Phase 2 - MSK Flashcards

Question

Pathophys of fibromyalgia

Answer 1

Unknown Possibly hyper excitability of pain fibre

Answer 2

- **Increased sensitivity to pain** - **Fatigue** - **Sleep disturbance** - Fibro-fog (problems with memory + conc) - **Morning stiffness** esp back + neck - Headaches - IBS

Answer 3

Clinically diagnosed: - Issues with widespread pain in combination with fatigue, memory, sleep difficulties - **need to feel pain in 11+ out of 18 regions palpated** all over body No serological markers; NO raised ESR/CRP

Answer 4

- Educating patient on the condition - Exercise/physiotherapy - Relaxation - Analgesia (paracetamol, tramadol/codeine) - CBT, counselling, low dose tricyclic antidepressants - for SEVERE NEUROPATHIC PAIN

Answer 5

- affects quality of life - anxiety, depression, insomina - opiate addiction

Answer 6

An autoimmune disorder which causes a hypercoaguable state due to increasing the tendancy of blood to clot - characterised by thrombosis, recurrent miscarriages + aPL Abs Can be primary or secondary to other AI e.g. SLE

Answer 7

Mostly in YOUNG FEMALES

Answer 8

- FEMALE - DIABETES - HTN - OBESITY - Smoking - Oestrogen therapy (at menopause) - other AI e.g. **SLE**

Answer 9

In APS abnormal antiphospholipid antibodies are produced and present in blood. These attack the phospholipids on the surface of blood constituent cells + vessel walls -> impaired blood flow. Can lead to arterial and venous clots. Particularly problematic in pregnancy with a risk of miscarriage.

Answer 10

Remember CLOTS: - Coagulopathy: - Thrombosis -> DVT, PE or Stroke/MI/Renal infarct (or antiphospholipid nephropathy)/Raynaud's - Livedo reticularis - Obstetric issues - **Recurrent miscarriages** or early/severe pre-eclampsia - Thrombocytopenia Balance problems, headaches, double vision etc.

Answer 11

- Hx of thrombosis/pregnancy complications - FBC: may show THROMBOCYTOPENIA - Ab screen: - +VE ANTICARDIOLIPIN Ab (IgG/M) - +VE LUPUS ANTICOAG - +VE ANTI-BETA-2 GLYCOPROTEIN 1 Ab (not necessarily all together) Diagnose after **2 abnormal blood tests 12 weeks apart**

Answer 12

- Low dose aspirin (or antiplatelets e.g. clopidogrel) if no history (prophylactic) - If history of clots + APS Ab: **WARFERIN** - *contraindicated in pregnancy (birth defects + placenta bleeding)* - **Pregnant: LMWH + ASPIRIN** - Lifestyle -> smoking cessation, reg exercise, healthy weight etc

Answer 13

CLOT: -Coag defect - Livedo reticularis - Obstetric complications - Thrombocytopenia (in some)

Answer 14

TUNA FISH: - Trauma (suggests osteoporsis) - Unexplained weight loss (cancer) - Neurological symptoms (cauda equina syndrome) - Age >50 or <20 (secondary bone cancer, ank spond, herniated disk) - Fever (infection) - IV drug use (infection - esp pseudomonas aruginosa) - Steroid use (infection) - History of cancer (spine mets)

Answer 15

- Lumbosacral muscle strains/sprains - Lumbar spondylosis - Herniated disk (oft involves L5/S1 nerve root) - Spondylolysis (minor stress fracture in lumbar vertebra) - Vertebral compression factor - Spondylolisthesis (a vertebra moves foward straining disk + connections to other vertebrae) Spinal stenosis

Answer 16

- Chondrosarcoma - Osteosarcoma - Ewing sarcoma (mesenchymal stem cell in bone marrow) - v. rare (seen in teens - 15 y/o) (also Fibrosarcoma - but is not a bone cancer) Rarer; more common in children Secondary tumours and MYELOMAS are most common

Answer 17

- Previous RADIOTHERAPY - Previous CANCER - PAGET'S DISEASE - Benign bone LESIONS More common in MALES

Answer 18

- Bone PAIN - **WORSE at NIGHT** (wake up at night) - Constant or intermittant (not associated with movement) - may increase in intensity - Resistant to analgesia - Atypical bony/soft tissue swelling/masses - Easy bruising (if affecting bone marrow) - may have path. fractures - Mobility issues (**unexplained limp, joint stiffness, reduced range of motion**) - esp of LONG BONE/VERTEBRAE - Inflammation/tenderness over bone - Systemic symptoms (fever, weight loss, fatigue)

Answer 19

- 1st line: X-RAY - Gold: BIOPSY - Bloods: - FBC, - **ESR/CRP, ALP, LDH, Ca all raised** - U+E - CT chest/abdo/pelvis (staging)

Answer 20

- Osteosarcoma: -looks fluffy (bone destruction), - sun burst, - Codman's triangle (periosteum lifted off bone - can't lay down new bone) - can have LUNG METS - Chondrosarcoma: - Popcorn calcification - Endosteal scalloping - Ewing sarcoma: - Onion skin change

Answer 21

Chemo/Radiotherapy - Bisphosphonates if increased bone lysis Surgery -> limb sparing or amputation

Answer 22

Hypercalcemia, bone pain, metastases, pathological fractures

Answer 23

Osteosarcoma - is the most common primary bone balignancy in general

Answer 24

Poor bone mineralisation leading to soft bone, usually due to vit D deficiency (in adults) AFTER EPIPHYSIAL FUSION Rickets is specifically caused by inadequate mineralisation of bone and epiphyseal cartilage in a GROWING skeleton ie BEFORE EPIPHYSIAL FUSION (children)

Answer 25

- Inherited - Hyper PTH (could be due to low vit D) - Low vit D - Malabsorptive disorders (IBD) - low sunlight exposure/live in colder climate + spend most of time indoors - darker skin - **CKD** (kidneys convert vit D to 1,25-dihydroxyvitamin D (Calcitriol)) - Liver disease (decreased vit d hydroxylation - cholecalciferol -> 25-hydroxyvitamin D) - Anticonvulsant drugs (increased Cytochrome P450 metabolism of Vit D)

Answer 26

Poor bone mineralisation due to CALCIUM DEFICIENCY - usually due to vit D deficiency -> reduced Ca2+ and PO4^3- (forms hydroxyapitite - mineralises bones) -> soft bones

Answer 27

- Fatigue - Bone pain + tenderness - **dull ache which is worse on weight-bearing exercises** - **difficulty weight-bearing** - **Fractures (esp in neck of femur)**; abnormal fractures - PROXIMAL weakness/muscle aches - Waddling gait; difficulty with stairs

Answer 28

- Growth retardation - Hypotonia - **Skeletal deformities**: - Knock knees (valgus deformatiy) - Bow legs (varus deformity) - Wide epiphysis on imaging

Answer 29

- **X- ray**: loss of cortical bone due to defective mineralisation - **Looser zones (transverse lucencies w/ sclerotic borders)** - basically partial fractures - osteopenia - more radiolucent bones - DEXA -> low bone mineral density - Bloods: **low serum calcium + phosphate**, PTH will be raised if vit D def; ALP raised - **Serum 25-hydroxyvitamin D - low** - **Bone biopsy - incomplete mineralisation - DIAGNOSTIC**

