Musculoskeletal/Rheumatology Flashcards
Give 3 causes of inflammatory joint pain.
- Autoimmune disease, e.g. RA, vasculitis, connective tissue disease
- Crystal arthritis
- Infection
Give 2 causes of non-inflammatory joint pain.
- Degenerative, e.g. osteoarthritis.
- Non-degenerative, e.g. fibromyalgia
What are the 5 cardinal signs of inflammation?
- Rubor (redness)
- Calor (heat)
- Dolor (pain)
- Tumor (swelling)
- Loss of function
How does inflammatory pain differ from degenerative non-inflammatory pain? Are you more likely to see swelling in inflammatory or degenerative pain?
- Inflammatory pain tends to ease with use whereas degenerative pain increased with use
- In inflammatory pain you are likely to see synovial swelling. There is often no swelling in degenerative pain
Name 2 inflammatory markers that can be detected in blood tests.
- ESR (erythrocyte sedimentation rate)
- CRP
Explain why ESR levels are raised in someone with inflammatory joint pain.
Inflammation leads to increased fibrinogen which means the RBC’s clump together. The RBC’s therefore fall faster and so you have an increased ESR
Explain why CRP levels are raised in someone with inflammatory joint pain.
Inflammation leads to increased levels of IL-6. CRP is produced by the liver in response to IL-6 and therefore is raised
What is vasculitis? How is vasculitides categorised? Name some diseases in each category.
- Vasculitis = group of autoimmune diseases that cause inflammation of blood vessels
- Vasculitides can be categorised blood vessel size: small, medium, large
- Large vessel vasculitis: Giant cell arteritis, Takayasu’s arteritis
- Medium vessel vasculitis: Polyarteritis nodosa, Kawasaki disease
- Small vessel vasculitis: Henoch-Schonlein purpura, Granulomatosis with polyangiitis (Wegener’s granulomatosis)
- EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS CAN BE SMALL OR MEDIUM VESSEL VASCULITIS
- Variable vessel vasculitis = Behcet’s disease
What is the pathophysiology of Giant cell arteritis?
- Affects aorta and/or its major branches (carotid and vertebral branches)
- Temporal artery often involved (temporal arteritis)
What are the risk factors for Giant cell arteritis?
- Almost exclusively in >50 year olds
- Northern European
- Female
- Hx of polymyalgia rheumatica
What is the clinical presentation of Giant cell arteritis?
- HEADACHE - new onset, typically unilateral over temporal area
- Scalp tenderness
- Jaw claudication
- Visual disturbances: blurred vision, diplopia
What are the investigations for Giant cell arteritis?
- Increased ESR and/or CRP (=highly sensitive) ESR >50mm/hr
- Halo sign on ultrasound of temporal and axillary artery
- TEMPORAL ARTERY BIOPSY = GOLD STANDARD (show multinucleate giant cells, granulomatous inflammation)
Describe the management for Giant cell arteritis.
High dose glucocorticoid ASAP - usually prednisolone 40-60mg
What are the complications of Giant cell arteritis?
- Blindness
- Irreversible neuropathy
What is the pathophysiology and epidemiology of Takayasu’s arteritis?
- Pathophysiology: mainly affects aorta and its branches, also affects pulmonary branches
- Epidemiology: <40 years, Asian, female
What is the clinical presentation of Takayasu’s arteritis?
- PULSELESS DISEASE (difficulty in detecting peripheral pulse due to narrowing)
- Arm claudication
- Syncope
- Non-specific symptoms: fever, malaise, muscle aches
What are the investigations for Takayasu’s disease?
- CT angiography = GOLD STANDARD
- Granulomatous inflammation on histology
- Elevated ESR and CRP
Describe the management for Takayasu’s arteritis. What are the complications?
- Management: prednisolone
- Complications: aortic aneurysms
What is the epidemiology of Polyarteritis nodosa?
- Associated with hepatitis B
- More common in developing countries
- Affects all ages, all racial groups, no sex predominance
What is the presentation of Polyarteritis nodosa?
