Rheum Flashcards
Summarise Osteoarthiritis
Pathophysiology: Wear and tear of joints, secondary to age/ injury
Presentation: Stiff, painful joints, loss of function, worse with activity, derformities, asymmetrical. Commonly hips, knees, sacro-iliac, DIP, wrist and c-spine.
Signs: Heberdens (DIP) and Bouchards (PIP); squaring of thumb base
Ix: XR (LOSS) - but diagnosis is clinical
Mx: Lose wt, exercise, topical NSAIDs (if knee/ hand) + PO paracetamol --> PO NSAID + PPI --> Opiates Intra-articular steroid injections Joint replacement
Summarise Rheumatoid Arthirtis
Pathophysiology: Autoimmune inflammation synovial lining, HLA DR4 association.
Presentation: Symmetrical joint pain, swelling, stiffness, loss of function, worse in morning and improves with activity. Usually effects small joints e.g. wrist, ankle, MCP, PIP. Can be acute or chronic.
Systemic sx: Fatigue, wt loss, muscle ache, pulmonary fibrosis, sjogrens, anaemia, CVD, episcleritis and scleritis, nodules, lymphadenopathy, carpal tunnel, amyloidosis
Signs: Z thumb, swan neck, boutonnieres, ulnar deviation
Ix: RF (present in 70%), anti-CCP (more sensitive and specific), CRP, ESR, XR (Joint loss, soft tissue swelling, periarticular oseteopenia, bony erosions), synovitis can be shown on US
Mx: MDT
1. DMARDs (Hydroxychloroquine if mild, methotrexate/ sulfasalazine if not)
2. 2 x DMARD
3. biological therapy - usually TNF inhibitor (adalimumab, infliximab)
4. Rituximab
Surgery
steroids on flare up
Summarise Psoriatic arthirits
Pathophysiology: inflammatory seronegative arthiritis
Presentation: Psoriasis, nail pitting, onycholysis, dactylitis, enthesitis (tendon insertion inflammation), joint pain, swelling, conjunctivits, anterior uveitis.
Commonly effects: Spine, sacroiliac, achilles tendon, planat fascia
Ix: XR (pencil in cup, periositis, osteolysis, ankylosis)
Mx: NSAIDs, DMARDs, Anti-TNF, ustekinumab
Summarise Reactive Arthiritis
Pathophysiology: Secondary to GI/ STI (chlamdyia most common), seronegative spondylarthropathy
Presentation: Dysuria, joint pain and swelling, bilateral conjunctivits, anterior uveitis, balanitis
Ix: Aspirate joint - gram stain, MCS, crystal
Mx: NSAIDs, setroid injection, steroids
Summarise Ankylosing Spondylitis
Pathophysiology: HLA B27 associated, spondyloarthropathy,
Presentation: Usually young man. Gradual sacroiliatic and lower back pain and stiffness, better with activity and worse with rest.
Systemic: wt loss, fatigue, CP, enthesitis, dactylitis, anaemia, anterior uveitis, aortitis, pulmonary fibrosis, IBD
Ix: Schober’s test, XR spine and sacrum (bamboo spine, squaring vertebral bodies, subchondral sclerosis, syndesmophytes, ossification ligaments, fusion), CRP, ESR, HLA B27, MRI shows early changes
Mx: 1) NSAIDs + PT, steroids in flare ups, anti-TNF eg adalimumab, secukinumab DMARDs are only useful in PERIPHERAL joint involvement
Summarise SLE
Pathophysiology: Autoimmune connective tissue disease, relapses and remits.