Answer 30

- **< 25 nmol/L = vit D deficiency** - 25-50 nmol/L = vit D insufficiency - >75 nmol/L = optimal

Answer 31

- Vit D supplements (-> rapid mineralisation + reduce symptoms) - Colecalciferol (D3 tablets)/increase in diet e.g. eggs - for deficiency: - 50 000 IU 1/wk for 6wks - 20 000 IU 2/wk for 7wks - 4000 IU daily for 10wks - If dietary insufficiency/after initial treatment - 800 IU or more /day for life - If malabs - give IM calcitriol

Answer 32

Focal disorder of excessive bone turnover/ remodelling that results in areas of sclerosis and lysis

Answer 33

- Age >50 - MALE - European origin - FHx

Answer 34

- Excessive Osteoblast/clast activity (resorption + disorganised new bone formation) -> excessive bone turnover - Patchy areas of sclerosis in some places and lysis in others - Enlarged + misshapen bones -> risk of fracture - Particularly affects axial skeleton (skull, spine), pelvis + long bones of limbs Happens in 3 phases: - lytic phase - mixed phase - blastic phase

Answer 35

X-ray: - Bone enlargement + deformity - Osteoporosis circumscripta (well defined lytic lesions) in some places (esp skull) - Cotton wool appearance in skull (poorly defined areas of sclerosis + lysis) - V-shaped defects in long bones Bloods: **ALP RAISED**, everything else normal

Answer 36

- Bisphosphonates - Calcium + vit D supplements (esp while on bisphosphonates) - NSAIDs for bone pain - Surgery to correct deformaties

Answer 37

- OSTEOSARCOMA - Spinal stenosis (narrowing of spinal canal) -> cord compression -> potential neuro symps

Answer 38

Inflammatory condition that causes pain in shoulders, pelvic girdle and neck.

Answer 39

Strong association with GCV - oft occur together - Age > 50 - FEMALE - Caucasian

Answer 40

Cause unknown but believed to be multifactorial. Inflammation of muscles in shoulder, neck + pelvic girdle -> pain + stiffness

Answer 41

Symps **must have been present for 2 weeks to be diagnosed** - Bilateral shoulder pain (may radiate to elbow) - Bilateral pelvic girdle pain - **Worse in morning (>30min)/with inactivity** - Interferes with sleep - RESPONDS WELL TO STEROIDS (like GCV) Systemic: weight loss, fatigue, low grade fever, low mood - upper arm tenderness - carpel tunnel syndrome - pitting oedema

Answer 42

- SLE - myositis - hyper/hypo thyroid - Osteomalacia - Osteoarthritis - Rheumatoid arthritis - Cervical spondylosis - Adhesive capsulitis - Fibromyalgia

Answer 43

Diagnosis mainly based on clinical presentation + response to steroids - Bloods: Raised inflam markers - NORMAL CREATINE KINASE (diff from myositis - no muscle damage) and creatinine (rhabdomyolysis) For diffs - check before starting steroids: - FBC, U+E, urin dipstick, LFTs, Ca, TSH, CK, RF (-ve) - Serum protein electrophoresis (for myeloma/other protein abnormalities)

Answer 44

Initially: **15mg PREDNISOLONE per DAY** - rapid improvement If poor response to steroids after 1 week - probs not PMR - stop steroids + consider alt diagnosis After 3 weeks: - would expect 70% improvement in symps + normal inflam markers to diagnose PMR -> reducing regime (15mg till fully controlled, 12.5mg for 3 wks, 10mg for 4-6wks, reduce by 1mg every 4-8 wks)

Answer 45

Pt needs to be aware they will become steroid dependant after ~3 weeks and must not stop steroids as - risk of ADRENAL CRISIS think STOP: - Sick day rules - if sick, increase dose - Treatment card - to inform others they are steroid dependant if they become unresponsive - Ostoporosis prevention (consider prophylactic bisphosphonates + calcium/vit d supplements) - PPIs (consider for gastric protection)

Answer 46

Autoimmune inflammation (and subsequent destruction) of joints (typically starting with small joints leading onto big joint inflammation) in a symmetrical pattern of involvement. No spinal involvement

Answer 47

- 1-2% population - 2-3x more common in females - Middle age (but any age) - Increase risk of mortality esp CVD - Increasing damage + disability if left untreated (infalmmation treatable. Damage irreversible)

Answer 48

- **Women 30-50 - 3x more likely than in men pre-menopause** - equalises with men after menopause - FHx - HLA DRA/HLA DRB1 genetic link (same group as DM) - Smoking

Answer 49

- ARGININE -> CITRULINE mutation in T2 COLLAGEN - anti-CCP (cyclic citrulinated peptide) formation - Increased T cell mediated w/ neutrophil + monocyte involvement inflammation - releases cytokines -> **SYNOVIAL LINING HYPERPLASIA** -> PANNUS (inflam cells + cytokines) - **Pannus releases metalloproteinase + grows past joint margins -> Erode into cartilage and then bone** - After cartilage breakdown - **bones rub against each other + degenerate**

Answer 50

IL-1 + TNFa

Answer 51

- Pain, hot swelling of: - Symmetrical, typically small joints: hands, wrists, - forefeet - DIP sparing - **Hand deformaties**: - **Boutonniere (like pushing button) - Swan neck - Z thumb - Ulnar finger deviation** - Prolonged early MORNING STIFFNESS (>1 hour) - improves as day progresses - Sudden change in function - Big joints involved later, bad prognostic sign if involved at presentation - BAKER'S CYST - popliteal synovial sac bulge Can get Intermittent, Migratory or Additive involvement - No spinal involvement Extra-articular involvement

Answer 52

- Lungs = pulm fibrosis - Heart = increased IHD risk - eyes = episcleritis, keratoconjunctivitis siccs (dry eyes) - Kidney = CKD - RHEUMATOID SKIN NODULES (most common - esp at elbows) - increased risk of vasculitis and Sjogren's

Answer 53

- Physical Exam - Bloods: - CRP (+/-ESR) - can be raised up to 100 in a flare - RF (70% with RA are RF +ve but non-specific) - **Anti-CCP (cyclic citrullinated peptide) - 70-80% with RA are +ve (specific)** - Selective for patients with most AGGRESSIVE disease (likelihood of damage, multisystem features - tells us additional treatment needed) - **XR esp Hands + feet - DIAGNOSTIC + prognostic**

Answer 54

- Decreased grip strength / difficulty in fist formation - Often subtle synovitis – MCPs, PIPs, MTPs, ankles - DIPs are spared - Usually symmetrical - Deformity unusual at presentation

Answer 55

LESS - LOSS OF JOINT SPACE (narrowing) - EROSION OF BONE - Soft tissue swelling - Soft bone from PERIARTICULAR OSTEOPENIA (imbalanced remodelling)

