Musculoskeletal Flashcards
1
Q
What is ankylosing spondylitis?
A
Chronic progressive seronegative inflammatory arthropathy affecting preferentially the axial skeleton and large proximal joints
2
Q
Summarise the epidemiology of ankylosing spondylitis
A
Common
2.5:1 M:W
2nd decade of life
3
Q
Explain the aetiology of ankylosing spondylitis
A
Unknown
Strong association with HLA-B27 gene (>90% of cases HLA-B27 positive)
Hypothesised infective triggers and antigen cross-reactivity with self-peptides
4
Q
What are the risk factors for ankylosing spondylitis?
A
HLA-B27
Endoplasmic reticulum aminopeptidase 1 (ERAP1) and interleukin 23 receptor (IL23R) genes
FHx
5
Q
What are the presenting symptoms of ankylosing spondylitis?
A
Lower back and sacroiliac pain: worse in morning/rest, better w activity
Disturbed sleep
Progressive loss of spinal movement
Asymmetrical peripheral arthritis
Pleuritic chest pain (costovertebral joint involvement)
Heel pain (plantar fasciitis)
Non-specific: malaise, fatigue
6
Q
What are the signs of ankylosing spondylitis O/E?
A
Reduced range of spinal movement (esp hip rotation)
Reduced lateral spinal flexion
Schober’s test: reduced increase in space between fingers <5cm
Tenderness over sacroiliac joints
Later stages:
Thoracic kyphosis
Spinal fusion
Question mark posture
7
Q
What are the signs of extra-articular disease in ankylosing spondylitis?
A
5 As: Anterior uveitis Apical lung fibrosis Achilles tendonitis Amyloidosis Aortic regurgitation
8
Q
How can ankylosing spondylitis be investigated?
A
Bloods:
FBC - anaemia of chronic disease
Rheumatoid factor -ve
ESR/CRP - high
Radiographs:
Anteroposterior and lateral of spine - bamboo spine
Anteroposterior of sacroiliac joints - symmetrical blurring of joint margins
Later stages - erosions, sclerosis, sacroiliac joint fusion
CXR - apical lung fibrosis
Lung function tests:
assess mechanical ventilatory impairment due to kyphosis
9
Q
What is carpal tunnel syndrome?
A
The symptom complex brought on by compression of the median nerve in the carpal tunnel
10
Q
Explain the aetiology of carpal tunnel syndrome
A
Symptoms caused by median nerve compression as it runs through the carpal tunnel
Usually idiopathic
May be secondary to:
- Tenosynovitis (eg in rheumatoid arthritis)
- Infiltrative disease of canal/increased soft tissue (eg amyloidosis, acromegaly)
- Bone involvement in wrist (eg OA, fracture)
- Fluid retention states (eg pregnancy, nephrotic syndrome)
- Obesity, menopause, DM
11
Q
What are the risk factors for carpal tunnel syndrome?
A
> 30 High BMI Female Fractured wrist/carpal bones Rheumatoid arthritis DM Dialysis Pregnancy
12
Q
What are the presenting symptoms of carpal tunnel syndrome?
A
Tingling pain in hand and fingers
Numbness
Weakness and clumsiness of hand
Worse at night
13
Q
What are the signs of carpal tunnel syndrome O/E?
A
Sensory impairment in median nerve distribution (thumb, finger 1, finger 2 and half of finger 3)
Weakness and wasting of thenar eminence
Tinel’s sign - tapping carpal tunnel causes symptoms
Phalen’s test - flexion of wrist for 1 min may cause symptoms
Signs of underlying cause - acromegaly, hypothyroidism
14
Q
How can carpal tunnel syndrome be investigated?
A
- EMG - focal slowing of conduction velocity; prolongation of median distal motor latency; possible decreased amplitude of median sensory and/or motor nerves
- US/MRI wrist if SOL suspected, e.g. ganglion cyst
15
Q
What is fibromyalgia?
A
A condition characterised by chronic widespread pain and a heightened pain response to pressure
16
Q
Summarise the epidemiology of fibromyalgia
A
F:M = 6:1
Undiagnosed in 75% of affected people
17
Q
Explain the aetiology of fibromyalgia
A
- Cause unknown
- Genetic + environmental factors
- Runs in families, many genes involved
- Environmental factors: psychological stress, trauma, certain infections
- Pain appears to result from processes in CNS
18
Q
What are the risk factors for fibromyalgia?
