Rheum Flashcards
What are the symptoms af arthritis?
Pain Stiffness Swelling Functional impairment Systemic symptoms
What are the signs of arthrtiis?
Tenderness Swelling Restriction of movement Heat Redness Systemic features
What are the types of rheumatoid disease?
RA Sero-negative arthritis Crystal arthritis Connective tissue diseases Systemic vasculitis Bone disease Osteoarthritis
What are the functions of the synovium?
Maintenance of intact tissue surface
Lubrication of cartilage
Control of synovial fluid volume + composition
Nutrition of chondrocytes within joints
How does rheumatoid affect a joint?
Cartilage thinned
Inflammed synovium across joint surface
Inflammed tendon
Erosion of corner of bone
What is rheumatoid arthritis?
Chronic symmetric polyarticular inflammatory joint disease
Characterised by inflammatory cell infiltration, synoviocyte proliferation and neoangiogenesis
Synovial fluid contains neutrophils
Synovial panus causes bone and cartilage destruction
Primarily affects small joints of hand and feet
What auto-antibodies are associated with rheumatoid arthritis?
Rheumatoid factors
Anti-citrullinated protein
In what type of rheumatoid arthritis are autoantibodies found?
Seropositive RA
What genes are associated with RA?
HLA-DRB1 - role in promoting autoimmunity
PTPN22
CTLA4
What environmental factors are associated with RA?
Smoking and bronchial stress
Infective agents
Repeated insults to joints
What infective agents are associated with RA?
Viruses
E. coli
Mycoplasma
Perodontal disease
What is the pathophysiology of synovitis in RA?
Villous hyperplasia
Infiltration of T cells, B cells, macrophages and plasma cells
Intimal cell proliferation causing thickening of membrane
Production of cytokenes
Cytokines along with local hypoxic conditiosn causes increase vascularity
Makes self worse
Whar are the main cytokines produced?
TNF-a
IL-6
What is the action of the inflammatory cytokines?
Induce expression of endothelial cell adhesion molecules
Promote angiogensis
Supress T-regs
Activate leukocytes
Promote autoAB production
Activates synovial fibroblasts, chondrocytes, osteoclasts
What is the action of IL-6?
Mediates systemic effects
Acute phase response
Anaemia
Cognitive dysfunction
Lipid metabolism dysregulation
What mediates cartilage and bone destruction in RA?
Bone mediated y osteoclasts that are activated under the influence of RANKL
Cartilage - metalloproteinases + aggrecanases
What are teh systemic consequences of uncrontrolled chronic RA?
Vasculitis
Nodules
Scleritis
Amylodosis
What are the systemic consequences of RA?
Cardiovascular disease - altered lipid metabolism
Secondary fibromyalgia (congnitive fuction decline as well)
Muscles - sarcopenia
Bone - osteoporosis
Secondary sjogrens syndrome
Liver - anaemia (IL-6)
Who is likely to get rheumatoid arthritis?
1% of population
3x more common in women
Often 4-5th decade - any age from 16
What is the aeitiology of rheumatoid?
Genetic ~ 50-60% contribution
Environmental - smoking, chornic infection
How do you investigate rhuematoid arthritis?
Immunology - rheumatoid factor (IgG, IgM)
Anti-cyclic citrullinated antibodies (anti-CCP, ACPA) - Better test, more specificity
Ultrasound
How do you diagnose RA?
Joint involvement (multiple more likely)
Serology
Acute phase reactants
Duration more than 6 weeks
What are the therapeutic categories for reheumatoid arthritis?
NSAIDS
Disease modifying anti rheumatic drugs
Biologics
Corticosteroids
What are the common disease modifying anti rheumatic drugs?
Methotrexate!
Sulfasalazine
Hydrochloroquine
Leflunomide
How do you approach rheumatoid treatment?
Early and aggressive intervention
Effective suppression of inflammation improves symptoms + prevents disaability
What are the downsides to biologics?
Toxciity - increased rate of infection
Expensive
Injection
Efficacy - increased when used with methotrexate
What are the advantages of biologics?
Work rapidly and well tollerated
What are the benefits of methotrexate?
Effective
Well tollerated
Cheap
What gene is seronegative arthritis associated with?
HLA-B27
What is seronegative arthritis?
Arthritis with negative rheumatoid factor
Usually asymmetric
Involves axial skeleton (spine)
Enthesitis (soft tissue irritability)
Extra-articular features - uveitis, inflammatory bowel disease
What are the different presentations of seronegative arthritis?
Ankylosing spondylitis
Psoriatic arthritis
Bowel related arthritis (chron’s, UC)
Reactive arthrits
What is ankylosing spondylitis?
Chronic inflammatory rheumatic disorder
Predilection for axial skeleton + Antheses
Who is most likelt to get ankylosing spondylitis?
Males more than females
Onsets 2nd-3rd decade
How is spinal mobility tested?
Modified shober test
Lateral spinal flexion
Occiput/tragus to wall
Cervical rotation
What is the modified shober test?