- CUTANEOUS/SUBCUTANEOUS NODULES (hallmark feature)
- UNILATERAL ORCHITIS (characteristic feature)
- Peripheral neuropathy - mononeuritis multiplex
- Livedo reticularis
- HTN
- Abdominal pain
What are the investigations for Polyarteritis nodosa?
- Increased ESR and/or CRP
- HBsAg
- Biopsy: shows transmural fibroid necrosis
Describe the management for Polyarteritis nodosa.
- If Hep B negative - corticosteroids + cyclophosphamide
- If Hep B positive - antiviral agent, plasma exchange and corticosteroids
What are the complications of Polyarteritis nodosa?
- GI perforation and haemorrhages
- Arthritis
- Renal infarcts
- Strokes
- MI
What is the pathophysiology of Kawasaki disease?
- Arteritis associated with mucocutaneous lymph nodes
- Acute and self-limited
- Usually affects coronary arteries
What are the risk factors for Kawasaki disease?
- <5 years old
- Males 1.5x more affected
- More common in children of Japanese descent
What is the clinical presentation of Kawasaki disease?
- Fever for >5 days
- Non-purulent bilateral conjunctivitis
- Strawberry tongue
- Erythema + desquamation of palms and soles
What are the investigations for Kawasaki disease? Describe the management. What are the complications?
- Investigations: increased ESR and/or CRP, echocardiogram
- Management: aspirin and IV immunoglobulins
- Complications: coronary artery aneurysm
What is the pathophysiology of Eosinophilic granulomatosis with polyangiitis (EGSA, or Churg-Strauss syndrome)? What is its epidemiology?
- Pathophysiology: small and medium vasculitis, most associated with lung and skin problems (but can also affect kidneys)
- Epidemiology: late teenage years, early adulthood
What is the clinical presentation of EGSA? What are the investigations? Describe the management.
- Presentation: severe asthma, peripheral neuropathy, palpable purpura
- Investigations: high eosinophils on FBC, diagnose with p-ANCA (MPO antibodies)
- Management: inhaled corticosteroids - prednisone
What is the pathophysiology of Henoch-Schonlein purpura? What is its epidemiology?
- IgA vasculitis
- Due to IgA deposits in the blood vessels of affected organs such as skin, kidneys, GI tract
- Often triggered by upper airway infection, e.g. tonsillitis or gastroenteritis
- Epidemiology: < 10 years old
What is the clinical presentation of Henoch-Schonlein purpura?
- Symmetrical purpuric rash affecting lower limbs or buttocks in children
- Joint pain
- Abdominal pain
- Renal involvement (HTN)
What are the investigations for Henoch-Schonlein purpura?
- Take BP (check for HTN)
- Urinalysis (can see microscopic haematuria/proteinuria)
- Perform abdominal exam (check for bowel obstruction)
Describe the management for Henoch-Schonlein purpura. What are its complications?
- Supportive: simple analgesia, rest and plenty of fluids
- Complications: IgA nephritis, INTUSSUSCEPTION, orchitis, arthralgia
What is the pathophysiology of Granulomatosis with polyangiitis? What are the risk factors?
- Pathophysiology: small vessels vasculitis, affects respiratory tracts and kidney
- Risk factors: late teenage years, early adulthood
What is the clinical presentation of Granulomatosis with polyangiitis?
- CLASSIC SIGN ON EXAMS: SADDLE SHAPED NOSE
- Epistaxis
- Crusty nasal/ear secretions = hearing loss
- Sinusitis
- Cough, wheeze, haemoptysis
What are the investigations for Granulomatosis with polyangiitis?
- High eosinophils on FBC
- Histology shows granulomas
- Presence of c-ANCA
Describe the management for Granulomatosis with polyangiitis. What are the complications?
- (Nasal) corticosteroid
- Cyclophosphamide
- Complication: glomerulonephritis
Compare Giant cell arteritis, Takayasu arteritis, Polyarteritis nodosa and Kawasaki disease.
Compare GPA, EGPA, and MPA.
What is osteoporosis? What is it characterised by?
