Osteoarthritis + RA, reactive + seronegative arthritis Flashcards by Hannah Gibson

Prevalence for hip + knee

11% hip

24% knee

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Pathology of OA

Loss of cartilage, remodelling of adjacent bone + associated inflammation

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RF for OA

Genetic 
Ageing
Females
Obesity 
Joint injury 
Reduced muscle strength
Joint laxity + misalignment

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Symptoms of OA

Joint pain exacerbated by exercise
Hip OA = felt in groin + anterior/ lateral thigh
Joint stiffness in morning + after rest
Reduced function

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Signs of OA

Reduced range of movement 
Pain on movement 
Joint swelling
Crepitus 
Bony swellings due to osteophytes

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Management of OA

Exercise 
Physio
Weight loss 
Topical NSAIDs + paracetamol 
Intra-articular corticosteroid injections 
Refer for surgery if not responding

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RF for RA

Female 
Smoking 
HLA-DR1 linked 
Winter onset 
High birth weight 
Obesity 
DM

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Pathology of RA

Chronic, autoimmune systemic inflammatory disease

Symmetrical, deforming, peripheral polyarthritis

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Symptoms of RA

Fatigue, flu, fever, sweats, weight loss
Insidious symmetrical polyarthritis, commonly in small joints of hands and feets
Heat, redness, swelling, pain, stiffness (especially in morning or after rest)
Progressive deformity + disability

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Signs of RA

Muscle wasting + tendon rupture

Ulnar deviation, swan neck + Boutonniere’s deformity, Z deformity of thumb + piano key deformity of wrist

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Other manifestations of RA

Eyes: secondary Sjogrens syndrome, scleritis, episcleritis
Leg ulcers + rashes
Rheumatoid nodules on eyes, subcut, heart, lung
Vasculitis, valvulitis, fibrosis

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Investigations for RA

Rheumatoid factor positive in 70%
Inflammation = high platelets, high ESR, high CRP
Positive anti-CCP + negative ANA
FBC: normochrmoic, normocytic anaemia

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X Ray findings for RA

Soft tissue swelling, juxta-articular osteopenia + decreased joint space
Bony erosions, sublucation + carpal destruction

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Management of RA

Early use of DMARDs eg methotrexate, sulfasaline, hydroxychloroquine
Biological agents (TNF alpha inhibitors = infliximab)
Steroids to reduce symptoms + inflammation = methylprednisolone
NSAIDs for symptomatic relief

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Complications of RA

Immunosuppression - neutropenic sepsis

Vasculitis, lymphadenopathy, dry eye syndrome, neuropathy, Felty’s syndrome (enlarged spleen + low white cell count)

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Complications of DMARDs

Methotrexate = pneumonitis, oral ulcers, hepatotoxicity 
Sulfasaline = rash, low sperm count, oral ulcers 
Hydroxychloroquine = irreversible retinopathy

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Complications of biological agents used to treat RA

Infections, reactivation of TB, worsening HF, hypersensitivity, blood disorders

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Differentials for back pain

Sciatica 
Sacro-iliac joint dysfunction 
Cauda equina 
Fractured vertebrae 
Bone mets 
Ankylosing spondylitis (young males)

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What is a yellow flag?

Psychosocial factors indicative of long term chronicity + disability

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What is seronegative arthritis?

Group of inflammatory rheumatic disease with involvement of axial + peripheral joints + enthesitis

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What is enthesitis?

Inflammation at site of insertion of tendons + ligaments to bone

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What diseases are in the group of seronegative spondyloarthropathies?

Ankylosing spondylitis
Reiters syndrome 
Enteropathic arthritis 
Psoriatic arthritis 
Behcet's disease
Juvenile idiopathic arthritis

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What is the gene involved in seronegative spondyloarthropathies?

hla-b27

How do seronegative spondyloarthropathies present?

