Rheum Flashcards
Gout
Investigations
treatment
causes of hyperuricaemia
chronic- tophi in skin around joints- ear, fingers, achilles
Bloods + ESR + urate
Joint aspiration in acute if concern re diagnosis- negatively birefringent and needle shaped
Clinical diagnosis reasonable
XR- punched out erosions in junta-articular bone
Treatment:
- NSAID (colchicine second line)
- if 2 or more episodes then allopurinol prophylaxis (inhibits xanthine oxidase)- start 2 weeks after acute
- alternative is febuxostat
causes of hyperuricaemia
increased production: alcohol, tumour lysis/ lymphoproliferative
reduced excretions: CKD, thiazide diuretics, ciclosporin, hypothyroid, hyperparathyroid
CPPD
different types- monoarthropathy or symmetrical polyarthritis (pseudo rheumatoid)
on joint asp see weakly positive birefringement crystals which are rhomboid
RF: haemochromatosis
treatment: NSAIDs, inrtarticular steroids
seronegative spondyloarthropathies
A-E
•Asymmetrical large joint oligoarthritis (<5 joints) or monoarthritis
•HLA B27 (dont test for this though- 88% in AS, in all at least 50%)
•Certain joints- Axial (spinal and sacroiliac) inflammation
•Dactylitis- inflammation of entire digit (sausage digit due to soft tissue oedema and tenosynovial and joint inflammation
•Enthesitis- inflammation of site of insertion of tendon or ligament in to bone e.g. plantar fascitis, achilles tendonitis, costrochondritis
•Factor- no rheumatoid factor- i.e. seronegative
•Extra-articular-
o Anterior uveitis
o Psoriaform rashes
o Oral ulcers
o Aortic valve incompetence
o IBD
seronegative spondyloarthropathies-what are they?
1- ank spond
2- enteric arthropathy
3- psoriatic arthropathy
4- reactive (Reuters)
ank stond
Treatment
88% HLA B27
affects spine and sacroiliac
worst in morning, relieved by exercise
treat: exercises, NSAIDs, TNF alpha if persistent disease activity
ank spond associated
6 As apical fibrosis anterior uveitis aortic regurgitation achilles tendonitis AV node block amyloidosis
enteropathic arthritis
large joint mono/asymmetrical oligoarthritis
10-15% of UC and crohns
improves with bowel symptoms
reactive arthritis
after GI or STI- due to crossreactivity
3 key symptoms:
- arthritis (knees, ankles, toes)
- urinary sx
- conjunctivitis
cause: chlamydia
occurs a few weeks after acute infection
signs:
- enthesitis
- keratoderma blenorrhagica
- dactylitis
psoriatic arthritis
20% of patients with psoriasis - esp if nail involvement
asymmetric involvement of small joints of hand INCLUDING DIP/ symmetrical seronegative/ arthritis mutilans/ sacroilitis
XR- pencil in cup deformity by bone erosion
NSAIDS, intraarticualr steroids, DMARDS as per RA
osteoarthritis XR findings
Only abnormal in advanced disease – LOSS • Loss of joint space • Osteophytes- see hand pic • Subarticular sclerosis • Subchrondral cysts
Heberdens
DIP
- think OA
differential of DIP affected:
chronic gout
psoriatic arthritis
bouchards
PIPJ
- think OA
- can be seen in RA
Differentials of hand joint swellings
- RA
- OA
- CPPD (pseudo OA)
- chronic gout
psoriatic arthritis
septic arthritis
most common cause staph aureus
single joint + systemic features
urgent joint aspiration for MCS
treat with flucloxacillin
Acute monoarthritis
Differentials
Septic arthritis
Seronegative spondyloarthopathies- enteropathic and reactive
Crystal arthropathies- gout and CPPD
Trauma
Investigations acute mono arthritis
FBC, ESR, CRP, blood cultures
joint aspiration
consider XR if concern re fracture/ as baseline
If urinary symptoms MCS/ swab for chlamydia
back pain red flags
<20 or >55 constant/ nocturnal worse lying down fever/ sweats/ weight loss hx of malignancy immunosuppression prolonged steroid use thoracic back pain morning stiffness neurological signs bilateral