Discoid = scarring alopecia and hyper/ hypopigmentation
Presentation:
MD SOAP BRAIN (Malar flush, discoid rash, serositis, oral ulcers, arthiritis, photosensitivity, bloods low, renal, ANA, immunologic, neurological)
Also: Fatigue, wt loss, fever, lymphadenopathy, spleenomegaly, raynauds
Ix:
Anti-DsDNA (specific), ANA, anti-histone in drug induced, anaemia, thrombocytopenia, leukopenia,
Mx:
- NSAIDs, steroids, hydroxychloroquine, suncream
- Other DMARDs
- Biologics - rituximab and belimumab
Complications:
Infection due to immunosuppressants, CVD, anaemia, pericarditis, pleuritis, ILD, neuropsychoatric, VTE + recurrent miscarriage due to anti-phospholipid (anti-cardiolipin Ab) syndrome –> Give warfarin outside of pregnancy and LMWH + aspirin in pregnancy
Summarise Systemic Sclerosis
Pathophysiology: Two types: Limited cutaneous (CREST only) and Diffuse cutaneous (CREST plus systemic)
Presentation:
Calcinosis
Raynauds
Esophageal dysmotility
Sclerodactyly - skin tight hands –> restricts ROM
Talangiectasia
DIffuse: CVD, pulmonary htn and fibrosis, glomeulonephritis
Ix: Anti-centromere Ab (limited), Anti-scl-70 Ab (diffuse), ANA. If only present with Raynauds do nailfold capillaroscopy to rule out CREST
Mx:
MDT
Raynauds: No smoking, avoid cold, nifedipine
Oeseophageal: PPI and metoclopramide
Sclerodactaly: Emoillients
Steroids and immunosuppressants in diffuse
Summarise Polymyalgia Rheumatica
Pathophysiology: Associated with GCA
Presentation: Usually in older adults. Bilateral Hip + shoulder pain and stiffness in AM, worse with movement, fatigue, wt loss, low grade fever, low mood
Ix: ESR, CRP, FBC, UE, LFT, serum protein electrophoresis, TFT, CK, RF - rule out differentials
Mx: Prednisolone 15mg - taper off slowly
Bisphoshonate, vit D and calcium. PPI.
Summarise Giant Cell Arteritis
Pathophysiology: Vasculitis of medium and large arteries
Presentation: jaw claudication, scalp tenderness, unilateral temporal headache, vision blurred/ diplopia, painless sight loss, fever, fatigue, wt loss, anorexia
Ix: Temporal biopsy (multinucleated giant cells), ESR
Mx:
Prednisolone 40-60mg (PPI, bisphosphonates)
Refer rheum
IV methylprednisolone if visual loss + emergency opthamology r/v
Summarise poly/ dermatomyositis
Definition:
Polymyositis: inflammation muscles
Dermatomyositis: connective tissue disorder with inflammation of skin and muscles
Presentation: Muscle pain, fatigue, weakness, bilateral, girdle pain, gradual onset
Dermatomyositis: Gottron lesions, photosensitive erythematous rash, periorbital oedema, calcinosis
Ix: CK initially, muscle biopsy gives definitive, Look for paraneoplastic syndromes.
Anti-Jo Ab: Polymyositis
Anti-Mi Ab: Dermatomyositis
ANA: Dermatomyositis
Mx: refer rheum - steroids first, immunosuppressants, IV Ig, biologicals
Summarise Sjogrens
Presentation: dry mouth, eyes and vagina. May be associated with SLE/ RA
Ix: anti-ro and anti-la Ab, Schirmer test (filter paper on eyelid)
Mx: artifical saliva, tears, lube, hydroxychloroquine
Summarise Behcets Disease
Pathophysiology: Inflammation affecting multiple systems, linked to HLA B51
Presentation: PO and genital ulcers - painful, sharply circumscribed, red halo.
Erythema nodosum, papules/ pustules, anterior uveitis, retinal haemorrhage, arthralgia, GI ulcers, migraines, DVT, budd-chiari
Ix: Clinical + Pathergy test for skin hypersensitivity
Mx: topical/ PO steroids, colchicine, immunosuppresants, biologics
Summarise the features you would expect to see in any vasculitis
Presentation: Purpura, joint pain, peripheral neuropathy, renal impaitment, GI disturbance, htn,, anterior uveitis, scleritis, fatigue, fever, wt loss, anaemia
Tests: Raised CRP, ESR and ANCA
Mx: Steroids and immunosupressants
Summarise Henoch-Schonlein Purpura
Pathophysiology: IgA vasculitis, IgA deposits in blood vessels, often triggered by URTI or gastroenteritis.