Patient stading erect
Line connected posterior superior iliac spine. Then line 10cm above
Patient bends and see difference between two lines
What is the lateral spinal flexion test?
Hand down against thigh without bending
Measure difference between normal hand + how far it can go
What is the cervical rotation test?
Sit in chair
Goniometer in line with nose
Record how far they can turn head
What are the clinical features of anylosing spondylitis?
Inflammatory back pain
Limitation of movements in antero-posterior + lateral planes at lumbar spine
Limitation of chest expansion
Bilateral sacroiliitis on x-rays
What is the grading for sacroiitis?
0 - normal
1 - suspicious changes
2 - minimal abnormality (no alteration to joint width)
3) unequivicol abnormality (moderate-advanced, erosions, sclerosis, widening, narrowing or partial ankylosis)
4 - severe, total ankyloitis
What are the other features of anyylosing spondylitis?
Peripheral joint arthritis Achilles tendonitis, dactylitis Uveitis Cardiac (aortic incompetence, heart block) IBD Osteoporosis /spinal fractures Cauda equina syndrom Secondary amyloidosis
How do you manage aknylosing spondylitis?
Physio NSAIDs Disease modifying rheumatoid drugs - sulfasalazine Anti-TNF Anti-IL-17 Joint replacements
What joints are commonly affected by psoriatic arthritis?
Neck/shoulder Elbows/knees Toes + ankles Hand + wrist Base of spine
What is the treatment for psoaritic arthritis?
DMARD - sulfasalazine
Methotrexate
Leflunomide
Cyclosporine Anti-TNF Anti-IL 17/23 Steroids Physio/occupational therpay
What isreactive arthritis?
Sterile synovitis after distant infection
What infections often cause reactive arthritis?
Salmonella Shingella Campyloobacter Chlamydia (often recurrent attacks) Trachomatis Pneumonia Borrelia Neisseria Streptococci
(throat, urogenital, GI)
How does reactive arthritis present?
Mono or oligoarthritis
Dactylitis or enthesitis also seen
Skin/mucous membrane involvement
What conditions are seen in skin/mucous membrane involvement?
Keratoderma Blenorrhagica Circinate Balanitis Urethritis Conjunctivitis Iritis
What is reiters syndrome?
Arhtritis
Urethritis
Conjunctivitis
What indicates chronic reactive arthritis?
Hip/heel pain
High ESR
Family history + HLA-B27 positive
How do you treat reactive arthritis?
NSAIDs
If acute - joint injection if no infection
Antibiotics in chlamudia
If chronic - DMARD
What is enteropathic arthritis?
A chronic inflammatory arthritis developing in people with inflammatory bowel diseases
Rarely seenin infectious enteritis, whipples disease or coeliac disease however
Enthesopathy common
How do you treat enteropathic arthritis?
Sulfasalazine Methotrexate Steroids Anti-TNF Bowel resection may alleviate peripheral disease
What is a crystal depositation disease?
Where mineralised material is deposited in joints and periarticular tissue
What are the common crystal deposition diseases?
gout - Monosodium urate
pseudogout - Calcium pyrophosphate dihydrate (CPPD)
calcific perarthritis/tendonitis - Basic calcium phosphate hydroxy-apatite (BCP)
What is a tophi?
A massive accumulation of uric acid
What are the methods by which hyperuricaemia can occur?
Overproduction
Underexcretion
What can cause overproduction of uric acid?
Malignancy Severe exfoliative psoriasis Drugs (ethanol, cytotoxic drugs) Hereditary erros of metabolism HGPRT deficiency
What can cause under excretion of uric acid?
Renal impairment Hypertension Hypothyroidism Drugs (alohol, low dose, aspirin, diuretics, cyclosporin) Exercise, starvation, dehydration Lead poisoning
What is Lesch Nyan syndrome?
Deficiency of HGPRT X-linked recessive disease Intellectual disability People have aggressive + impulsive behaviour Self mutilate Have gout + renal disease
Who is likely to get gout?
Men more common in all ages
After menopause gout rate increases in women
How is an acute flare up of gout treated?
NSAIDs
Colchine
Steroids
When is hyperuricaemia treated?
1st attack not treated unless - single attack of polyarticular gout
Tophaceous gout
Urate calculi
Renal insufficiency
Do not treat asymptomatic hyperuricaemia
What drugs are used to lower uric acid?
Xanthine oxidase inhibitor (allopurinol)
Febuxostat
Uricosuric agents (sulphinpyrazone)
Canakinumab
What are the rules regarding lowering uric acid levels?
Wait until any acute attack has settled before treatment
Prohylatic NSAIDs/low dose cholchinie/steroids until urate acid normal
Adjust allopurinol dose occording to renal function
What is the main treatment for gout?
Adjust lifestyle factors
What is pseudogout?
Common in knee
Erratic flares, often triggered by trauma or intercurrent illness
Who gets pseudogout?
Elderly females
How do you manage pseudogout?
NSAIDs
Steroids
What is polymyalgia theumatica?
Inflammatory arthritic condition of the elderly
Associated with giant cell arteritis & high ESR
Who is likely to get polymyalgia pheumatica?