- Osteoporosis = low bone mineral density
- Characterised by an imbalance between bone formation and bone resorption
- ↓ bone mass/density and micro-architectural deterioration
- ↑ in bone fragility and susceptibility in fracture
What are the risk factors for osteoporosis? How can this be remembered?
- Risk factors = ‘SHATTERED’:
- Steroid use
- Hyperthyroidism, hyperparathyroidism, hypercalciuria
- Alcohol + tobacco use
- Thin (BMI < 18.5)
- Testosterone (low)
- Early menopause
- Renal or liver failure
- Erosive/inflammatory bone disease, e.g. myeloma or RA)
- Dietary low calcium/malabsorption or Diabetes type 1
What is the clinical presentation of osteoporosis?
FRACTURE - asymptomatic until this occurs
What are the investigations for osteoporosis? How about the risk assessment?
- DEXA scan - decreased bone mineral density
- Ca, phopshate, ALP (normal)
- Risk assessment:
- FRAX score - 10-year probability of a hip fracture >3% or osteoporosis-related fracture >20%
- QFRACTURE
Describe the T-score categories for a DEXA scan.
- Normal: T > -1.0
- Osteopenia: -2.5 < T < -1.0
- Osteoporosis: T < -2.5
- Established osteoporosis: T < -2.5 with > 1 fragility fractures
Describe the management for osteoporosis.
- Vitamin D + calcium supplementation - 1ST LINE
- Bisphosphonates (reduce osteoclastic activity as osteoclasts absorb them), e.g. alendronate, risendronate, zolendronic acid - 1ST LINE
- Denosumab (monoclonal Ab that blocks the activity of osteoclasts - bind to RANK-ligand) - 2ND LINE
- Lifestyle advice - exercise, maintaining a healthy weight, stop smoking, reduce alcohol
- HRT
- Prompt surgery in the case of hip fracture
What is arthritis caused by?
Inflammation of the joints
What is the pathology of osteoarthritis? What are the risk factors?
- NON-INFLAMMATORY degenerative progressive destruction of articular cartilage (underlying bone of synovial joints) from repeated mechanical forces
- The damage to the articular cartilage causes the disruption of chondrocytes (cells responsible for cartilage formation) prevents rebuilding
- Risk factors: high intensity labour, old age
What is the clinical presentation of osteoarthritis?
- Painful joints that are stiff for 30 minutes or less in the morning. Worse throughout the day
- Proximal Bouchard’s nodes, distal Herberden’s nodes - interphalangeal joints
- Sharp pain worsened by activity
What are the investigations for osteoarthritis?
- X-ray - LOSS (loss of joint space, osteophytes, subchondral sclerosis, subchondral cysts)
- Serum ESR and CRP
Describe the management of osteoarthritis. What are the complications?
- Analgesia, e.g. acetaminophen, tramadol, NSAIDs
- Cortisol injections
- Osteotomy
- Complications: destruction of the joint and loss of function
What is the pathology of rheumatoid arthritis?
Autoimmune destruction of the synovium. The inflammation causes damage to bone, cartilage (connective tissue), tendons (muscle to bone), and ligaments (bone to bone)
What are the risk factors for rheumatoid arthritis?
- Young
- Female - 3x more than men
- Family history
- Other autoimmune diseases
Describe the clinical presentation of rheumatoid arthritis. What are the systemic symptoms?
- Symptoms: painful, swollen, stiff joints for >1 hour in the morning, better with movement
- Signs: SWAN NECK THUMB, ULNAR DEVIATION, Boutonnière deformity
- Systemic symptoms: scleritis, pleural effusions, pericarditis
What are the investigations for rheumatoid arthritis?
- Bloods: anti CCP (most sensitive), rheumatoid factor, raised ESR/CRP
- X-ray = LESS: loss of joint space, erosion, soft tissue swelling, soft bones
What is the diagnostic criteria for rheumatoid arthritis?