Answer 56

- DMARDs - need to give quickly as 65-75% efficacy raised to 90% if started within 3 months - **METHOTREXATE (Gold - contraindicated in preg - inhibits folate) - 10-25mg per week** - Also Sulfasalazine, Leflunomide, Hydroxychloroquine (sulfasalzine + hydroxychloroquine ok in preg) - Physio, Ortho, Podiatry -> support + educate - Escalate to BIOLOGICS if RESISTANT (v expensive) - Anti- TNF = **INFLIXIMAB (1ST LINE biologic - alongside MTX)**, ADALIMUMAB - **Rituximab (anti CD20 - ie anti B cell) - 2nd line** - Tocilizumab (IL-6 inhib) - Abatacept (anti-T cell) - JAK INHIBITORS (Baricitinib/Filgotonib) - NSAIDs - STEROIDS injections if v painful (can give oral too) - Ice - Splints/rest

Answer 57

Acute joint pain + swelling caused by inflammatory response to deposition of monosodium urate crystals intra-articularly

Answer 58

Gout 6x more common in MEN (7.3% >75 y/o) + ELDERLY - esp OVERWEIGHT - Overall male : female ratio 5:1 - Uncommon in females under 50 due to hormone

Answer 59

Hyperuricaemia Intake: - ALCOHOL (beer, lager, stout) - rich in GUANOSINE - Diet – red meat, shellfish, offal - Sweetened soft drinks (**fructose shares renal uric acid transporter so promotes uric acid pathway -> don’t get rid of uric acid -> hyperuricemia**) Output: - CKD (more common in elderly) -> lactic acid + ketones - Drugs - esp DIURETICS, aspirin, cyclosporin, TB drugs - Genetics - Fructose shares renal uric acid transporter Uric acid also a product of DNA/RNA metabolism - high cell turnover -> increased urate

Answer 60

HYPERURICAEMIA (plasma supersaturated at 360mmol/L -> MONOSODIUM URATE crystal formation - deposit in joints -> affects synovial cells - immunological reaction initiated to try and remove them, leads to acute pain and swelling

Answer 61

- Acute episodes (will recover spontaneously within 7-10) - recurrent - typically predictable = MONOARTICULAR esp MTP big toe joint - also Mid-foot, ankle, knee, wrist, elbow, hand - esp at NIGHT - Swelling, Erythema, Shiny overlying skin - possible periarticular involvement - E.g. Olecranon bursitis - bursa fills with extra fluid due to irritation/inflam -> swollen - activates inate immune so sometimes get systemic - can't put weight on it - Chronic = has Tophi (pathognomonic)

Answer 62

Septic arthritis Trauma Gout Calcium Pyrophosphate Arthritis (pseudogout) Rheumatoid Arthritis (Osteoarthritis!) - also oft commonly involves toe

Answer 63

🡪 asymptomatic hyperuricemia, 🡪 acute/recurrent gout, 🡪 intercritical gout (recurrent flares - intercritical = time between flare, typically occurs within 2 years) - more + more frequent 🡪 chronic tophaceous gout (typically after 10yrs or more of recurrent polyarticular/poorly controlled gout - Tophi can form in soft tissue, osseous tissues, ligaments and different organs and either in presence or absence of gouty arthritis) - tophi is just the name of the stone like monosodium urate deposits - esp undersurrounding skin

Answer 64

Gold = JOINT ASPIRATION + POLARISED LIGHT MICROSCOPY - STRONGLY NEGATIVELY BIREFRINGENT NEEDLE SHAPED crystals - not seen in normal health Also: - FBC (raised WCC) - U+E (checking kidney function - affects treatment) - LFT if concern re alcohol - Serum Uric Acid (often normal during acute attack as uric acid is in joint so less in blood) - CRP - Only use Xray if recurrent episodes or concern re sepsis - Punched out/Rat bite EROSIONS (joint space preserved but erosion away from/below articular border) - extensive in late disease

Answer 65

- Rest, ice, hydrate, continue urate lowering therapy - NSAID (short course) but CONTRAINDICATED if: - Renal failure - Peptic Ulcer Disease - Some pts with asthma - COX-2 inhibitors (NSAID alt) - Elderly don’t tolerate NSAIDs well - Colchicine (alt to NSAIDs) - anti-mitotic - disrupts multiple inflam pathways - SE = Diarrhoea - Corticosteroids - Intra-articular injections - Oral - low dose (5-10mg short course) Other analgesics don’t work! - they don’t deal with inflammation EDUCATE PATIENT - explain the disease -Advice about lifestyle, Alcohol, Diet, Weight loss - reduce purines, increase dairy - Adequate fluid intake (increased incidence in summer due to dehydration)

Answer 66

URIC ACID LOWERING THERAPY: Xanthine Oxidase Inhibitors: - 1. **Allopurinol** (1st line) - 2. Febuxostat (if allopurinol not tolerated/doesn’t work - e.g. CKD) – more potent Xanthine Oxidase Inhibitor Increases urate excretion - 3. Benzbromarone / Probenecid – if allergic / intollerant - Losartan Give Colchicine 500microg OD for 6 months alongside this as there is an increased risk of CV morbidity (lots of uric acid being moved around body)

Answer 67

1. Recurrent attacks 2. Evidence of tophi or chronic gouty arthritis 3. Associated renal disease 4. Normal serum Uric acid cannot be achieved by life-style modifications

Answer 68

REDUCE URIC ACID BELOW <300 umol/l

Answer 69

Disability and misery Tophi Renal disease: - Calculi 10 -15% - Chronic urate nephropathy - Acute urate nephropathy (cytotoxics)

Answer 70

Deposition of CALCIUM PYROPHOSPHATE crystals along joint capsule

Answer 71

3x more common in WOMEN - esp ELDERLY - Typically on background for OA

Answer 72

- Diabetes - metabolic disease - OA

Answer 73

- oft POLYARTICULAR w/ KNEE commonly involved (also wrists, hands) - SWOLLEN, HOT, RED joint

Answer 74

JOINT ASPIRATION + POLARISED LIGHT MICROSCOPY - **slightly positive birefringent rhomboid shaped** crystals - can sometimes be found in normal health Also: - FBC (raised WCC) - CRP - X RAY - CHONDROCALCINOSIS - May see subcondral cysts

Answer 75

Only acute treatment - NSAIDs - then Colchicine - then Steroid injections

Answer 76

A systemic skeletal disease characterised by **low bone mass and microarchitectural deterioration** of bone tissue, with a consequent increase in bone fragility **and susceptibility to fracture**

Answer 77

% of people who will get an osteoporotic fracture: - 50% of females over 50 (POST MENOPAUSAL CAUCASIAN WOMEN) - 20% of males over 50

Answer 78

SHATTERED - Steroids or RAISED CORTISOL (Cushings) - increase resorption + induce osteoblast apoptosis - Hyperthyroid/Hyper PTH - Alcohol + smoking (poisons osteoblasts) - Thin (low BMI)/reduced skeletal loading - Testosterone LOW - EARLY MENOPAUSE (low oestrogen) - Renal/Liver failure - Erosive/**Inflam disease** - cytokines increase resorption - DMT1 or Malabsorption Older age, any type of hypogonadism, previous fractures - FAMILY HISTORY (50% bone structure inherited) Drugs: Depo-provera (in young women) Aromatose inhibitors (breast cancer) GnRH analogues Androgen deprivation

Answer 79

Fractures triggered by some sort of force greater than strength of bone Bone strength affected by: - Bone mineral density (standard measure of osteoporosis) - Bone size - Bone quality (depends on Turnover, Architecture + Mineralisation) Oestrogen keeps bone turnover damped down - Post menopausal -> loss of restraining effects Increased bone turnover (more and more left in partially resorped state) → net loss of bone Trabecular architecture becomes poorer with age: -> loss of cross connecter trabeculae which prevent buckling -> ~16x weaker bone Remodelling unit activation frequency increases with age - damage more likely so remodelling needed more

