Osteoarthritis and Reactive Arthritis Flashcards by Wasim Silmi

What is reactive arthritis?

Sterile inflammation in joints following infection especially urogenital (e.g. Chlamydia trachomatis) and gastrointestinal (e.g. Salmonella, Shigella, Campylobacter infections) infections

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Extra-articular manifestations of reactive arthritis? (4)

Important extra-articular manifestations include:
 Enthesopathy
 Skin inflammation
 Eye inflammation
 Reactive arthritis may be first manifestation of HIV or hepatitis C infection

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What 2 need to happen for reactive arthritis? (1 can control 1 can’t)

with genetic predisposition (e.g. HLA-B27) and environmental trigger (e.g. Salmonella infection)

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Which HLA predisposes to ReA?

HLA-B27

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Onset of symptoms post infection?

1-4 weeks

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3 categories of musculoskeletal symptoms of ReA?

Arthritis
ENTHESITIS
SPONDYLITIS

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Manifestations of arthritis in ReA? Typically affects…?

Asymmetrical
Oligoarthritis (<5 joints)
Lower limbs typically affected

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Symptoms of enthesitis in ReA? (3)

Heel pain (Achilles tendonitis)
Swollen fingers (dactylitis)
Painful feet (metatarsalgia due to plantar fasciitis)

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Symptoms of spondylitis in ReA? (2)

Sacroiliitis (inflammation of the sacro-iliac joints)

- Spondylitis (inflammation of the spine)

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Extraarticular areas of manifestations of ReA and the manifestation? (3)

OCULAR:
-	Sterile conjunctivitis
GENITO-URINARY:
-	Sterile urethritis
SKIN:
-	Circinate balanitis
-	Psoriasis-like rash on hands and feet (keratoderma blennorrhagicum)

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Rheumatoid vs reactive arthritis:

More common in what sex?

Rheumatoid: Females

Reactive: Males

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Rheumatoid vs reactive arthritis:

Age of onset?

Rheumatoid: all ages

Reactive: 20-40

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Rheumatoid vs reactive arthritis:

Differences in arthritis

Rheumatoid: Symmetrical, polyarticular, small and large joints

Reactive: asymmetrical, oligorticular, large joints

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Rheumatoid vs reactive arthritis:

Enthesopathy present??

Rheumatoid: No

Reactive: Yes

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Rheumatoid vs reactive arthritis:

Spondylitis present?

Rheumatoid: Yes (except anti-axial joint in cervical spine)

Reactive:

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Rheumatoid vs reactive arthritis:

Urethritis present?

Rheumatoid: No

Reactive: Yes

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Rheumatoid vs reactive arthritis:

Skin involvement to what level?

Rheumatoid: Subcutaneous nodules

Reactive: K. blennorhagicum, circinate balanitis

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Rheumatoid vs reactive arthritis:

Rheumatoid factor present

Rheumatoid: Yes

Reactive: No

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Rheumatoid vs reactive arthritis:

HLA association?

Rheumatoid: HLA-DR4

Reactive: HLA-B27

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How to establish diagnosis of ReA?

Clinical diagnosis

2. Investigations to exclude other causes of arthritis e.g. septic arthritis

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What investigations would you conduct to exclude other causes of arthritis?

Microbiology
Immunology
Synovial fluid examination

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Septic vs reactive arthritis:

Synovial fluid culture

Septic: Positive

Reactive: Sterile

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Septic vs reactive arthritis:

Antibiotic therapy

Septic: Yes

Reactive: No

Septic vs reactive arthritis:

Joint lavage

Septic: Yes - for large joints

Reactive: No

Articular treatment of ReA? (2)

- NSAIDs | - Intra-articular corticosteroid therapy

Extra-articular treatment of ReA? (2)

- Typically, self-limiting, hence symptomatic therapy e.g. topical steroids & keratolytic agents in keratoderma

Refractory disease treatment of ReA? (2)

- Oral glucocorticoids | - Steroid-sparing agents e.g. sulphasalazine

What is osteoarthritis?