A
FHx
Rheumatological conditions
20-60yo
Female
19
Q
What are the presenting symptoms of fibromyalgia?
A
Chronic pain >3/12 Widespread (L+R, above+below waist + axial skeleton) Profound fatigue Unrefreshing sleep Significant fatigue and pain w/small increases in physical exertion Headaches Numbness/tingling Stiffness
20
Q
What are the signs of fibromyalgia O/E?
A
Diffuse tenderness on examination
Sensitivity to sensory stimuli - bright lights, odours, noises
21
Q
How is fibromyalgia investigated?
A
Clinical diagnosis:
Presence of chronic (>3 months), widespread body pain in muscles and joints, plus at least 11 of 18 tender points
ESR/CRP - normal (?inflamm) TFT - normal (?hypo) FBC - normal (?anaemia, iron deficiency) RF - normal (?RA) Anti-cyclic citrullinated protein antibody - normal (?RA) ANA - normal (?SLE) Vitamin D - normal
22
Q
What is giant cell arteritis?
A
A granulomatous vasculitis of large and medium-sized arteries
Primarily affects branches of the external carotid artery
23
Q
Summarise the epidemiology of giant cell arteritis
A
> 50s Incidence rises steadily after age 50 Highest between 70-80 Women 2-4x more than men Northern Europe > Southern Europe Whites > Blacks
24
Q
Explain the aetiology of giant cell arteritis
A
Exact cause unknown
Genetic + environmental factors
Genetic polymorphisms in HLA-DRB104 and DRB101 alleles predispose
Infectious agents - Mycoplasma pneumoniae, parvovirus B19, parainfluenza virus, Chlamydia pneumoniae, VZV
25
What are the risk factors for giant cell arteritis?
> 50
Female
Live in N Europe/N European ancestry
Women: smoking, atherosclerosis
26
What are the presenting symptoms of giant cell arteritis?
```
Subacute onset (few weeks)
Headache in temporal/occipital areas
Scalp tenderness
Jaw claudication
Blurred vision
Sudden blindness in one eye
Systemic: malaise, low-grade fever, lethargy, weight loss, depression
Symptoms of polymyalgia rheumatica: early morning pain and stiffness of muscles of shoulder + pelvic girdle
```
27
What are the signs of giant cell arteritis O/E?
Swelling and erythema overlying temporal artery
Scalp and temporal tenderness
Thickened non-pulsatile temporal artery
Reduced visual acuity
Stiff neck, shoulders, hips, and proximal extremities
Swelling of distal joints
28
How is giant cell arteritis investigated?
Bloods:
- High ESR > 50
- High CRP
- FBC - normochromic, normocytic anaemia of chronic disease - normal WCC, elevated platelets, mild leukocytosis
- LFTs: elevated transaminases, ALP
Temporal artery biopsy IMMEDIATELY:
- within 48h of starting corticosteroids
- -ve biopsy doesn't exclude GCA
- granulomatous inflammation
- multinucleated giant cells
29
How is giant cell arteritis managed?
Prednisolone IMMEDIATELY to prevent vision loss
Aspirin
Osteoporosis prevention: calcium carbonate + ergocalciferol + alendronic acid
Tocilixumab/methotrexate
30
What are the possible complications of giant cell arteritis?
Carotid artery aneurysm
Aortic aneurysm
Thrombosis
Embolism to ophthalmic artery --> visual disturbance and loss of vision
31
What is the prognosis of giant cell arteritis?
Lasts around 2 years before complete remission
32
What is gout?
A disorder of uric acid metabolism causing recurrent bouts of acute arthritis caused by deposition of monosodium urate crystals in joints, and also soft tissues and kidneys
33
Summarise the epidemiology of gout
10x more common in males
V rare pre-puberty
Rare in pre-menopausal women
More common in higher social classes
34
What can precipitate an acute attack of gout?
```
Trauma
Infection
Alcohol - red wine
Starvation
Seafood
Introduction/withdrawal of hypouricaemic agents
```
35
What are the risk factors for gout?