Answer 80

FRACTURES - Wrist (Colles) - fall on outstreatched wrist - more common in 50-60 y/o - Hip/Proximal femur - older ppl fall + can't catch themselves - Compression vertebral crush (may cause kyphosis)

Answer 81

Bone densitometry - **DEXA scan** - Duel energy XR absorptionometry but low radiation dose - For risk assessment + diagnosis - Sites: - LUMBAR SPINE - PROXIMAL FEMUR - DISTAL RADIUS - Gives a T-SCORE - a standard deviation score: - Number used for DIAGNOSIS - Compares with a GENDER-MATCHED YOUNG ADULT mean Also FRAX score (Fracture Risk Assesment Tool) - assess 10y fracture risk in osteoporotic patients

Answer 82

T-score - Osteoporosis = < -2.5 - Osteopenia = -1 - -2.5 severe osteoporosis os <-2.5 + a fracture

Answer 83

Anti-resorptive: - BISPHOSPHONATES - inhibit osteoclasts by inhibiting RANK-L signelling - Oral: ALENDRONATE (daily/weekly), Risedronate, Ibadronate - IV: Ibadronate, Zolendronate (once yearly) - Denosumab - rapid acting RANK-RANKL inhibitor (potential rebound turnover increase if stopped) Anabolic: Teriparatide (PTH analogue) - expensive Also: - HRT - oestrogen receptor modulator - raloxifere

Answer 84

Direct bacterial infection of a joint - direct access or haematogenou spread

Answer 85

45% > 65 y/o Prosthetic joint infection > native - Risk of infections in prosthetic joints increasing - Septic revision = X2 cost of non-septic and >3x cost of primary replacement M = F

Answer 86

- V Painful, red, swollen, hot joint w/ joint in previously fit person - Children may just not use it so you may not notice at first - 90% monoarthritis (don’t rule out if polyarticular) - KNEE > Hip > shoulder MEDICLA EMERGENCY - can destroy knee in 24hrs or less!

Answer 87

- Any cause for bacteraemia - Direct/penetrating TRAUMA - Local skin BREAKS/ULCERS - DAMAGED joints - PROSTHETIC JOINTS - IMMUNOSUPPRESSION (including just steroids) - ELDERLY (>65 Y/O) - RA or other immune diseases - DIABETES

Answer 88

- **Staph Aureus** (esp consider if have RA/DM) - mc - Strep - Group A (pyogenes) - b haemolytic - Group B - Strep pneumoniae - Neisseria gonorrhoea (consider in young, sexually active, MSM) - Gram -ve bacilli (consider in extremes of age, if systemically unwell or IVDU) - E coli - Pseudomonas Aeruginosa - Anaerobes (diabetes) - Clostridium - Bacterioides - Mycobacterium - typically TB (immunocomp) - Fungi (immunocomp)

Answer 89

<2 y/o: - S AUREUS - Strep esp Gp A - Gram -ve bacilli (e.g. Kingella Kingae - a oropharyngeal commensal) - Historically most common were HAEMOPHILUS INFLUENZA, s aureus and strep (Gp A) but H influenza is no longer a common infection due to the vaccination program >2 y/o: - S AUREUS - Strep - Gram -ve bacilli -Historically H influenza was more common than gram -ve

Answer 90

- STAPH AUREUS (most common) - Enterococci - MRSA - Enterobacter - Pseudomonas - Diphtheriodes - Haemolytic strep - Anaerobes

Answer 91

- FBC: high WCC (neutrophilia) - CRP raised (esp if over 100 - up to 100 could indicate a RA flare) - ESR can be normal - Blood cultures (sepsis) - sexual health review to check for gonorrhoea - **Joint aspirate** (usually seeded by bacteraemia) - GOLD, always do - Turbid fluid (ie more opaque/cloudy/thick+gloopy) - Leukocyte positive - Gram stain for microbes - polarised light microscopy to rule out gout/pseudogout

Answer 92

- History - Oft present with just pain (not hot/swollen) - Local: wound healed slowly; always been sore (means infection was always there since prosthesis put in - presents faster) - Haematogenous: became painful after recent infection/dental work - Examination - X-rays - FBC (usually unfelpful - high WCC uncommon as usually chronic) - ESR, CRP - Single CRP >10 and ESR >30 = 50% chance of infection (if normal 90% chance not infected) - Multiple raised = 80% chance of infection (if multiple normal = 95% chance not infected) If other tests inconclusive: Alpha defensin (antimicrobial peptide secreted by neutrophils) - sensitivity/specificity ~95% but v expensive **ASPIRATION** -> Microbio culture (aerobic + anaerobic) - Patient *needs to be off antibiotics for at least 2 weeks*

Answer 93

- Stop immunosuppression - If on long term steroids - DOUBLE DOSE as they may be unable to naturally increase steroid levels - Analgesia (NSAIDs) - **JOINT ASPIRATION (repeatedly if needed) + washout until no recurrent effusion** - empirical ANTIBIOTICS - long course: 6 WEEKS MIN - flucloxacillin for g-ve, - vancomycin for MRSA, - **ceftriaxone + azithromycin (gonorrhoea)** - Splinting/rest/off-load with crutches/physio

Answer 94

- Analgesia - Stop immunosuppression, increase steroids etc Potential options: - after determining specific bacteria -> ANTIBIOTIC SUPPRESSION - will not eliminate sepsis but used if unfit for surgery/if they have multiple prosthetic infections - DEBRIDEMENT + retention of prosthetic - NOT FOR CHRONIC, retains infection - only if prosthesis not loose - EXCISION ARTHOPLASTY (remove only infected section, let it fill in with scar tissue) - if HIGH RISK - One stage arthroplasty - RADICAL DEBRIDEMENT - avoid bone graft - will reinfect - 85% success - Two stage arthroplasty - radical debridement - can put in local antibiotic spacer/give systemic Abx in waiting period - 90-95% success - Amputation

Answer 95

Occurs from disseminated gonococcal infection - Fever (potentially), arthritis, tenosynovitis (inflammation of tendon sheath/synovial membrane around tendons - harder to aspirate) - Polyarticular - multiple joint, small + large - Maculopapular (grey base - pustular lesions) - Esp in Peripheries (palms, soles) - Painful before it is visible - Usually >5 lesions

Answer 96

Acute inflamed infected BM

Answer 97

Increasing incidence of chronic osteomyelitis - increased prevalence of predisposing conditions such as diabetes mellitus and peripheral vascular disease. - Ageing population **Bimodal age distribution ** - Children 80% of acute, haematogenous osteomyelitis - Adults >50 y/o - Adolescents and adults get contiguous osteomyelitis/direct inoculation (often associated with direct trauma) - Older patients: oft contigous linked to Diabetes mellitus/Peripheral Vascular disease/Arthroplasties