20-40 y/o 
Inflammatory back pain, stiffness in AM 
Sacroiliitis 
Peripheral arthritis 
Enthesitis 
Dactylitis 
Psoriasis 
Anterior uveitis

Investigations for seronegative spondyloarthropathies

``` ESR + CRP Serum urate Rheumatoid factor, ANA X ray of sacroiliac joints MRI lumbar spine ```

Management of seronegative spondyloarthropathies?

Physical therapy NSAIDs DMARDS (sulfasalazine + methotrexate) Surgery - joint replacements

Complications of seronegative spondyloarthropathies?

Aortitis Mitral valve insufficiency Restrictive lung disease Amyloidosis

What is reactive arthritis?

Form of seronegative spondyloarthritis associated with inflammatory back pain, additive or migratory oligoarthritis + extra-articular symptoms that follow a gastro/ uro infection by 1-6 weeks.

What is Reiter's syndrome?

Clinical subtype of reactive arthritis | Characterised by presence of large joint oligoarthritis, urogenital tract infection + uveitis

What are the 2 subgroups of Reiters syndrome?

``` Post-enteric = following campylobacter, salmonella or shigella Post-venereal = following chlamydia or HIV ```

How does reactive arthritis present?

``` 2-4 weeks after infection Acute onset with fatigue + fever Asymmetrical, lower extremity oligoarthritis Lower back pain Heel pain ```

What is the Reiter's triad?

Urethritis, conjunctivitis, arthritis

Investigations + results for reactive arthritis

``` Microbial tests negative ESR + CRP high FBC - normocytic normochromic anemia HLA-B27 positive RF + ANA negative PCR for chlamydia ```

Management of reactive arthritis

``` Rest joints, then physio NSAIDs Corticosteroids - intra-articular or systemically DMARDs Abx to treat infection ```

Common sites of osteoarthritis

``` Hand (DIP, PIP, 1st CMC) Hip Knee 1st MTP L4-L5, L5-S1 C spine ```

How much calcium do we need a day?

1200mg

When to do bone mineral testing?

Everyone over 65 Anyone under 50 w/ fragility fractures, hypogonadism, chronic inflammatory conditions, hyperparathyroidism 50-65 with fragility fractures, prolonged steroid use, parental hip fractures, vertebral fractures, osteopenia, high alcohol intake, low body weight

Management of moderate fracture risk (+ what is it?)

10 yr fracture risk = 10-20% T4-L4 X ray Consider medications

What is RA, OA + SPA a disease of?

``` RA = disease of synovium OA = disease of cartilage + bone SPA = disease of enthesitis ```

What does osteopenia look like on x ray?

black

RA X ray findings

Erosions, loss of joint space, subluxed joints (partially dislocated)

What bloods are done in ?RA + what blood is used to monitor?

Rheum investigations: anti CCP, RF, CRP, ESR | Monitoring: CRP

OA X ray findings

LOSS (loss of joint space, osteophytes, subchondral sclerosis + subchondral bone cysts)

Where are Bouchards + Heberdens nodes found?

``` Bouchards = PIP Heberdens = DIP ```

What are the forms of SPA?

AS, juvenile SPA, reactive arhtritis, psoriatic, ant uveitis associated

What drugs work for AS, and which don’t?

DMARDS don’t work | Anti-TNF works

What hand joints are affected by RA + OA?

OA - DIP PIP | RA - MCP, PIP

What drugs can be used long term for gout?

Allopurinol + febuxostat

What are the causes of secondary raynauds?

``` Occlusive arterial disease Connective tissue disease Vascular injury Neurovascular compression Drugs (BB, bleomycin, cocaine, caffeine) Hyperviscosity ```

Presentation of NOF fracture

Shortened, abducted + externally rotated | Pain exacerbated with rotation of hip

What is the Beighton score?

``` Evidence of joint hypermobility Palms on the ground Elbow extension Knee extension Thumbs extended to forearm 5th finger extended ```

What are the types of biologics?

T cells (type of white blood cell) Tumor necrosis factor (chemical in body that causes inflammation) Il-1 or Il-6 (inflammatory chemicals) B cells (type of white blood cell

Describe the presentation of Behcets

Syndrome of mouth + genital ulcers, skin problems + other symptoms

What screening needs to be done before starting a biologic?

Hep B/C, HIV, CXR, TB

What is myositis vs dermomyositis?

``` Myositis = inflammation of muscles, autoimmune Dermatomyositis = myositis + rash ```

How do you diagnose myositis?

Electromyography test, muscle biopsy, MRI nbv