M 40-60
F 50-70
Male
Post-menopausal women
Meat, seafood alcohol
Thiazide + loop diuretics
Ciclosporin + tacrolimus (increased tubular reabsorption of urate, decreased glomerular filtration + interstitial nephropathy)
Pyarzinamide (increased urate re-abs)
Aspirin (increase urate)
HPRT/PRPP/G6PD deficiency (over produce urate)
High cell turnover state - haem malignancy, myeloproliferative disorders, psoriasis, chemo
36
Explain the aetiology of gout
Hyperuricaemia due to renal under-excretion of urate (90%) or over-production (10%) or both
37
What are the presenting symptoms of gout?
```
Sudden excruciating monoarticular pain
Usually affects metatarsophalangeal joint of great toe (podagra)
Symptoms peak at 24h
Resolve over 7-10 days
Attacks often recurrent
Symptom-free between attacks
```
38
How is gout investigated?
Synovial fluid aspirate:
- monosodium urate crystals present- needle-shaped, -ve birefringence under polarised light microscopy
- WCC > 2 x10^9
Bloods:
FBC - raised WCC
Uric acid high > 416 micromol/L M/360 W
XR/US of joint:
Periarticular erosions
Tophi
Double contour line
AXR/KUB film
Uric acid renal stones
39
What is osteoarthritis?
Age-related degenerative joint disease when cartilage destruction exceeds repair, causing pain and disability
40
Summarise the epidemiology of osteoarthritis
Common
25% of those over 60
More common in females, caucasians and asians
41
Explain the aetiology of osteoarthritis
Synovial joint cartilage destruction
Eventually, loss of joint volume due to altered chondrocyte activity
Patchy chronic synovial inflammation
Fibrotic thickening of joint capsules
Primary - unknown aetiology, multifactorial
Secondary - other disease lead to altered joint architecture and stability
42
What are the risk factors for osteoarthritis?
```
> 50
Female
Obesity
FHx
Manual occupation
Knee malalignment
```
43
What are the presenting symptoms of osteoarthritis?
```
Joint pain and discomfort, use-related
Stiffness or gelling after inactivity
Difficulty with certain movements
Feel unstable
Restriction walking, climbing stairs and doing manual tasks
No systemic features
```
44
What are the signs of osteoarthritis O/E?
```
Local joint tenderness
Bony swellings along joint margins:
Heberden's nodes: distal IPJ
Bouchard's nodes - proximal IPJ
Crepitus and pain during joint mvmt
Joint effusion
Restriction of range of joint mvmt
```
45
How is osteoarthritis investigated?
Joint XR:
1. Loss of joint space (narrowing)
2. Osteophytes
3. Subchondral cysts
4. Subchondral sclerosis
46
What are the secondary causes of osteoarthritis?
- developmental abnormalities, eg hip dysplasia
- trauma, eg previous fractures
- inflamm eg rheumatoid arthritis, gout, septic arthritis
- metabolic - haemochromatosis, acromegaly
47
What is osteomyelitis?
Infection of the bone leading to inflammation, necrosis and new bone formation
Can be acute, subacute or chronic
48
Summarise the epidemiology of osteomyelitis
Mostly in young children
| <20% cases in adults
49
Explain the aetiology of osteomyelitis
Causative organisms:
Staphylococcus aureus
Group A Streptococcus
50
What are the risk factors for osteomyelitis?
```
Penetrating injuries - open fracture
Surgical contamination
IV drug misuse
DM
Immunosuppression
Prosthesis
SCA
Peridontitis
```
51
What are the presenting symptoms of osteomyelitis?
```
Pain in affected area
Fever
Malaise
Rigors
Hx of preceding skin lesion, sore throat, trauma or operation
```
52
What are the signs of osteomyelitis O/E?
```
Localised erythema
Tenderness
Swelling
Warmth
Painful/limited mvmt of affected limb
Seropurulent discharge from associated wound/ulcer
```
53
How is osteomyelitis investigated?
Bloods:
FBC - raised WCC
ESR - raised
CRP - raised
```
XR of affected area:
Osteopenia
Bone destruction
Cortical breaches
Periosteal reaction
```
54
What is polymyalgia rheumatica?
An inflammatory condition of unknown cause, which is characterised by severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle
Does NOT cause weakness
55
Summarise the epidemiology of polymyalgia rheumatica
Relatively common
> 50s
Peak age of onset = 73
3x more common in females
56
Explain the aetiology of polymyalgia rheumatica
Unknown
Genetic + env factors
Associated w temporal arteritis
57
What are the risk factors for polymyalgia rheumatica?
>50
Giant cell arteritis
Female
58
What are the usual inclusion criteria for polymyalgia rheumatica?