RF RISES:
- Rheumatoid factor positive
- Finger/hand/wrist involvement
- Rheumatoid nodules present
- Involvement of ≥ 3 joints
- Stiffness in the morning for > 1 hour
- Erosions seen on X-Ray
- Symmetrical involvement
More than 6 weeks, more than 4 of the above
Describe the management for rheumatoid arthritis.
- DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs), e.g. methotrexate = hallmark of RA treatment. 2nd line = methotrexate + hydroxychloroquine. 3rd line = biologic DMARDs, e.g. rituximab (suppress B-cells) + methotrexate
- Ibuprofen/NSAIDS
- Short-term, low-dose glucocorticoid (class of corticosteroids = a class of steroids)
What are the complications of rheumatoid arthritis?
- Cervical spinal cord compression - weakness and loss of sensation
- Lung involvement - interstitial lung disease, fibrosis
What is Felty syndrome?
Rare disorder characterised by the presence of three conditions: RA, splenomegaly, granulocytopenia
What are the two types of crystal arthritis?
- Gout
- Pseudogout
What is the pathology of gout?
Over-production/under-excretion of uric acid
What are the risk factors for gout?
- Middle-aged, overweight males
- High purine diet (uric acid produced when these are broken down) - found in meat
- Increased cell turnover
- Heavy alcohol consumption
What is the clinical presentation of gout?
- Symptoms: inflamed joints - 1st metatarsal and distal interphalangeal joints often affected
- Signs: tophi-lumps of urate salts
What are the investigations for gout?
- GOLD STANDARD = ARTHROCENTESIS (joint aspiration) with synovial fluid extraction and polarised light microscopy (NEEDLE-LIKE NEGATIVE BIREFRINGENT CRYSTALS)
- 1st line = bloods - increased monosodium urate
Describe the management of acute and chronic gout.
ACUTE:
- 1st line: NSAIDs (not good for kidneys which is a risk factor for gout, so careful when prescribing) or COLCHICINE (causes diarrhoea)
- 2nd line: intra-articular steroid injection
CHRONIC:
- 1st line: ALLOPURINOL (xanthase oxidase inhibitor, reduces uric acid production)
- 2nd line: febuxostat
What are the complications of gout?
- Infection of the tophi
- Destruction of the joint
What are the side effects of allopurinol?
- Triggers or worsens acute episodes of gout
- Skin rash
- Stevens-Johnson Syndrome
What is the pathology of pseudogout?
Damage to a joint causes pathological formation of calcium pyrophosphate crystals
What are the risk factors for pseudogout?
- Females over 70
- Hyperthyroidism
- Hyperparathyroidism
- Excess iron or calcium
What is the clinical presentation of pseudogout?
- Symptoms: hot, swollen, tender joint, usually knees
- Signs: recent injury to the joint in the history
What are the investigations for pseudogout?
- Arthrocentesis with synovial fluid analysis and polarised light (RHOMBOID POSITIVE BIREFRINGENT CRYSTALS)
- X-ray of affected joints
- Serum calcium and PTH
Describe the management and complications of pseudogout.
- NSAIDs with colchicine
- Complications: damage to the joint - loss of function over time
What is septic arthritis? What is its pathophysiology? What is its aetiology?
- Septic arthritis = infection in the synovial fluid and joint tissues
- Pathophysiology: infection of joint = endotoxin production = cytokine release = neutrophil attraction = inflammation, damage of joint structures
- Aetiology: predominant organisms responsible are S.aureus, Neisseria gonorrhoea, E.coli
What are the risk factors for septic arthritis?
- Pre-existing joint disease (OA or RA)
- IVDU, alcohol misuse
- Immunosuppression
- Intra-articular corticosteroid injection
What is the clinical presentation of septic arthritis?
- Hot, swollen, painful, restricted joint
- Onset < 2 weeks
- Fever
- Commonest → knee
What are the investigations for septic arthritis?
- ASPIRATE JOINT and THEN GIVE ANTIBIOTICS (empirical until organism identified)
- Blood culture
- WCC → may be raised
- ESR + CRP → raised
Describe the management for septic arthritis.