Answer 98

- Behavioural factors -Ie risk of trauma - e.g. if they enjoy extreme sports etc - Vascular supply (poor) - Arterial disease - DM - Sickle cell disease - Pre-existing bone/joint problem - Inflammatory arthritis - Prosthetic material including arthroplasty - Immune deficiency - Immunosuppressive drugs - Primary immunodeficiency - Similar RFx to IE - IVDU - Central lines; on dialysis - Catheter - UTI/other infection

Answer 99

Common microbes: - STAPH AUREUS (mc) - coagulase-negative staphylococci, - aerobic gram-negative bacilli (30%) Others: - Streptococci (skin, oral) - Enterococci (bladder, bowel) - Anaerobes (bowel) - Fungi, (immunocomp) - Mycobacterium tuberculosis (immunocomp) In SCD: - SALMONELLA In IVDU: - PSEUDOMONAS AERUGINOSA - Serratia marcescens

Answer 100

- Direct innoculation - trauma/surgery (poly/monomicrobial) - Contigous spread - from adjacent soft tissue/joints (poly/monomicrobial) - Haematogenous seeding (monomicrobial)

Answer 101

Children = LONG BONES - High but slow blood flow to metaphysis of growing long bones (high metabolic activity) - Endothelial basement membranes absent (easier to get into bone) - Capillaries lack/have inactive phagocytic lining cells (less immune defence) - Predisposes to infection Adults = VERTEBRAE + clavicle/pelvis - Vertebrae become more vascular with AGE - Bacterial seeding of vertebral endplate more likely - Also: lumbar vertebral veins communicate with pelvic veins with valveless anastemoses. Can get infection via retrograde flow from lower GU infections IV Drug Users = CLAVICLE + PELVIS (oft younger so vertebrae less vascular)

Answer 102

Microbial surface components adhere to matrix molecules - Acutely -> inflammation + bone oedema - Chronic -> SEQUESTRUM INVOLUCRUM - Infalm exudate in marrow - Causes increased intramedullary pressue - Causing extension of exudate into bone cortex - It ruptures through periosteum - Interrupts periosteal blood supply -> NECROSIS - Leaves separated pieces of dead bone - NEW BONE forms - necrotic bone embedded in pus + thick sclerotic bone placed around sequestra to compensate + support abnormal

Answer 103

- Onset over SEVERAL DAYS - DULL BONY PAIN + HOT + SWOLLEN + ERYTHEMA - May be aggravated by MOVEMENT - Systemic: FEVER, RIGORS, sweats, malaise If Vertebral OM: lumbar most common - May extend posteriorly -> epidural/subdural abscess or meningitis - Anterior/lateral extension -> abscesses in surrounding structures e.g. retroperitoneum, psoas If chronic: typical signs + any of below - DEEP ULCERS (sequestrae) that fail to heal despite several weeks of treatment - Non-healing fractures - Draining sinus tract Can also occur close to joint and pus can discharge into joint when infection breaks through cortex (more common in infants)

Answer 104

- Soft tissue infection (Cellulitis (deep dermis + subcut) and erysipelas (dermis +/- superficial cutaneous lympatics)) - Bursitis (swelling of joint soft tissue) - CHARCOT JOINT - Progressive degeneration of weight bearing joint + bony destruction due to sensory nerve damage e.g. in DIABETIC NEUROPATHY - Oft affects foot -> presents w/ Diabetic feet - Gout - Avascular necrosis of bone (from steroids, radiation, bisphosphonates) - Fracture - Malig

Answer 105

- History (symptoms) - Examination (signs) - Lab tests: CRP + WCC (FBC) - Acute - HIGH WCC - Chronic - can have NORMAL WCC - CRP raised but can be normal - Imaging: - PLAIN XR - Poor sensitivity/specificty esp in EARLY OM - Only osteopenia initially - **>1-2 weeks before bone changes** - MRI (more senstitive) - marrow oedema from 3-5 days - Delineates cortical, bone marrow and soft tissue inflammation - CT (alternative to MRI) - Nuclear Bone scan if metalwork makes CT/MRI impossible - BLOOD CULTURES (can be diagnostic) - may not need invasive diagnostic testing if organism isolated from blood is a pathogen likely to cause osteomyelitis. - +ve in 50% of Acute OM - BIOPSY (diagnostic) - Open bx >>> needle bx - 2 specimens better than 1 - Culture - 16sRNA PCR may be necessary (to get enough to culture) - Histology showing inflammation and osteonecrosis

Answer 106

- cortical erosion, - periosteal reaction, (edge raised) - mixed lucency, - Sclerosis - sequestra - soft tissue swelling

Answer 107

- Immobilise - ANTIMICROBIAL THERAPY - **6 weeks IV minimum** - first broad spectrum empirical then tailor to specific - Vanc/Teicoplanin (MRSA + s aureus) - Fusidic acid (s aureus) - Flucoxacillin (salmonella) - poor penetration to bone if vascular disease - stop based on CRP response - failure to respond -> re-image (but bone changes may persist even with infection resolution) - faster resolution if TOTAL SURGICAL DEBRIDEMENT

Answer 108

it's longer lasting - GI upset - Pruritis

Answer 109

TB OM - May be **slower onset** - Systemic symptoms - Epidemiology different from pyogenic OM - Blood Culture less useful - **Biopsy essential** - prolonged mycobacterial culture - **Caseating Granolumata on histology** - Induced sputum may help (sometimes occult pulmonary TB) - **Longer treatment 6 months**

Answer 110

- Asymmetrical inflammation of BIG joints with SPINAL involvement (excluding psoriatic arthritis which can be Symmetrical) - Seronegative = RF negative - More common in MEN - ASSOCIATED w/ HLA B27 (MHC-1) - link to IBD

Answer 111

SPINE ACHE - Sausage digits (dactylitis) - Psoritis - Inflam back pain - NSAID GOOD RESPONSE - Enthesitis (inflam of enthesis - site where ligaments insert into bone - esp heel) - Arthritis - Crohn's/Colitis/raised CRP (can have normal CRP in AnkSpond) - HLA B27 - Eye (anterior uveitis)

Answer 112

Abnormal stiffening of joints - primarily sacrioiliac + axial skeleton - due to new bony formation - Prolonged Inflam/oedema -> fatty change -> calcium deposists along tendon - SYNDESMOPHYTES (vertical abnormal growth) esp at corners of vertebrae - make spine less mobile

Answer 113

- HLA-B27 ASSOCIATED - class 1 so in all cells (possible to have without HLA-B27 tho) - Molecular mimicry (e.g. if pathogenic molecule has compound similar to HLA-B27 -> ) - Misfolding theory (sets of inflam due to diff shape) - IL23, IL17, 16, TNFa - KEY - Heavy chain homodimer hypothesis - **MALE - usually <40 y/o** - Smokers

Answer 114

- Progressively worsening (in flares) LOWER BACK PAIN + STIFFNESS - Worse in morning/after inactivity; better with movement - alternating nagging sacroileac/BUTTOCK pain - EMPHASITIS (esp achiles tendon) - swollen, thick, increased blood flow - Anterior uvitis - photophobia, possible vision blurring, iris scarring if recurrent - Psorisis (elbows + knees - extensor surfaces) - red base, white scale, itchy - clear synovial fluid accumulation - End-stage: fusion of spine + SI joint - Severe kyphosis (question mark posture) - can get costovertebral + costosternal inflammation -> potenitally eventual restrictive lung disease Complication: vertebral fractures