```
Non-specific
Usual inclusion criteria:
>50
Symptoms > 2 weeks
Bilateral shoulder or pelvic girdle aching, or both
Morning stiffness > 45 minutes
High ESR/CRP
```
No weakness
Symptoms worst when walking
Difficulty getting out of bed/raising arms to brush hair
59
How is polymyalgia rheumatica investigated?
High ESR
High CRP
FBC
US - bursitis, joint effusions
60
How is polymyalgia rheumatica managed?
Initial:
Corticosteroid - prednisolone
Ca + vit D + bisphosphonate - alendronic acid + cholecalciferol + calcium carbonate
NSAID - naproxen/ibuprofen
61
What are the possible complications of polymyalgia rheumatica?
Chronic relapsing PMR
Secondary to corticosteroids:
- increased risk of infection
- osteoporosis
- DMII
- HTN
- muscle weakness
- cataracts, glaucoma
- skin changes
GCA
62
What is the prognosis of polymyalgia rheumatica?
Overall prognosis is good
Relapses are common
Tx for 2-3 years
Increased risk of relapse: female, high ESR > 40, peripheral arthritis
63
What are polymyositis and dermatomyositis?
Connective tissue diseases characterised by inflammation of muscles
64
Summarise the epidemiology of polymyositis and dermatomyositis
Polymyositis 30-60yo
Dermatomyositis any age: peak 5-10 and 50
Both 2x more common in females
65
Explain the aetiology of polymyositis and dermatomyositis
Autoimmune basis
| Viral infection
66
What are the presenting symptoms of polymyositis?
Inflammatory myopathy with onset over weeks or months
Steady progression
Diffuse weakness in proximal muscles:
- difficulty rising from low chair, stairs, lifting objects, brushing hair
- fatigue, myalgia, muscle cramps
67
What are the presenting symptoms of dermatomyositis?
Inflammatory myopathy
Onset over weeks or months
RASH
Systemic upset w fever, arthralgia, malaise, weight loss
Possible cardiac disease - conduction blocks, tachyarrhythmia
GI ulcers and infections
Interstitial lung disease
Kids have more non-muscular features
68
What are the signs of polymyositis O/E?
```
Muscle weakness
Not painful
Proximal myopathy
Extra-ocular muscles and distal muscles spared
Weak forced flexion of neck
Muscular atrophy
Muscles may be tender on palpation
```
69
What are the signs of dermatomyositis O/E?
RASH characteristics:
- blue-purple discolouration of the upper eyelids with periorbital oedema
- flat red rash involving the face and upper trunk
- raised purple-red scaly patches over extensor surfaces of joints and fingers
- rash may affect knees, shoulders, back and upper arms
- rash may be exacerbated by sunlight
- proximal myopathy
- muscle pain and tenderness in early disease
70
How is polymyositis investigated?
```
CK - 50x higher
Electromyography
Muscle biopsy - definitive test
Autoantibodies - eg myositis specific antibody, anti-Jo-1 antibody
Enzymes - eg SGOT, SGPT, LDH
```
71
How is dermatomyositis investigated?
```
CK
Enzymes - SGOT, SGPT, LDH raised
Autoantibodies - ANA, anti-mi-2, anti-jo-1
EMG - may be normal though
Muscle biopsy
```
72
What is reactive arthritis?
Characterise by a sterile arthritis occurring after an extra-articular infection (commonly GI or urogenital)
73
Summarise the epidemiology of reactive arthritis
20x more common in males
| 20-40 years
74
Explain the aetiology of reactive arthritis
Associated with infections:
GI - salmonella, shigella, yersinia, campylobacter
Urogenital - chlamydia trachomatis
Initial activation of immune system by microbial antigen followed by autoimmune reaction that involves skin, eyes, and joints
HLA-B27 allele in 70-80% of patients
75
What are the risk factors for reactive arthritis?
Male
HLA-B27
Preceding chlamydial or GI infection
76
What are the presenting symptoms of reactive arthritis?
3-3 days after infection
Constitutional: fever, fatigue, weight loss
Enthesitis: heel pain
Mouth ulcers
Rash on soles or palms (keratoderma blenorrhagica)
Burning or stinging when passing urine (urethritis)
Arthritis
Low back pain (sacroiliitis)
Conjunctivitis
77
What are the signs of reactive arthritis O/E?
