He also complains of a painful Achilles tendon when walking. You note that he last attended the practice 1 month ago with a red eye.
What is the most likely diagnosis?
A. Spinal stenosis B. Multiple myeloma C. Ankylosing spondylitis D. Reactive arthritis E. Polymyalgia rheumatica
Ankylosing spondylitis
Most likely diagnosis is ankylosing spondylitis – Inflammatory sounding back pain (worse in morning eases on exercise) + Red eye = iritis, Achilles tendonitis = enthesitis
Spinal stenosis – Classically causes neurogenic claudication (Pain and weakness of calves and thighs when walking), may also have numbness or parasthesia
Multiple myeloma - Common cause of lower back pain in ELDERLY. Features are remembered as CRAB: Hypercalcaemia, Renal injury, Anaemia, Bone pain.