Chronic slowly progressive disorder due to failure of articular cartilage that typically affecting joints of the hand (especially those involved in pinch grip), spine and weight-bearing joints (hips and knees)

OA typically affects what joints? (3+5)

``` - Joints of the hand:  Distal interphalangeal joints (DIP)  Proximal interphalangeal joints (PIP)  First carpometacarpal joint (CMC) - Spine - Weight-bearing joints of lower limbs  Especially knees and hips  First metatarsophalangeal joint (MTP) ```

What are Heberdens nodes

Osteophytes at the DIP joint

What are Bouchards nodes

Osteophytes at the PIP joint

Osteophytes at the PIP joint are termed...

Bouchards nodes

Osteophytes at the DIP joint are termed...

Heberdens nodes

OA is associated with... (6)

- Joint pain worse with activity, better with rest - Joint crepitus creaking, cracking, grinding sound on moving affected joint - Joint instability - Joint enlargement e.g. Heberden’s nodes - Joint stiffness after immobility (‘gelling’) - Limitation of motion

4 radiographic features of OA? (4)

- Joint space narrowing - Subchondral bony sclerosis - Osteophytes - Subchondral cysts

Rheumatoid vs reactive arthritis: Joint space narrowing present?

Rheumatoid: No Reactive: Yes

Rheumatoid vs reactive arthritis: Subchondral sclerosis present?

Rheumatoid: No Reactive: Yes

Rheumatoid vs reactive arthritis: Osteophytes present?

Rheumatoid: No Reactive: Yes

Rheumatoid vs reactive arthritis: Osteopenia present?

Rheumatoid: Yes Reactive: No

Rheumatoid vs reactive arthritis: Bony erosions present?

Rheumatoid: Yes, initially at markings of the joint where synovium is in direct contact with bone Reactive: No

What is a bone spur

Lack of cartilage space leading to bone pressing bone and sometimes a little ridge comes out

Cause of OA? | A and B leading to C, D and E causing F, G and H

Abnormal stress and abnormal cartilage leading to loss of proteoglycans, chondrocyte apoptosis and collagen fibril damage causing cartilage fibrillation, osteophyte formation and subchondral sclerosis

What is articular cartilage made of? (2)

T2 collagen and aggrecan (proteoglycan)

What is synovium made of? (4)

1-3 cell deep lining Macrophage like phagocytic cells Fibroblast like cells T1 collagen

What is synovial fluid composed of? (4)

Hyaluronic acid

what secretes hyaluronic acid?

Fibroblast like cells

Weight-bearing properties of articular cartilage depend on X and Y

intact collagen scaffold and high aggrecan content

Articular cartilage structure? Type of collagen? Cells in it? Molecule in it?

Avascular, aneuronal Collagen type 1 Chondrocytes Proteoglycan monomers (aggrecan)

What are proteoglycans?

glycoproteins containing one or more sulphated glycosaminoglycan (GAG) chains

what molecular group do many proteoglycans contain?

Sulphates

X is the major proteoglycan in articular cartilage

Aggrecan

Hyaluronic acid is the only X GAG and is major component of YY where it has an important role in ZZZZ

non-sulphated synovial fluid maintaining synovial fluid viscosity

Hyaluronic acid disaccharides are:

glucuronic acid and N-acetyl glucosamine

Cartilage changes in OA? (3)

1. reduced proteoglycan 2. reduced collagen 3. chondrocyte changes e.g. apoptosis

BONE CHANGES IN OA: (2, 2 and 2)

1. Changes in denuded sub-articular bone  Proliferation of superficial osteoblasts results in production of sclerotic bone e.g. subchondral sclerosis Focal stress on sclerotic bone can result in focal superficial necrosis 2. New bone formation at the joint margins (termed osteophytes)  Sometimes you can detect osteophytes clinically (‘at the bedside’) and these have names  Osteophytes at the distal inter-phalangeal joints are called ‘Heberden’s nodes’  Osteophytes at the proximal inter-phalangeal joints are called ‘Bouchard’s nodes’

Management of OA? (7)

- Education - Physical therapy – physiotherapy, hydrotherapy - Occupational therapy - Weight loss where appropriate - Exercise - Analgesia Paracetamol, NSAIDs, intra-articular corticosteroid injection - Joint replacement

Medicinal treatments aids for OA?

There are none in the UK