Rheum Flashcards
What are the risk factors for osteoporosis?
Obesity Age Occupation Woman FHx Trauma
What are the four x-ray changes in osteoporosis?
LOSS
L= loss of joint space O= osteophytes S= subchondral cysts S= subarticular sclerosis
What are the commonly affected joints in osteoarthritis?
Hips Knees Sacro iliac joints Distal interphalangeal joints in the hands MCP at the base of the thumb Wrist Cervical spine
What are the signs in the hands for osteoarthritis?
Bouchard nodes in PIP joint Heberden nodes in the DIP joint Weak grip Squaring at the base of the thumb at the carpo metacarpal joint Reduced range of motion
What is the management of osteoarthritis?
Pt education- lifestyle changes like weight loss
Physiotherapy
Occupational therapy and orthotics to support activity and function
What is the drug management of osteoarthritis?
Stepwise approach…
1) oral paracetamol and topical NSAIDS
2) add oral NSAIDS
Intra articular steroid injections
Joint replacement
What is rheumatoid arthritis?
Autoimmune condition which causes inflammation of the synovial lining of joints, bursa and tendon sheaths.
Does rheumatoid tend to be symmetrical or asymmetrical?
Symmetrical and affects multiple joints
What are the genes associated with rheumatoid arthritis?
HLA DR4
HLA DR1
What is the autoantibody associated with rheumatoid arthritis?
Rheumatoid factor presenting in around 70% of pts
Anti CCP are more specific and sensitive than rheumatoid arthritis
What is the presentation of rheumatoid arthritis?
Swelling pain and stiffness
Symmetrical distal polyarthropathy
Pts usually attend complaining of pain and stiffness in the small joints of the hand and feet, typically ankle wrist, MCP, PIP
Onset can be rapid or over months to years
There can also be associated systemic symptoms…
1) fatigue
2) weight loss
3) flu like illness
4) muscles aches and weakness
Does RA ever affect the DIP joint?
Noooo very rarely, if you come across a pt with pain in the DIP joint it is most likely heberdens nodes due to OA.
What are the signs in the hand of RA?
Boutonnieres deformity
Swan neck deformity
Z shaped deformity to the thumb
Ulnar deviation of the fingers at the MCP joint
What are the extra articular manifestations of RA?
Pulmonary fibrosis Anaemia of chronic disease Feltys syndrome (RA, neutropenia, splenomegaly) CVD Eye manifestations Rheumatoid nodules Lymphadenopathy Carpal tunnel syndrome Amyloidosis
What are the eye manifestations in RA?
Scleritis Episcleritis Keratitis Cataracts Retinopathy
What are the investigations done for RA?
Mostly clinical in pts with features of RA (symmetrical polyarthopathy affecting small joints), a few extra investigations are required at diagnosis…
. Check rheumatoid factor
. If RF negative then check anti CCP antibodies
. Inflammatory markers- CRP, ESR
. X ray of hands and feet
Ultrasound scan of the joints can be used to evaluate and confirm synovitis
What are the xray changes seen in RA?
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Bony erosions
What score system is used in RA to determine disease activity score?
DAS28
What is the management of RA?
MDT
Short course of steroids can be used at first presentation and during flare ups to quickly settle the disease
CRP and DAS28 are used to monitor the success of treatment
First line is monotherapy with methotrexate, sulfasalazine, leflunomide.
Hydroxychloroquine can be considered in mild disease
Second line is 2 of these in combination
Third line is methotrexate plus a biological therapy, usually a TNF inhibitor
Fourth line is methotrexate plus rituximab
What DMARDs can be taken in pregnancy?
Sulfasalazine
Hydroxychloroquine
What biological therapies can be used for RA?
Anti TNF- infliximab, adalimumab
How does methotrexate work?
Works by interfering with folate metabolism and suppressing certain components of the immune system
It is taken by injection or tablet once a week
Folic acid 5mg is also prescribed once a week, to be taken on a different day to methotrexate
What are the side effects of methotrexate?
Mouth ulcers and mucositis Liver toxicity Pulmonary fibrosis Bone marrow suppression and leukopenia Is teratogenic should be avoided prior to conception in mothers and fathers
What are the side effects of hydroxychloroquine?
Nightmares
Reduced visual acuity (macular toxicity)
Liver toxicity
Skin pigmentation
What are the notable side effects of anti TNF biologics?
Vulnerability to severe infections and sepsis
Reactivation of TB and hep B
What is the key investigation of acute mono arthritis?
Joint aspiartion asap
Can be presence/absence of blood pus etc…
The aspirate is then sent for a white cell count, gram stain and culture and for polarised light microscopy
What is the benefit of joint aspiration?
There is a two-fold benefit to doing a joint aspiration. Other than the diagnostic reason, removing all the fluid (especially any pus!) is protective for the joint. Patients are regularly assessed for joint swelling and joint aspirations can be done regularly to remove the fluid.