vasculitis types
large: GCA, Takayasau
medium: PAN, kawasaki
Small
ANCA pos: microscopic polyangitis, GPA, churn strauss
ANCA neg: HSP, cryoglobulinaemia
vasculitis signs
- purpura
- ulcers
- livedo reticular
- eye symptoms - episcleritis/scleritis
- haemoptysis
- nasal crusting + epistaxis
wegeners- saddle nose
charge strauss- asthma
behcets
multisystem disorder recurrent ulceration
- oral ulcers
- genital ulcers
- eye lesions- uveitis
- skin lesions e.g. erythema nodosum
- skin pathergy
DMARD
METHOTREXATE
- lung, liver
- folic acid
- trimethoprim and septrin CI
SULFASALAZINE
-rash, ulcers
LEFLUNOMIDE
- ulcers, liver, BP
HYDROXYCHLOROQUINE
- retinopathy
- NB continue in illness (only one)
sarcoid sx and signs
erythema nodosum polyarthralgia lupus pernio resp signs- SOB, cough fever
lofgrens
BHL + erythema nodosum + fever + polyarthralgia
excellent prognosis
marfans features
- tall stature with arm span to height ratio > 1.05
- high-arched palate
- arachnodactyly
- pectus excavatum
- pes planus
- scoliosis of > 20 degrees
- heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation, mitral valve prolapse (75%),
- lungs: repeated pneumothoraces
- eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia
- dural ectasia (ballooning of the dural sac at the lumbosacral level)
Rheumatoid arthritis - typical symptoms
symmetrical swollen, painful and stiff
morning stiffness
PIP, MCP NOT DIP
extraarticular:
- rheumatoid nodules on extensor surfaces
- tenosynovitis/ bursitis
- raynauds
- lung fibrosis
- pericarditis
- episcleritis/ scleritis
associated with sjogrens
NB felts is splenomegaly and neutropenia (1%)
rheumatoid signs
symmetrical
tender joints
nodules
Boutonierre=injury to the tendons that straighten the finger. Is PIP flexion with DIP hyperextension
Swan neck= DIP flexion and PIP hyperextension
Ulnar devaition
atlano-axial subluxation
Lungs: fibrosis/ effusion
Feltys
rheumatoid investigations
Treatment
FBC, UES, LFTs, CRP, ESR
RhF, CCP, ANA
Imaging: XR - juxta-articular osteopenia and decreased joint space–> erosions, subluxation or complete carpal destruction!
Calculate the DAS score
>5.1= active disease
<3.2= low disease activity
<2.6= remission
treatment:
NICE guidelines:
New active RA= methotrexate and one other DMARD + short term corticosteroids
Established stable RA= cautiously reduce doses (return to disease controlling if flares)
Move on to biologics if fit criteria only
dactylitis vs sclerodactyly
dactylitis= inflammation of a digit/ toes
think seronegative spondyloarthropathies e.g. psoriasis, 5% gout, sickle cell
sclerodactyly=localised thickening and tightness
scleroderma
alopecia
Alopecia areata: non scarring loss of scalp hair only (as opposed to alopecia universalis, which is complete loss of hair over the scalp and body).
Associations:
autoimmune- Hashimoto’s thyroiditis, pernicious anaemia, DM and vitiligo.
Other differentials:
- trichtotillomania
- Scarring hair loss is caused by discoid lupus erythematosus and lichen planus.
arthritis multilans- differentials
psoriatic
RA
rheumatoid examination
hand exam features
Swellings of MCP, PIP, wrist, redness, boggy on palpation
guttering of interossei
deformities (subluxation and ulnar deviation at MCPJs, subluxation of wrist, swan neck, Boutonnieres, z thumb),
nails (psoriasis, infarcts, vasculitis)
thin and bruised skin (steroids)
scars (carpal tunnel release, wrist arthrodesis, tendon transfer etc)
rashes (psoriasis)
dactylitis (psoriatic arthritis)
RA diagnosis criteria
ACR/EULAR 2010 criteria (need 6/10 score)
Joints (swollen/tender/USS/MRI evidence of synovitis, small joints)
Serology (RF or anti-CCP positive)
Acute phase reactants (CRP/ESR raised)
Duration ≥ 6 weeks