```
Asymmetrical oligoarthritis
Lower extremities
Sausage-shaped digits
Anterior uveitis
Oral ulceration
Circinate balanitis
Keratoderma blenorrhagica
```
78
Identify the appropriate investigations for reactive arthritis
```
ESR: raised
CRP: raised
ANA: -ve
RF: -ve
Urogenital and stool cultures: -ve
XR: sacroiliitis or enthesopathy
Arthrocentesis w synovial fluid analysis: -ve
```
79
What is rheumatoid arthritis?
Chronic inflammatory systemic disease characterised by symmetrical deforming polyarthritis and extra-articular manifestations
80
Summarise the epidemiology of rheumatoid arthritis
Common
1% of general population
3x more common in females
Peak incidence = 30-50yo
81
Explain the aetiology of rheumatoid arthritis
```
Autoimmune
Unknown cause
Associated w other AI diseases, eg Sjogren's
HLA-DR1
HLA-DR4
```
82
What are the presenting symptoms of rheumatoid arthritis?
```
Gradual onset
Joint pain
Swelling
Morning stiffness
Impaired function
Usually affects peripheral joints symmetrically
Systemic: fever, fatigue, weight loss
```
83
What are the signs of rheumatoid arthritis O/E?
Arthritis - most common in hands
Early signs:
- spindling of fingers
- swelling of MCP and PIP joints
- warm, tender joints
- reduction in ROM
Late signs:
- symmetrical deforming arthropathy
- ulnar deviation of fingers due to subluxation of MCP joints
- radial deviation of wrist
- swan neck deformity
- Boutonniere deformity
- Z deformity of thumb
- trigger finger
- tendon rupture
- wasting of small muscles of hand
- palmar erythema
- rheumatoid nodules
84
What are the appropriate investigations for rheumatoid arthritis?
RF: +ve
Anti-cyclic citrullinated peptide antibody: +ve
Radiographs: erosions
85
What are the risk factors for rheumatoid arthritis?
Genetic predisposition
86
What is sarcoidosis?
Multisystem chronic granulomatous inflammatory disorder
87
Summarise the epidemiology of sarcoidosis
Most common in Africans and Scandinavians
| >50
88
Explain the aetiology of sarcoidosis
```
Unknown
Transmissible agents (eg viruses), environmental triggers and genetic factors
```
Unknown antigen presented on MHCII complexes on macrophages to CD4+ T-cells
These accumulate and release cytokines
Leads to formation of non-caseating granulomas in organs
89
What are the risk factors for sarcoidosis?
20-40yo
FHx
Scandinavian
Female
90
What are the presenting symptoms and signs of sarcoidosis?
General: fever, malaise, weight loss, bilateral parotid swelling, lymphadenopathy, hepatosplenomegaly
Pulmonary: breathlessness, dry cough, chest discomfort, minimal clinical signs
Musculoskeletal: bone cysts (eg dactylitis), polyarthralgia, myopathy
Eye: keratoconjunctivitis sicca, uveitis, papilloedema
Skin: lupus pernio, erythema nodosum, maculopapular eruptions
Neuro: lymphocytic meningitis, SOLs, pituitary infiltration, cerebellar ataxia, CN palsies, peripheral neuropathy
Cardiac: arrhythmia, BBB, pericarditis, cardiomyopathy, congestive HF
91
What are the appropriate investigations for sarcoidosis?
Lung involvement
CXR - hilar and/or paratracheal adenopathy w upper lobe predominant, bilateral infiltrates; pleural effusions (rare), egg shell calcifications (very rare)
Lung function tests - restrictive/obstructive/mixed pattern
Splenic/BM involvement:
FBC - anaemia, leukopenia
Renal involvement:
Urea - elevated
Creatinine - elevated
Hepatic involvement:
LFTs - AST and ALT elevated
Cardiac involvement:
ECG - conduction defects
Serum Ca - elevated
Purified protein derivative of tuberculin (PPD) - -ve
92
What is septic arthritis?
The infection of 1 or more joints caused by pathogenic inoculation of microbes
93
Summarise the epidemiology of septic arthritis
Developed countries incidence = 6/100,000/yr
| Underlying joint disease x10 = 70/100,000/yr
94
Explain the aetiology of septic arthritis
Caused by pathogenic inoculation of micro-organisms into the joint, either directly or by the haematogenous route
Predominant causative organisms = staphylococci, streptococci
95
What are the risk factors for septic arthritis?