Answer 115

- Youngish patient (teens/20s) - Gradual onset over >3 months - Can go to sleep fine but wake up in middle of night due to (usually thoracic) back pain - Improves with movement - Significant morning stiffness (>30 mins) - Alternating, nagging buttock pain - radiating down back of thigh (sacroileac joint pain)

Answer 116

- **CRP + ESR - raised (1st LINE)** - HLA B27 genetic test - oft positive - MRI spine - Subchondral periarticular bone marrow oedema (early changes) breaking out of cortical bone - over time heals with fatty change - XR spine/pelvis (takes 8-10 years to show up usually) - bamboo spine (END STAGE) due to ossification of ligaments, discs + joints (calcium has grown along ligaments, fused spine together) -> radiographic stage (ankylosing spondilitis) - Syndesmophytes (bony growth originating from spinal ligament - like stalactites) - more common in men; more likely if elevated CRP - Squaring of vertebral bodies - Subchondral sclerosis + erosions - Can get ribcage involvement (fusion of facet + costovertebral joints) - Sacroiliitis (sacrum + hips) - have fused together - stops being painful but reduced mobility

Answer 117

SCHOBER TEST - they make marks 10cm above and 5cm below the ileac crest or L5 (around 15 cm apart) - When they bend over with the legs fully extended (and feet 30 cm apart) - the marked area should extend by around 5cm or more (at least ~20cm) - <5cm increased length on flexion = indicative of ank spond - <2 = severe

Answer 118

- Exercise, Physiotherapy, lifestyle advice (smoking ceaseation) - NSAIDs - Biologics (disease modifying) - Anti-TNF, - **etanercept (not an Ab), infliximab**, adalimumab - Anti-IL17 - Secukinumab - JAK inhib (good for whole spectrum) - works inside cells SULFAZALASINE DOESN’T WORK on SPINAL INFLAM

Answer 119

- 10-40% w/ psorisis develop within 10 y - 1 in 5 with psoriasis have psoriatic artheritis - 40-60% have HLA B27

Answer 120

- Symmetrical or Asym - INVOLVES DIPs - ATLANTA-AXIAL joint involvement - ENTHESITIS - Achiles tendon, plantar fascia - DACTYLITIS - NAIL PITTING (>5-10 pits across both hands = indicative) - ONYCHOLYSIS - lifiting of nail from nail bed - End-stage = bone fusion

Answer 121

ARTHRITIS MUTILANS (v rare) - Occurs in phalanxes - Osteolysis of bones around joints in digits → progressive shortening - Skin then folds as digit shortens → **telescopic finger** PENCIL IN CUP DEFORMITY

Answer 122

- Bloods: ESR + CRP - normal or raised; RF -ve; ant-CCP -ve - HLA-B27 genetic test - may be positive - X RAY: - DIP EROSION - Periarticular NEW BONE formation (looks DARKER) - Osteolysis (destruction) - Dactylitis (diffuse inflam appears as soft tissue swelling - may be more visible on MRI) - Pencil-in-cup deformity (in MUTILANS)

Answer 123

- NSAIDs for symps - steroid injection if severe - Physio - DMARDS esp METHOTREXATE - try avoid sulfasalazine - CVD issues - if fails then ANTI-TNF (INFLUXIMAB, ETANERCEPT, adalimumab) - if that fails: IL12/23 BLOCKERS - USTEKINUMAB - works best for peripheries - IL17 blockers

Answer 124

Sterile inflammation of synovial membranes + tendons triggered by infection at DISTANT site - usually GI or genital/STI

Answer 125

- **C trachomatis** - Campy jejuni - Salm enteritidis - Shigella Also: - yersinia - ureaplasma urealyticum

Answer 126

Usually 2 days - 2 weeks post infection - Asymmetrical Oligoarthritis (affects 4 or less joints) - esp knees, ankles, feet - hot, swollen, painful, red + stiff joint - Dactylitis - REITER'S TRIAD: can't see, can't pee, can't climb a tree - Conjunctivitis (discharge, burning, photophobia) - typically bilateral - may have anterior uveitis - Urethritis/Circinate balanitis (inflam of penile head with lesions) - Reactive arthritis + Enthesistis - Keratoderma blennorrhagica - palmo-plantar browny pustular rash

Answer 127

- Bloods: ESR + CRP raised - HLA B27 may be +ve - ANA - negative - RF - negative - X-RAY - Sacroiliitis (pain in SI joints) - Enthesitis - Joint aspirate (MC+S) - negative (to exclude septic) - Can confirm not gout if sent for crystal examination Sexual health review + stool culture

Answer 128

- NSAIDs - Steroid injections (systemic steroids if polyarticular) - Prophylactic Abx till septic excluded >6 consequtively = CHRONIC - DMARDs (MTX) then anti-TNF if MTX doesn't work

Answer 129

Inflam arthritis that flares up alongside IBD. Oft has inflam pain without overt arthritis. Oft involves SACROILIITIS. Peripheral arthritis that subsides with remission of IBD. - same extra-articular manifestations as IBD

Answer 130

Autoimmune systemic inflammation caused by a Type 3 hypersensitivity reaction (antigen-antibody complex deposition) Impaired apoptotic debris is pressented to TH2 cells -> B cell activation -> immune complex formation + deposition -> inflammation + tissue damage

Answer 131

Most common in FEMALES - more common in Afro-Caribbean premenopausal women (20-40)

Answer 132

- FEMALE (12x higher risk) (16-64 - of child bearing age) - HLA B8/ DR2/DR3 - Low C4 (due to null allele) - Drugs (e.g. isoniazid - anti-TB) Strong association with Antiphospholipid syndrome + thrombosis

Answer 133

Specific skin changes: - Acute: - **Malar (butterfly) rash (photosensitive) - sparing of nasolabial folds** (crease from nose to mouth) - Generalised erythema - Bullous LE (blistering) - Subacute - Annular (ring around lesions) - Psoriasiform - Chronic - **Discoid (scarring)** - Scarring alopecia (no hair regrowth) - Lupus profundus (tender, deep, subcutaneous nodules/plaques - localised on esp lateral aspects of arms/shoulders, breast, trunk, buttocks; also scalp, face, proximal extremities) Non-specific skin changes: - Panniculitis (inflammation of subcut fat - red + tender) - Urticarial lesions (raised, v itchy rash e.g. hives/welts) - Vasculitis - Livedo reticularis (mottled appearance) - **Oral lesions** - Non-scarring alopecia Joints: - Symmetrical + non-errosive - Deformaties can be corrected - Less proliferative than RA Can affect any system: - GLOMERULONEPHRITIS (nephrItic) - *Seizures + Psychosis* - **Serositis (pleural/peritoneal/pericardial inflam)** - **Pleural effusion** - ANAEMIA (AHA - Coombs pos) - RAYNAUD'S - Potential Pyrexia - **Recurrent miscarriages - Antiphospholipid syndrome**

Answer 134

- FBC - CYTOPENIAS (Hb, WCC, plts) - RAISED ESR - CRP may be NORMAL - Creatinine raised - Urine dipstick - haematuria + proteinuria (Nephritic syndrome) - Serology: - *99% ANA +VE* (sensitive) - **Anti-dsDNA Ab (specific - monitor progression)** - Anti-Ro, La, SM (smooth muscle) - may have ribonucleoprotein Ab - LOW C3 + C4 - CXR - potential PLEURAL EFFUSION