What are the important conditions to rule out in acute monoarthritis?
Septic arhtitis - prompt action with aspirating the joint and staring abx
Prosthetic joint infection
What is ankylosing spondylitis?
Sero negative inflammatory arthritis primarily involving the axial skeleton
What are the key features of ankylosing spondylitis?
Inflammatory back pain- often early morning stiffness (gets better with activity) with tenderness of the sacroiliac joints and limited range of spinal motion on examination
Peripheral enthesitis (achilles tendonitis, plantar fasciitis) and peripheral arthritis may occur in up to 1/3 of patients
What Ix do you do for ank spond?
HLA-B27 FBC Inflammatory markers X-ray (complete fusion of vertebral column in late stages= bamboo spine) MRI
What is the pharmacological treatment of Ank spond?
NSAIDs first line often prescribed with a protein pump inhibitor
Disease- modifying-anti-rheumatic- drugs (DMARDs) such as sulfasalazine and methotrexate are more useful in patients with enthesitis than axial symptoms, so are given in addition to analgesia in patients with concomitant peripheral disease. These drugs do not improve spinal inflammation.
Local steroid injections can be used as an adjunct
Patients who have failed to control symptoms with NSAIDs/ have severe disease may be offered TNF-alpha inhibitors such as Infliximab.
What is Lupus?
Systemic lupus erythematosus (“lupus”) is an inflammatory autoimmune connective tissue disease. It is “systemic” because it affects multiple organs and systems and “erythematosus” refers to the typical red malar rash that occurs across the face. It presents with varying and non-specific symptoms. It is more common in women and Asians and usually presents in young to middle aged adults but can present later in life.
It often takes a relapsing-remitting course, with flares and periods where symptoms are improved. The result of chronic inflammation means patients with lupus often have shortened life expectancy. Cardiovascular disease and infection are leading causes of death.
Pathophysiology
SLE is characterised by anti-nuclear antibodies. These are antibodies to proteins within the persons own cell nucleus. This causes the immune system to target theses proteins. When the immune system is activated by these antibodies targeting proteins in the cell nucleus it generates an inflammatory response. Inflammation in the body leads to the symptoms of the condition. Usually, inflammation is a helpful response when fighting off an infection however it creates numerous problems when it occurs chronically and against the tissues of the body.
What is the presentation of SLE?
SLE presents with non-specific symptoms:
Fatigue Weight loss Arthralgia (joint pain) and non-erosive arthritis Myalgia (muscle pain) Fever Photosensitive malar rash. This is a “butterfly” shaped rash across the nose and cheek bones that gets worse with sunlight. Lymphadenopathy and splenomegaly Shortness of breath Pleuritic chest pain Mouth ulcers Hair loss Raynaud’s phenomenon
What Ix do you do for SLE?
Autoantibodies (see below)
Full blood count (normocytic anaemia of chronic disease)
C3 and C4 levels (decreased in active disease)
CRP and ESR (raised with active inflammation)
Immunoglobulins (raised due to activation of B cells with inflammation)
Urinalysis and urine protein:creatinine ratio for proteinuria in lupus nephritis
Renal biopsy can be used to investigate for lupus nephritis
Autoantibodies; anti nuclear antibodies (ANA) , anti DsDNA
What are the treatments for SLE?
As with most autoimmune conditions anti-inflammatory medication and immunosuppression is the mainstay of treatment. There is no cure and the aim is to reduce symptoms and complications. It will be guided by a rheumatology specialist. Treatment is usually titrated upwards to find the minimal medication with the least side effects required to control the symptoms.
First line treatments are:
NSAIDs
Steroids (prednisolone)
Hydroxychloroquine (first line for mild SLE)
Suncream and sun avoidance for the photosensitive the malar rash
What are the complications of SLe?
CVD Infection Anaemia of chronic disease Pericarditis Pleuritis Interstitial lung disease Lupus nephritis Neuropsychiatric SLE Recurrent miscarriage VTE (associated w/ anti phospholipid syndrome occurring secondary to SLE)
What is discoid lupus erythematous?
Discoid lupus erythematosus is a non-cancerous chronic skin condition. It is more common in women and usually presents in young adults between ages 20 to 40. It is more common in darker-skinned patients and smokers.
It is associated with an increased risk of developing systemic lupus erythematosus, however this risk is still below 5%. Rarely the lesions can progress to squamous cell carcinoma (SCC) of the skin.
What is poly myalgia rheumatica, what are the symptoms and what is the management?
Chronic inflammatory rheumatic condition of unknown cause
Symptoms: bilateral shoulder and/or pelvic girdle pain
Stiffness lasting >45 mins after waking or resting
Systemic sx
Management Steroids- 15mg pred Steroids weaned off gradually, usually over approximately 2 years Bone protection Referral