- Joint aspiration
- Empirical Abx, e.g. flucloxacillin (penicillin allergic = clindamycin), MRSA = vancomycin
- Surgical wash out
- Pathogen-directed Abx once identified
- Pain medications, e.g. NSAIDs
What is osteomyelitis? What is it most commonly caused by?
Osteomyelitis is an inflammatory condition of bone caused by an infecting organism - most commonly STAPHYLOCOCCUS AUREUS
What are the risk factors for osteomyelitis?
- Diabetes
- Fractures
- Recent surgery
- IVDU
- Distant or local infection
- Children - upper respiratory tract or varicella infection
What is the clinical presentation of osteomyelitis?
- Limp or reluctance to weight-bear (children)
- Non-specific pain at site of infection
- Low grade fever
- Malaise + fatigue
What are the investigations for osteomyelitis?
- FBC - elevated WCC, ESR and CRP raised
- GOLD STANDARD = bone biopsy
- Blood culture
- X-ray
Describe the management for osteomyelitis.
- Long-term IV antibiotics
- Surgical removal of dead bone
What are spondyloarthropathies? What are they all associated with? Name the different conditions.
- Spondyloarthropathies: family of chronic diseases of the joints
- All associated with HLA-B27 (encoded by MHC on chromosome 6)
- Seronegative (RF -ve)
- Conditions:
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Juvenile idiopathic arthritis
- Enteropathic arthritis
What are the features of spondyloarthropathies?
- SPINEACHE:
- Sausage digit (dacytylitis)
- Psoriasis
- Inflammatory back pain
- NSAID - good response
- Enthesitis (heel)
- Arthritis
- Crohn’s/colitis/elevated CRP (can be normal)
- HLA B27
- Eye (uveitis)
What is ankylosing spondylitis? What is its pathophysiology? What are the risk factors?
- Ankylosing spondylitis = chronic, multisystem inflammatory disorder involving primarily inflammation of the sacroiliac joints + axial skeleton
- Pathophysiology: inflammatory arthritis of spine + rib cage → leads to new bone formation + fusion of joints = loss of spinal movements
- Risk factors: HLA-B27 gene, male (3x more common)
Describe the clinical presentation of ankylosing spondylitis.
- Typical presentation male in late teens or 20s
- Lower back pain + stiffness → worse with rest + improves with movement
- Sacroiliac pain
- Flares of worsening symptoms
What are the complications of ankylosing spondylitis?
- Aortic regurgitation
- Uveitis
- Enthesitis
- Dactylitis
- Decreased pulmonary function
What are the investigations for ankylosing spondylitis? Which criteria is used?
- X-ray of spine + sacrum:
- BAMBOO SPINE
- Squaring of vertebral bodies
- Subchondral sclerosis + erosions
- Syndesmophytes
- Ossification of ligaments, discs + joints
- Fusion of facet, SI + costovertebral joints
- MRI spine - bone marrow oedema in early disease before x-ray changes
- CRP and ESR - raised
- HLA-B27 genetic test
- NEW YORK CRITERIA
Describe the management for ankylosing spondlyitis.
- FIRST LINE = NSAIDs, e.g. ibuprofen
- Steroids during flares. DMARDs during severe flare ups
- MAbx against TNF-alpha: infliximab, adalimumab, certulizomab
- Anti-TNF drugs: etanercept
- Physiotherapy, lifestyle advice
- Surgery for deformaties
What is psoriatic arthritis? What is its epidemiology?
- Psoriatic arthritis = chronic inflammatory joint disease associated with psoriasis
- 1 in 5 patients with psoraisis have psoraitic arthritis
What is the clinical presentation of psoraitic arthritis?
- Inflammatory joint pain
- Plaques of psoriasis
- Onycholysis (separation of nail from nail bed)
- Dactylitis (inflammation of full finger)
- Enthesitis (inflammation of entheses - point of insertion of tendons into bone)
What are the investigations for psoriatic arthritis?
- Plain film x-rays of hands and feet:
- Erosion in DIPJ + periarticular new-bone formation
- Osteolysis
- PENCIL-IN-CUP/POT deformity
- ESR + CRP - normal or raised
- Rheumatoid factor -ve
- Anti-CCP - negative
- Joint aspiration - no bacteria or crystals
Describe the management for psoriatic arthritis.