Answer 135

No treatment if mild: - Educate + support (avoid triggers esp sunlight) - Assess any major organ damage - IF ANTIPHOSPHOLIPID AB +VE - AFFECTS TREATMENT DURING PREG - Control atherosclerosis risk factors - Topical - Sunscreen - **Corticosteroids** - **Oral/IV steroids if evidence of active disease (not long term)** - Topical/oral Cytotoxic if SEVERE (careful in pregnancy) - **Azathioprine, Mycophenolate**, Ciclosporin, Methotrexate, Cyclophosphamide (most powerful) - **NSAIDs (for joints)** - **Hydroxychloroquine if DMARD needed** - Anticoags - Biologics - Rituximab (if severe) - Belinumab - Autologous stem cell transplant (last resort)

Answer 136

- Pale + cyanotic changes esp in peripheries - Can be precipitated by drugs - Can get vascular damage e.g. Atherosclerosis, frostbite, secondary to vibrating tools Primary: - Fairly benign - No digital ulcers Secondary - related to connective tissue diseases esp Systemic sclerosis, SLE and mixed - Can develop later in life - Can get digital ulcers

Answer 137

Multisystem autoimmune EXOCRINE DYSFUNCTION Can be primary or secondary (Associated with other AI conditions)

Answer 138

**Dry, dry, dry** - Dry eyes (keratoconjunctivitis sicca) - Dry mouth (xerostomia) - Parotid swelling - Dry vagina Also: - Arthritis - Rash - Vasculitis - Neurological - Interstitial lung disease - Association with pericarditis - Renal tubular acidosis (type 1)

Answer 139

- Serology: - **Anti-Ro + Anti La (for PRIMARY sjogren's)** - ANA oft +ve; RF may be +ve - SCHIRMER TEST - induce tears + place filter paper in/under eyes - <10mm significant (healthy should travel at least 15mm) - US - abnormal salivary glands Uncommonly a lip biopsy may be done -> Sialadenitis (salivary gland infection)

Answer 140

- Tear + saliva replacement - Vaginal lubrication - Hydroxychloroquine - if history of fatigue, mayalgia, arthralgia or rashes - can stop progression - Corticosteroids (if organ-threatening involvement) - Immunosuppression if lung/kidney involvement

Answer 141

Risk of RENAL TUBULAR ACIDOSIS - type 1: - Syndrome characterised by hyperchloremic metabolic acidosis (ie acidosis caused by bicarb loss) with a normal anion gap - (type 1 = problem at distal part of tubules; type 2 = problem at proximal part of tubules, type 3 = carbonic anhydrase 2 def + carbonic anhydrase inhib block metabolism of bicarbonate + carbonic acid (rare); type 4 = hyperkaelemic distal) - Treat with alkali therapy **Directly confers Increased risk of LYMPHOMA** - Eye infections (conjunctivitis, corneal ulcers) - Oral problems (dental cavities, candida infections) - Vaginal problems (candidiasis, sexual dysfunction)

Answer 142

A vasculopathy related to excessive collagen deposition. There is inflammation and often autoantibodies are produced. - Most common type is LIMITED CUTANEOUS SCLERODERMA - Diffuse cutaneous - Sine scleroderma (no skin changes) - Mixed connective tissue disease

Answer 143

CREST - Calcinosis (deposits subcutaneously) - can feel chalky if they break through skin-> RENAL FAILURE - Raynaud's (long history) -> digital ulcers - Esophageat dysmotility/STRICTURES (swallowing difficulty) - SCLERODACTYLY (local skin thickening/tightening on digits) -> restricted movement (similar skin tightening can occur on the face -> small mouth) - Telangiectasia (spider veins - skin/mucous membranes - sometimes just look like erythamatous points) - whiten when pressed -> risk of pulm HTN at late stage Can get iron deficiency anaemia - can see 'watermelon stomach' on endoscopy

Answer 144

- Proximal scleroderma (skin tightening) with trunk involvement - Shorter history of raynaud’s - Increased risk of renal crisis, - Increased risk of cardiac involvement, (e.g. myocarditis, pericarditis) - Increased risk of interstitial lung fibrosis

Answer 145

Limited: - ANTI CENTROMERE Ab - 70% Diffuse = Scl-70 (topoisomerase) Ab - Oft ANA +VE - may be RNA polymerase Ab pos

Answer 146

No cure - treat symps Raynauds: - Physical protection e.g. gloves - Vasodilators - issue if hypotensive - Nifedipine, Iloprost (IV for digital ulcers), Sildenafil, Bosentan - Fluoxitine (SSRI) - Sympathectomy (strip away adventitia from affected vessels) - Gastro-oesophageal reflux = PPIs for life - Prevent renal crisis -> ACE-I Early detection of pulm arterial HTN: - Annual echos + pulm function tests **Treat pulm fibrosis - Cyclophosphamide** - Nintedanib Treat skin oedema: - No treatment (mild) - Mycophenolate (more severe) - Autologous stem cell transplantation (widespread + severe)

Answer 147

Included in a group of autoimmune conditions characterised by progressive muscle weakness, aching or pain. Causes inflam + necrossi of skeletal muscle - Dermatomyositis also affects skin Can be caused as part of paraneoplastic syndrome

Answer 148

POLYMYOSITIS: more common in WOMEN; esp 30-60 Y/O DERMATOMYOSITIS: more common in WOMEN; can also affect CHILDREN (juvenile dermatomyositis) HLA B8/DR3 genetic link

Answer 149

- Symmetrical wasting of muscles of shoulder + pelvic girdle -> stiffness worse in morning, improves with activity - oft complains: trouble raising arms/raising from chairs or squatting - may involve resp muscles - linked to INTERSTITIAL LUNG DISEASE Derm: - GOTTRON’S PAPULES - rashes on backs of knuckles (DIPs, PIPs) - HELIOTROPE eyelid rash - Photosensitive shawl sign - may get Malar rash - may get calcinosis cutis

Answer 150

- Bloods: LDH + Creatine Kinase RAISED - Serology: Anti Jo1 - **Dermatomyositis only = Anti Mi2** - Electromyography (EMG) - muscle inflam - MUSCLE FIBRE/skin BIOPSY -> Inflam/NECROSIS (DIAGNOSTIC) - CXR, pulm function tests, high res CT - check lungs Screen for malig (PET-CT)

Answer 151

- 1st line = steroids: PREDNISOLONE - 1 m then titre down dose - If inadequate response -> Immunosuppression - MYCOPHENOLATE, AZATHIOPRINE - IV Rituximab if needed

Answer 152

Heterogenous, multisystem inflammation of blood vessels Large vessel: - Giant cell arteritis - Takayatsu (same as GCA but specifically affects aortic arch of east asian, mainly women) Medium vessel: - POLYARTERITIS NODOSA - Buerger's disease (male smokers 20-40, peripheral skin necrosis) - Kawaski disease (Coronary artery aneurysm in KIDS) Small vessel: - pANCA ASSOCIATED (Eosiniophilic granulomatosis w/ polyangitis) - cANCA ASSOCIATED - GRANULOMATOSIS w/ POLYANGITIS (GPA) - Henloch Schonlen Purpura/IgA vasculitis (Immune complex mediated)