```
Underlying joint disease - RA, osteoarthritis, crystal arthritides
Joint prostheses
IVD abuse
DM
Cutaneous ulcers
```
96
What are the presenting symptoms and signs of septic arthritis?
Hot, swollen, tender, restricted joint
Prosthetic joint
Short Hx of symptoms <2 weeks
Fever
97
What are the appropriate investigations for septic arthritis?
Synovial fluid Gram stain and culture: MO present, culture reveals organism
Synovial fluid WCC: >100,000 sepsis
Blood culture: MO present, culture
WCC: elevated
ESR: elevated
CRP: elevated
Radiograph: degenerative changes, chondrocalcinosis
US: effusion, to guide aspiration
98
What is Sjögren syndrome?
Chronic inflammatory and auto-immune disorder characterised by diminished lacrimal and salivary gland secretion (sicca complex)
99
Summarise the epidemiology of Sjögren syndrome
Most common systemic AI rheumatic disease
F:M = 9:1
Population prevalence = 0.5-1.5%
60% have disease secondary to RA, SLE, or scleroderma
2 age peaks: 20s-30s and after menopause (mid 50s)
100
Explain the aetiology of Sjögren syndrome
Lymphocytic infiltration into lacrimal and salivary glands
Genetic associations: HLA-B8, HLA-DR3
```
Associated AI diseases:
RA
Scleroderma
SLE
Polymyositis
Organ-specific AI disease - PBC, AI hepatitis, myasthenia gravis
```
101
What are the risk factors for Sjögren syndrome?
```
Female
SLE
Rheumatoid arthritis
Systemic sclerosis - scleroderma
HLA class II markers (A1, B8, DR3/DQ2)
20s-30s + after menopause
```
102
What are the presenting symptoms of Sjögren syndrome?
```
Fatigue
Dry eyes
Dry mouth
Fever
Weight loss
Depression
Dry cough, recurrent sinusitis
Dry skin or hair
Dry vagina --> dyspareunia
```
103
What are the signs of Sjögren syndrome O/E?
Keratoconjunctivitis sicca
Xerostomia
Parotid or salivary gland enlargement
104
What are the appropriate investigations for Sjögren syndrome?
Schirmer's test - quantitively measures tears: +ve (<5mm wet after 5 minutes)
anti-60 kD (SS-A) Ro and anti-La (SS-B): +ve
105
What is radiculopathy?
AKA pinched nerve
Set of conditions in which one or more nerves are a
106
Summarise the epidemiology of radiculopathy
F > M
| Cervical > lumbar
107
Explain the aetiology of radiculopathy
Mechanical compression of a nerve root usually at the exit foramen or lateral recess
May be secondary to degenerative disc disease, OA, facet joint degeneration/hypertrophy, ligamentous hypertrophy, spondylolisthesis
108
What are the risk factors for radiculopathy?
```
Degenerative disc disease
Osteoarthritis
Facet joint degeneration/hypertrophy
Ligamentous hypertrophy
Spondylolisthesis
Radiation
DM
Neoplastic disease
Lyme meningitis
Aseptic meningitis
```
109
What are the presenting symptoms of radiculopathy?
Sharp pain in back, arms, legs or shoulders
May worsen with certain activities - coughing, sneezing
Weakness or loss of reflexes in arms or legs
Numbness of skin "pins and needles" or other abnormal sensations in arms or legs
110
What are the appropriate investigations for radiculopathy?
Neuro exam to identify affected nerve root
XR/CT/MRI
Nerve conduction studies
111
What is spondylosis?
The degeneration of the spinal column from any cause
112
Summarise the epidemiology of spondylosis
Elderly people
113
Explain the aetiology of spondylosis
Caused by years of constant abnormal pressure, caused by joint subluxation, stress induced by sports, acute and/or repetitive trauma, or poor posture, being placed on the vertebrae and discs between them
Abnormal stress causes new bone formation to compensate for new weight distribution
114
What are the presenting symptoms of spondylosis?
Lhermitte sign: feeling of electric shock w neck flexion
115
What are the signs of spondylosis O/E?
Reduced ROM in neck
| Lhermitte sign: feeling of electric shock w neck flexion
116
What are the appropriate investigations for spondylosis?
