Rheum Flashcards
Adhesive Capsulitis (Frozen Shoulder)
Definition: Common cause of shoulder pain, most prevalent in middle-aged females; aetiology not fully understood.
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Associations:
- Diabetes Mellitus: Up to 20% of diabetics may experience frozen shoulder.
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Features:
- Develop over days
- External rotation more affected than internal rotation or abduction
- Both active and passive movement affected
- Painful freezing phase, adhesive phase, and recovery phase
- Bilateral in up to 20% of patients
- Episode lasts between 6 months and 2 years
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Diagnosis:
- Usually clinical, imaging may be required for atypical or persistent symptoms.
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Management:
- No single intervention improves long-term outcomes.
- Treatment options include NSAIDs, physiotherapy, oral corticosteroids, and intra-articular corticosteroids.
Anti-neutrophil cytoplasmic antibodies (ANCA) are important as they are associated with a number of small-vessel vasculitides, including:
-granulomatosis with polyangiitis
-eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
-microscopic polyangiitis
ANCA associated vasculitis common features:
Renal impairment
caused by immune complex glomerulonephritis → raised creatinine, haematuria and proteinuria
respiratory symptoms
dyspnoea
haemoptysiis
systemic symptoms
fatigue
weight loss
fever
vasculitic rash: present only in a minority of patients
ear, nose and throat symptoms
sinusitis
The Ottawa Rules for ankle x-rays
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
-inability to walk four weight-bearing steps immediately after the injury and in the emergency department
There are also Ottawa rules available for both foot and knee injuries
Ankylosing spondylitis features
a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old.
Features
typically a young man who presents with lower back pain and stiffness of insidious onset
stiffness is usually worse in the morning and improves with exercise
the patient may experience pain at night which improves on getting up
Ankylosing spondylitis clinical exam features
reduced lateral flexion
reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
reduced chest expansion
Ankylosing spondylitis associations
Other features - the ‘A’s
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome
peripheral arthritis (25%, more common if female)
Ankylosing spon X Ray
Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis. Radiographs may be normal early in disease, later changes include:
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis
Ankylosing spon management
encourage regular exercise such as swimming
NSAIDs are the first-line treatment
physiotherapy
the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement
the 2010 EULAR guidelines suggest: ‘Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments’
research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease
APS features
Features
venous/arterial thrombosis
recurrent miscarriages
livedo reticularis
other features: pre-eclampsia, pulmonary hypertension
APS blood tests
Investigations
antibodies
anticardiolipin antibodies
anti-beta2 glycoprotein I (anti-beta2GPI) antibodies
lupus anticoagulant
thrombocytopenia
prolonged APTT
APS management
Management - based on EULAR guidelines
primary thromboprophylaxis
low-dose aspirin
secondary thromboprophylaxis
initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
arterial thrombosis should be treated with lifelong warfarin with target INR 2-3
Azathioprine
metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis. A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.
Adverse effects include
bone marrow depression
consider a full blood count if infection/bleeding occurs
nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer
A significant interaction may occur with allopurinol and hence lower doses of azathioprine should be used.
Azathioprine is generally considered safe to use in pregnancy.
Bechets syndrome
Features
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
carpal tunnel exam
Examination
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