Answer 153

- Vessel size - Chappel Hill Consensus classification - Hybrid of vessel size, pathophys + underlying

Answer 154

Affects branches of EXTERNAL CAROTID Histologically: - Activated immune cell (lymphocytes/macrophages) infiltration of vessel wall -> DIRECT damage + stimulates smooth muscle cell remodelling - Blurred margin between media and adventitia - Intima proliferated into lumen -> narrowed - Vessel wall infiltration, proliferation + damage -> weakening + occlusion of vessel -> Ischaemia, infarction + ANEURYSM -> clinical manifestation Temporal = headaches Opthalmological = vision Facial = jaw claudication

Answer 155

- UK prevalence - 0.41% - most common vasculitis - Peak incidence 70-80 y/o; rare below 50 y/o - Most common in white esp Scandinavian

Answer 156

- Associated with polymyalgia rheumatica and ANCA associated vasculitis - Associated with CANCER - More common in FEMALE

Answer 157

Cranial GCA: - Temporal artery - NEW ABRUPT LOCALISED (oft TEMPORAL) HEADACHE - Changes to temporal artery: Tenderness, Thickening, REDUCED/ABSENT PULSATION - Granulomatous -> Skip lesions - SCALP TENDERNESS (classic - pain when brushing hair) - Lingual or facial artery - Tongue/JAW CLAUDICATION (less common) - builds up with chewing - Vision affected: - BLURRING - Amaurosis fugax (like veil over vision) - Diplopia (double vision) - Photopsia (flashing lights) - Visual loss Extra cranial - e.g. Aortitis - May mimic infection/cancer-CONSTITUTIONAL SYMPTOMS/B SYMPTOMS: - Weight loss, low-grade fever, Anaemia, Malasise - POLYMYALGIA - Limb CLAUDICATION

Answer 158

GCA has no: - Vomiting (related to raised intracranial pressure - NOT GCA) - Acute localising clinical signs (can indicate Acute intercranial bleeding, Encephalitis, Meningitis) - Fever (indicates infection - unusual in acute ischaemic cranial headache but may sometimes get fever in large vessel vasculitis if many extra-cranial vessels inflamed)

Answer 159

- 1st line = FBC -> RAISED ESR +/- CRP - anaemia of chronic disease - Thrombocytosis - Diagnostic: - TEMPORAL ARTERY US (colour doppler) -> HALO SIGN (non-compressable) - TEMPORAL ARTERY BIOPSY (large samples - granulomatous inflam of media + intima in skip lesions) - PET-CT + Axillary US - check extra-cranial (+ check for cancer) - If vision loss -> ophthalmology review - Pal optic disc

Answer 160

US: - Non invasive - Can check multiple sites/vessels (including extracranial) in one visit - Better sensitivity than TA biopsy BUT - Must be done quickly + OPERATOR DEPENDANT (variability in reliability based on experience) Biopsy: - Invasive - Only check 1 area at a time - 100% specific but 39% sensitive

Answer 161

- 40-60mg ORAL PREDNISOLONE (higher up to 60mg if Hx of ischaemic symptoms e.g. visual loss, limb/jaw claudication) - responds V. WELL - IV METYLPREDNISOLONE if EVOLVING visual loss - Reduce to zero over 12-18 months provided no return in symptoms For Relapse: - METHOTREXATE +/- TOCILIZUMAB (IL6 inhib - can be a steroid weaning measure)

Answer 162

- Steroid induced diabetes/worsens pre-existing DIABETES - OSTEOPOROSIS (assess to prevent fractures; give calcium + vitD (Adcal-D3)/bisphosphonates (Alendronic acid - 70mg)) - INFECTION - GI TOXICITY (peptic ulcers) **Can give PPIs + BISPHOSPHONATES**

Answer 163

- Strokes if untreated (1%) - SUDDEN PAINLESS VISION LOSS (can be bilateral) - temporary Amaurosis Fugax (seen in TIA) - if not treated asap -> PERMENANT -> HIGH DOSE IV METHYLPREDNISOLONE

Answer 164

- MALES > 50 Y/O - Associated with HEP B (hep C + HIV) - more common in developing countries

Answer 165

Affects muscles, skin, GI, kidneys + heart, nervous system (systemic) - particularly affects branching points

Answer 166

- Unilateral orchitis (characteristic) - Peripheral neuropathy -> mononeuritis multiplex (damage to at least 2 diff areas of PNS) - GI - Abdo pain - Malabsorption - Skin involvement: - Livedo reticularis - mottled, purpleish, lace like appearance - Ulcers - **Cutaneous/subcutaneous nodules** (hallmark) - Gangrene - Kidneys: - PRE RENAL AKI/CKD -> HTN - Heart: - HF, Coronary A obs

Answer 167

- CRP/ESR raised - HBsAg may be present - CT angiogram -> **beads-on-string appearance** (microaneurysms) - BIOPSY (in e.g. kidney): **transmural fibrinoid necrosis/NECROTISING VASCULITIS due to HTN**

Answer 168

- CORTICOSTEROIDS (+ cyclophosphamide if needed) - Control HTN -> ACE-I - If Hep B +ve = +antiviral + plasma exchange if needed

Answer 169

GI perforation + haemorrhages Arthritis Renal infarcts Strokes MI

Answer 170

Late teens/early adulthood - most commonly seen in caucasians but could be any ethnicity Staph aureus nasal carriage - associated with relapse in established disease

Answer 171

Triad of ENT, lung and kidney signs. - SADDLE SHAPED NOSE (due to perforated nasal septum) - Epistaxis - Crusty nasal/ear secretions - otorrhoea -> HEARING LOSS - Sinusitis - Cough, wheeze - Haemoptysis (may mistake for pneumonia on CXR) - GLOMERULONEPHRITIS (more advanced) + constitutional symps (fatigue, fever, malaise, night sweats, weight loss etc.) May also have: - ocular, rashes/ulcers, myalgia/arthralgia, neuropathy (esp mononeuritis multiplex) + thromboembolism (esp during active disease - but usually asymp)

Answer 172

- FBC: Anaemia (Eosniophilia??) - CRP +/- ESR elevated - CT chest (lung involvement oft present but asymp) - nodules; infiltrates - may do pulm function test -> elevated diffusion capacity = haemorrhage - **Immunoassay - (proteinase 3) PR3-ANCA +ve** - if -ve but still suspecious -> Immunoflouresence = **c-ANCA POSITIVE** (not p-ANCA) - If still -ve -> **Renal/skin biopsy**: GRANULOMAS, necrosis, vasculitis - Urinealysis + microscopy - check renal involvement - elevated creatinine shows up after haematuria etc.

Answer 173

- Nasal corticosteroid - Cyclophosphamide

Answer 174

- v common, oft self limiting - May be normal esp in ppl 20-55 - Trauma/work related

Answer 175

- ELDERLY (may be myeloma) - NEuropathic pain (spinal cord compression)

Answer 176

Degeneration of IV disc -> loss of compliance + thins over time - seen in ELDERLY Initialy asymp -> progressive - MC = L4/L5 or L5/S1 Give analgesia + physio if simple mechanical pain If serious pathology suspected -> XR + MRI

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