Cervical compression test: laterally flex patient's head and place downward pressure on it
- neck or shoulder pain on ipsilateral side = +ve result
MRI, CT
117
Summarise the epidemiology of systemic sclerosis
Age of onset = 30-60
Peak incidence in 5th decade
5x more common in females
88/million in England
118
Explain the aetiology of systemic sclerosis
Unknown
Genetic and environmental factors
Pathogenesis unclear
Activated monocytes, macrophages and lymphocytes may interact with:
- endothelial cells --> endothelial cell damage, platelet activation, BV narrowing
- fibroblasts --> lay down collagen in dermis
119
What are the risk factors for systemic sclerosis?
FHx
| Immune dysregulation - eg positive ANA
120
What are the presenting symptoms of systemic sclerosis?
```
Cold hands
Finger ulcers
Hand/foot swelling
Skin thickening
Can't grip objects
Heartburn, reflex, dysphagia
Bloating
Faecal incontinence
Arthralgia, myalgia
Difficulty breathing
Fatigue
Dry cough
Decreased exercise tolerance
```
121
What are the signs of systemic sclerosis O/E?
```
Secondary Raynaud's phenomenon
Digital pits or ulcers
Skin thickening:
diffuse cutaneous - proximal to elbows + anterior chest + abdo
limited cutaneous - distal to elbows + knees
both - face
Loss of function of hands
Sclerodactyly
Abnormal nail-fold capillaroscopy
Telangiectasia - fingers, palms, face, mucous membranes
Subcutaneous calcinosis
Dry crackles at lung bases
```
122
What are the appropriate investigations for systemic sclerosis?
Serum auto-antibodies: +ve ANA
FBC: normal/microcytic anaemia w chronic GI bleed/micro-angiopathic haemolytic anaemia w scleroderma renal crisis
Ur, Cr: normal/elevated w scleroderma renal crisis
ESR: normal/elevated
CRP: elevated in severe disease
Urine microscopy: normal/mild proteinuria w few cells or casts in renal crisis
Lung function tests: interstitial lung disease - decreased FVC and DLCO + restrictive pattern/pulmonary HTN - disproportionate drop in DLCO vs FVC
ECG: normal/arrhythmias
Echocardiogram: pulmonary HTN - rise in RVSP/pericardial effusion or RV/LV diastolic dysfunction
CXR: normal/bi-basilar interstitial infiltrates/cardiomegaly/RHF
Barium swallow: diminished oesophageal peristalsis and gastroparesis/diminished muscle tone in lower oesophagus/reflux of barium/strictures
123
What is pre-scleroderma?
Raynaud's phenomenon
Nail-fold capillary changes
Antinuclear antibodies
124
What is diffuse cutaneous systemic sclerosis?
```
Raynaud's phenomenon
Followed by skin changes w truncal involvement
Tendon friction
Joint contracture
Early lung disease
Heart, GI and renal disease
Nail-fold capillary dilatation
```
125
What is limited cutaneous systemic sclerosis?
```
Previously known as CREST syndrome:
Calcinosis
Raynaud's phenomenon
(o)Esophageal dysmotility
Sclerodactyly
Telangiectasia
```
126
What is scleroderma sine scleroderma?
Internal organ disease with no skin changes
127
What is scleroderma sine scleroderma?
Internal organ disease with no skin changes
128
What is vasculitis?
Inflammation and necrosis of blood vessels
129
How are primary vasculitides classified?
Based on main vessel size affected
Large:
1. Giant cell arteritis
2. Takayasu's arteritis
Medium:
1. Polyarteritis nodosa
2. Kawasaki's disease
Small:
1. Eosinophilic granulomatosis w polyangiitis (Churg-Strauss syndrome)
2. Microscopic polyangiitis
3. Wegner's granulomatosis
4. Henoch-Schonlein purpura
5. Mixed essential cryoglobulinaemia (MEC)
6. Relapsing polychondritis
130
Explain the aetiology of vasculitides
Unknown
Suggested autoimmune origin
Immune complex deposition in BV walls --> inflammation
131
What are the risk factors for eosinophilic granulomatosis with polyangiitis?
Hx of asthma, allergic rhinitis, or sinusitis
132
What are the risk factors for microscopic polyangitis?
pANCA
133
What are the risk factors for polyarteritis nodosa?
HBV infection
| 40-60 yos
134
What are the risk factors for Takayasu arteritis?