Presentation: Commony <10y. RAAR (Rash - purpuric over buttocks and lower limbs, arthitis, abdo pain, renal nephritis)
Ix: FBC (Thrombocytopenia), urine diptick for protein and haematuria, CRP, cultures for sepsis, BP fot htn
Mx: Supportive - analgesia, rest, hydration
Summarise Chrug-Strauss Syndrome
Pathophysiology: AKA eosinophilic granulomatosis with Polyangitis, small and medium vessels
Presentation: Severe asthma
Ix: Very raised eosinophils on FBC, p-ANCA
Summarise Wegeners Ganulomatosis
Pathophysiology: AKA Granulomatosis with polyangitis, affects small vessels
Presentation: Epistaxis, crusty nasal secretions, saddle shaped nose due to perforated septum, glomerulonephritis, asthma sx
Ix: CXR shows consolidation, urine dipstick, c-ANCA
Summarise Kawasaki Disease
Pathophysiology: Medium vessel vasculitis,
Presentation: <5 years, high fever >5 days, erythematous maculopapular rash, bilateral conjunscitivs, desquamation palms and soles, strawberry tongue, cracked lips, cervical lymphadenopathy
Ix: FBC - Thromobocytosis, leukocytosis, anaemia, LFT - hypoalbuminaemia, elevated enzymes, urinalysis shows raised WCC, echo for coronary artery
Mx: High dose aspirin (usually avoid in children due to Reye’s) to reduce risk thrombosis, IV Ig to reduce risk aneurysm
Complications: Coronary artery aneurysm
Summarise Takayasu’s Arteritis
Pathophysiology: Large artery vasculitis, mainly affects aorta
Presentation <40 y, arm claudication, loss pulses, syncope
Ix: CT Angio, doppler
Summarise Gout
Pathophysiology: Urate crystals collect in joints
RF: Alcohol, thiazide-like diuretics, seafood, obesity, male, CVD, fhx
Presentation: Acute, hot, red, swollen joint, most commonly MTP of foot/ wrist. carpometocarpal, if left can become tophi
Ix: Aspirate joint (MCS, gram staining, crystal microscopy - negatively birefringent needles), XR shows bone lytic lesions, punched out erosions with sclerotic edges
Mx:
1) NSAIDs 2) Colchicine 3) steroids in acute flare
Allopurinol ULT (Xanthine oxidase inhibitor)
Summarise Pseudogout
Pathophysiology: calcium pyrophosphate crystals in joints
Presentation: Acute, red, hot, swollen joint, commonly knees, shoulder, wrists, hips.
Ix: Aspirate (MCS, gram stain, crystal microscopy - positive bifringed, rhomboid), XR shows LOSS + chondrocalcinosis (thin white line in joint space)
Mx:
Asx - no treatment
NSAIDs, colchicine, steroid injections, PO steroids, washout if severe
Summarise Osteoporosis
Pathophysiology: Low bone density
RF: Female, steroids, age, smoking, low BMI, RA, alcohol, SSRIs, PPI, anti-epilpetics, anti-oestrogens, hyperparathyroidism
Presentation: Fragility fracture e.g. vertebrae, proximal femur, distal radius
Ix: BMD
Summarise Osteomalacia
Pathophysiology: Poor bone mineralisation –> Soft. Due to poor vitamin D. In children this is called rickets. Vitamin D is needed for bone reabsorption to increase serum calcium.
RF: Dark skin, low exposure sunlight
Presentation: Fatigue, bone pain, muscle weakness and aches, pathological #s.
In children: Bowing legs, rachitic rosary, craniotabes, delayed teeth
Ix: Serum-25-hydroxyvitamin D, Ca low, PO4 low, ALP igh, PTH high, XR show osteopenia (Radiolucent), DEXA shows low BMD
Mx: Vit D (colecalciferol)
Summarise Paget’s Disease
Pathophysiology: Excessive burn turnover due to increased osteoclast/ blast activity –> Pathological fractures
Presentation: Bone pain, deformity, fractures particularly in head ahd spine
Ix: XR which shows osteolytic lesions, enlargement, deformity, cotton wool appearance of skull (Patches of sclerosis and lysis), ALP raised
Mx: Bisphosphonates, monitor ALP to check progress, screen for osteosarcoma and spinal stenosis
Summarise Juvenile Idiopathic Arthiritis
Pathophysiology: Autoimmune condition >6 weeks in <16 years
Five types: Systemic, polyarticular, oligoarticular, enthesitis, psoriatic
Presentation:
Systemic - Salmon pink rash, high swinging fevers, wt loss, lymphadenopathy, joint pain and inflammation, spleenomegaly, pericarditis, pleuritis
Ix: Raised ESR, CRP, platelets and ferritin (due to inflammation)
Mx: NSAIDs, steroids, DMARDS, TNF inhibitors (infliximab, adalimumab)