- NSAIDs (mild disease)
- Physiotherapy
- Steroid injection, e.g. cortisol
- DMARDs - methotrexate, sulfasalazine
- TNF inhibitor or MAbx, e.g. infliximab, etanercept, adalimumab
- Ustekinumab - last line (MAb that targets IL 12 + 23)
What is arthritis mutilans?
- Most severe form of psoriatic arthritis
- Occurs in phalanges
- Osteolysis of bones around joints in digits → leads to progressive shortening
- Skin then folds as digit shortens → telescopic finger
What is reactive arthritis? What is its aetiology?
- Reactive arthritis = inflammatory arthritis that occurs after exposure to certain GI or GU infections
- Aetiology:
- Chlamydia - C trachomatis v. common
- Campylobacter jejuni
- Salmonella enteritidis
- Shigella
What is the clinical presentation of reactive arthritis?
- Begin 1-4 weeks after onset of infection
- Asymmetrical oligoarthritis
- Painful, swollen, warm, red + stiff joints
- Dactylitis
- CLASSICAL TRIAD → conjunctivitis, urethritis + arthritis (CAN’T SEE, CAN’T PEE, CAN’T CLIMB A TREE) (good for exams)
What are the investigations for reactive arthritis?
- ESR + CRP - raised
- ANA - negative
- RF - negative
- X-ray - sacroiliitis or enthesopathy
- Joint aspirate - negative (exclude septic arthritis + gout)
Describe the management for reactive arthritis.
- NSAIDs
- Corticosteroids
- DMARDs - chronic arthritis
What is juvenile idiopathic arthritis?
Juvenile idiopathic arthritis (JIA) describes a group of chronic paediatric inflammatory arthritides. Characterised by onset before 16 years of age and the presence of objective arthritis (in one or more joints) for at least 6 weeks
What is the complication of juvenile idiopathic arthritis?
10% develop disability in adulthood
What is the clinical presentation of juvenile idiopathic arthritis?
- Arthritis, e.g. joint pain, joint swelling
- Rheumatoid nodules, RF usually absent
What are the investigations for juvenile idiopathic arthritis?
- FBC
- ESR and CRP
- Antinuclear antibodies (ANA)
Describe the treatment for juvenile idiopathic arthritis.
Similar to RA treatment
What is systemic lupus erythmatosus? What is its pathology? What are the risk factors? What type of hypersensitivity reaction is this?
- It is an autoimmune disease in which the immune system attacks its own organs, causing widespread inflammation and organ damage. It is the most common type of lupus
- Pathology: characterised by the presence of ANTI-NUCLEAR ANTIBODIES (aNA). aNA and aDsDNA (anti-double stranded DNA) attack soft tissue causing inflammation and damage
- Risk factors: biologically female and of reproductive age, black people
- Type III hypersensitivity
What is the clinical presentation of SLE?
- Symptoms: butterfly rash (over cheeks), weight loss, fever, fatigue, joint pain, mouth ulcers
- Signs: correctable ulnar deviation, glomerulonephritis, depression
What are the investigations for SLE?
- Bloods: ESR raised, CRP normal, aNA and aDsDNA present
- Activated partial thromboplastin time
Describe the management of SLE.
- FIRST LINE FOR MILD SLE = hydroxychloroquine (anti-malaria)
- Ibuprofen (NSAID)
- Prednisolone (steroid)
- Methotrexate (more severe)
- Cyclophosphamide (immunosuppressant)
What are the complications of SLE?
Cardiovascular disease, renal failure, lung involvement
What is Sjogren’s syndrome? What are the two types? What are its risk factors?
- Sjogren’s syndrome = autoimmune condition that affects exocrine glands, especially the lacrimal or salivary glands
- Two types:
- Primary: the condition occurs in isolation
- Secondary: it occurs related to RA or SLE
- Risk factors: FHx (first degree relative = 7x increased risk), female, >40 years old