Genetic predisposition - Japan, SE Asia, India, Mexico
Female (8x)
<40
Asian ethnicity
135
What are the presenting symptoms and signs of all vasculitides?
General: fever, malaise, night sweats, weight loss
Skin: rash
Joint: arthralgia, arthritis
GI: abdo pain, haemorrhage, diarrhoea
Kidneys: glomerulonephritis, renal failure
Lungs: dyspnoea, cough, chest pain, haemoptysis, haemorrhage
CVS: pericarditis, coronary arteritis, myocarditis
CNS: mononeuritis multiplex, infarctions
Eyes: retinal haemorrhage, cotton wool spots
136
What are the specific characteristics of polyarteritis nodosa?
```
Microaneurysms
Thrombosis
Infarctions
HTN
Testicular pain
```
137
What are the specific characteristics of Takayasu's arteritis?
```
Limb claudication
Absent pulses
Unequal blood pressures
Vascular bruits
Low-grade fever
TIA
```
138
What are the specific characteristics of eosinophilic granulomatosis with polyangiitis?
```
Focal numbness or weakness
Nasal discharge or stuffiness
Facial pain
Palpable purpura and petechiae on legs
Wheeze
```
139
What are the appropriate investigations for eosinophilic granulomatosis with polyangiitis?
FBC: increased eosinophils
ANCA: +ve
ESR and CRP: raised
Ur and Cr: normal or raised
Urinanalysis: assess for glomerulonephritis - haem, prot, RBC casts
Lung function tests: reversible airway obstruction
CXR: interstitial infiltrates or nodules
ECG: LV regional wall motion abnormalities, intracardiac thrombus, pericardial effusion
140
What are the appropriate investigations for granulomatosis with polyangiitis?
```
Urinanalysis and microscopy: haematuria, proteinuria, dysmorphic RBCs, RBC casts
CT chest: lung nodules, infiltrates
ANCA: +ve
FBC: anaemia
Cr: raised
ESR: raised
```
141
What are the appropriate investigations for Takayasu's arteritis?
ESR: >50mm/hour in active disease
CRP: raised in active disease
CT/MRI angiography: segmental narrowing or occlusion, occasionally dilation, of affected vessels/aortic aneurysms/thickening of vessel walls
142
What are the appropriate investigations for polyarteritis nodosa?
ESR, CRP: raised
FBC: normocytic anaemia, mildly elevated WCC, raised platelets
Complement: reduced
Cr: raised or normal
MSU: mild proteinuria or normal
LFTs: raised
HBV serology: +ve
HCV serology: +ve anti-hepatitis C antibodies
CK: normal or mildly raised
Cryoglobulins, blood culture, ANCA, ANA, anti-dsDNA, RF, anti-CCP, Lupus anticoag, IgG antiphospholipid abs, B2 glycoprotein: -ve
Fibrinogen: normal or raised
Convential digital subtraction angiography: microaneurysms, vessel ectasia, focal occlusive lesions in medium-sized vessels
Echocardiogram: normal
143
What is pseudogout?
Arthritis associated with deposition of calcium pyrophosphate dihydrate (CPPD) crystals in the joint cartilage
144
Summarise the epidemiology of pseudogout
Dramatic increase with age
145
Explain the aetiology of pseudogout
Unknown
| CPP crystals in mid-zone of articular hyaline and fibro-cartilage
146
What are the risk factors for pseudogout?
```
<60
Injury
HyperPT (chronic hyperCa)
Haemochromatosis
FHx
HypoMg
Hypophosphatasia (deficiency of ALP)
```
147
What are the presenting symptoms of pseudogout?
Painful and tender joints
Wrist and shoulder involvement in OA
Sudden worsening of OA
Red and swollen joints
148
What are the signs of pseudogout O/E?
Red, swollen, tender joints
Wrist and shoulder involvement
Joint effusion and fluctuance
149
What are the appropriate investigations for pseudogout?
Arthrocentesis w synovial fluid analysis: positively birefringent rhomboidal crystals under polarised light confirms CPPD; fluids often bloody
XR: linear, stippled radio-opaque deposits in fibro-cartilage or hyaline articular cartilage of joints/calcified tendons/subchondral cysts/progressive rapid joint degeneration or bony collapse/patellofemoral knee involvement
```
Serum Ca: normal or raised
Serum PTH: normal or raised
Iron studies: normal or elevated
Serum Mg: normal or decreased
Serum ALP: normal or decreased
```
