Ortho/Rheum

Question 1

What is Henoch-Schonlein purpura?

Answer 1

IgA vasculitis
presents with purpuric rash affecting lower limbs and buttocks in children
Inflammation occurs in the affected organs due to IgA deposits in the blood vessles

Question 2

Where does HSP affect?

Answer 2

• skin
• kidneys
• GI tract

Question 3

What triggers HSP?

Answer 3

• upper airway infection
• gastroenteritis

Question 4

Most common age group to be affected by HSP?

Answer 4

Under 10

Question 5

4 Classic features of HSP?

Answer 5

• purpura
• joint pain
• abdo pain
• renal involvement

Question 6

How does HSP present?

Answer 6

• Purpura- usually starts on legs and spread to the buttocks and can also affect trunk and arms- skin ulceration and necrosis may develop
• Arthralgia or arthritis- knees and ankles, joints may become swollen and painful
• Abdo pain- can lead to GI haemorrhage, intussuception and bowel infarction
• IgA nephritis- haematuria (micro or macro) and proteinuria–> 2+ or more protein on dipstick–> nephrotic syndrome

Question 7

Investigations for HSP?

Answer 7

• A-E- EXCLUDE: meningoccocal septicaemia, leukaemia
• Bedside:
  urine dipstick- for proteinuria, BP- for hypertension
• Bloods:
  FBC and blood film- thrombocytopenia, sepsis and leukaemia
  Renal profile: kidney involvement
  Serum albumin: nephrotic syndrome
  CRP: sepsis
  Blood cultures: sepsis
  Urine protein: creatinine ration: quantity of proteinuria

Question 8

What is the criteria to diagnose HSP?

Answer 8

• EULAR/PRINTO/PRES criteria
• Requires: palpable purapura + at least one of:
• Diffuse abdo pain
• Arthritis
• IgA depostis on histology
• proteinuia or haematuria

Question 9

Management of HSP?

Answer 9

• Supportive with simple analgesia, rest and hydration
• steroid may be considered if severe GI or renal involvement
• Monitor closely:
  Urine dipstick: renal involvement
  BP: hypertension

Question 10

Prognosis of HSP?

Answer 10

• Abdo pains settles within a few days
• Pts w/o kidney involvement expect to recover within 4-6 weeks
• 1/3 pts have recurrence of diease within 6 months
• v small proportion will develop ESRD

Question 11

What is transient synovitis?

triggers, aetiology

Answer 11

• Irritable hip
• generally presents as acute hip pain following a recent viral infection
• commonest cause of hip pain in children.
• typical age group is 3-8 years.

Question 12

Features of transient synovitis?

Answer 12

• limp/refusal to weight bear
• groin or hip pain
• a low-grade fever is present in a minority of patients
• high fever should raise the suspicion of other causes such as septic arthritis

Question 13

What is imp to exlucude if child presents with ?transient synovitis?

Answer 13

• SEPTIC ARTHIRITIS
• if child has fever- red flag- needs specialist assessment

Question 14

Managment of transient synovitis?

Answer 14

• Self-limiting
• requiring rest and analgesia

Question 15

Ddx for purpuric rash?

Answer 15

• meningococcal septicaemia
• Leukaemia
• HSP
• idiopathic thrombocytopenic purpura
• Haemolytic uraemic syndrome

Question 16

Epidemiology of septic arthritis in children?

Answer 16

4-5 in 100,000
More common in M:F= 2:1

Question 17

Where is most commonly affected in septic arthritis?

Answer 17

• hip
• knee
• ankle

Question 18

Symptoms of septic arthritis?

Answer 18

• joint pain
• limp
• fever
• systemically unwell; lethargy

Question 19

Signs of septic arthritis?

Answer 19

• swollen red joint
• typically, only minimal movement of affected joint is possible

Question 20

Investigations in septic arthritis?

Answer 20

• joint aspiration for culture- will show increase WBC
• raised inflammatory markers
• blood cultures

Question 21

What is the Kocher criteria for the diagnosis of septic arthritis?

Answer 21

• fever > 38.5 degrees
• non-weight bearing
• raised ESR
• raised WCC

Question 22

What is reactive arthritis?

Answer 22

• HLA-B27 associated seronegative spondyloarthropathies
• Defined as: arthritis that develops following an infection where the organism cannot be recovered from the joint

Question 23

What is the ‘classic’ triad of reactive arthritis?

Answer 23

Urethritis, conjunctivitis and arthritis
* this used to be called Reiter’s syndrome- now reactive arthritis encompasses this

can’t pee, can’t see, can’t climb a tree

Question 24

What is the ‘classic’ triad of reactive arthritis?

Answer 24

Urethritis, conjunctivitis and arthritis
* this used to be called Reiter’s syndrome- now reactive arthritis encompasses this

can’t pee, can’t see, can’t climb a tree

Question 25

What organisms are associated with reactive arthritis?

Answer 25

• Shigella felxneri
• Salmonella typhimurium
• Salmonella enteritidis
• Yersinia enterocolitica
• Camplylobacter

Chamydia can also cause it- not AS relevant in children

Question 26

What is the time course of reactive arthritis?

Answer 26

• Typically develops 4 weeks of initial infection
• Symptoms last around 4-6 months
• 25% of patients have recurrent episodes
• 10% of patients develop chronic disease

Question 27

Features of reactive arthritis?

Answer 27

• Arthritis: asymmetrical oligoarthritis of lower limbs
• Dactylitis
• Symptoms of urethritis
• Conjunctivitis
• Anterior uveitis
• circinate balanitis (painless vesicles on the coronal margin of the prepuce)
• keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

Question 28

Management of reactive arthritis?

Answer 28

• Symptomatic: Analgesia, NSAIDs, intra-articular steroids
• Sulfasalzine and methotrexate are sometimes used for persistent disease
• Symptoms rarely last more than 12 months