Women 2x than men
Rare in under 50s, usually over 70
What are the clinical features of polymyalgia rheumatica?
Sudden onset of shoulder +/- pelvic girdle stiffness ESR > 45, often over 100 Anaemia Malaise Weight loss Fever depression Arthralgia /synovitis occasionally
How do you diagnose polymyalgia rheumatica?
50+ ESR 50+ Dramatic steroid response Compatible hisotry No specific diagnostic test
How do you treat polymyalgia rheumatica?
Prednisolone 15mg/day for 18-24 months
Bone prophylaxis
What are the differentials of polymyalgia rheumatic?
Myalgic onset inflammatory joint disease Underlying malignancy Inflammatory muscle disease Hypo/hyper thyroidism Bilateral shoulder capsulitis Fibromyalgia
What is juvenile idiopathic arthtis?
A group of systemic inflammatory disorders affecting children younger than 16
Important cause of disability and blindness
What is the most common juvenile idiopathic arthritis?
Rheumatic disease
What type of disease is JIA?
autoimmune disease
What are the diagnostic criteria for juvenile idiopathic arthritis?
Younger than 16 Symptoms for more than 6 weeks Joint swelling or 2 of following Painful/limited joint motion Tenderness Warmth
What are the three main subtypes of juvenile idiopathic arthritis?
Pauciarticular (most common - 55%)
Polyarticular
Systemic onset
What is pauciarticular juvenile idiopathic arthritis?
4 joints or less affected
Split into three types
who is affected by type 1 pauciarticular juvenile idiopathic arthritis?
Mainly girls (8:1) Before 5 yrs, most commoon 1-3
How does type 1 pauciarticular juvenile idiopathic arthritis present?
Limp rather than pain No constitutional manifestations Mainly lower limb affected With knee being most common (ankle, then hand or elbow) \+ve ANA in 40-75% Chronic uveitis in 20% Asymptomatic in 50% Irregular iris due to posterior synechiae
Who is affected by type 2 pauciarticular juvenile idiopathic arthritis?
Boys more often than girls (7:1)
After 8-9 yrs old
What is the presentation of type 2 pauciarticular juvenile idiopathic arthritis?
Constiutional features rare
Limp due to LL affection (knee, ankle mostly)
Hip can be affected with rapid damange (needs total hip replacement early in life)
Enthesitis
Sacroilliac joints affected
Acute iridocyclitis in 10-20%
Who is characterised to have juvenile ankylosing spondylitis?
HLA-B27 positive people with back involvement
Who presents with type 3 pauciarticular juvenile idiopathic arthritis?
Girls (4:1) more than boys
Any age during childhood
How does pauciarticular juvenile idiopathic arthritis present?
Asymmetric UL/LL arthritis (destructive) Dactylitis Family history of psoriasis Nail pitting Chronic iridocyclitis (10-20%)
What is polyarticular juvenile idiopathic arthritis?
5+ joints involved
What are the subtypes of polyarticular juvenile idiopathic arthritis?
Rhuematoid factor positive
Rhuematoid factor negative
Who gets RF negative polyarticular juvenile idiopathic arthritis?
Girls (9:1) more than boys
Any age, but often early
What is the presentation of RF negative polyarticular juvenile idiopathic arthritis?
Constitutional manifestations (low grade fever, malaise)
Hepato-splenomegaly
Mild anaemia
Growth abnormalities
Symmetric large and small joints affection: knees, wrists, ankles, MCPs, PIPs, neck
Iridocyclitis rare.
What is the presentation of RF positive polyarticular juvenile idiopathic arthritis?
Constitutional manifestations (low grade fever, malaise, weight loss)
Anaemia
Nodules.
Can be complicated by sjogren’s, Felty or vasculitis, AR, pulmonary fibrosis, AAS, CTS.
Similar to adult RA but in a child
Erosions in x ray occur early
Iridocyclitis rare.
What is likely to get RF positive polyarticular juvenile idiopathic arthritis?
Girls (7:1) more than boys
Late childhood - teens (12-16)
What defines systemic onset JIA (still’s disease)?
Extra-articular features
Start eraly and dissappear after 2-5 years
Who gets systemic onset juvenile idiopathic arthritis?
Throughout childhood, bu ages 4-6 most common
Roughly equal across gender girls (3:2) to boys
How does systemic onset juvenile idiopathic arthritis present?
Fever rising to 39.5 for at least weeks
Rash
Lymph nodes non-tendor generalise lymphadenopathy
Abdominal pain (hepatosplenmegaly in 50-75%)
Serositis
Arthritis (within 3-12 months of fever)
Describe the fever in systemic onset juvenile idiopathic arthritis present.
Evening/late afternoon, then returns to normal in morning
Whilst feverish looks toxic with chills, normal otherwise
Describe the rashin systemic onset juvenile idiopathic arthritis present.
Evanescent salmon red erruption on trunk/thighs
Accompanies fever
Brought on by scratching
How do you treat Juevenile idiopathic arthritis?
Simple pain killers NSAIDs If no response steroid injections Then disease modifying drugs/biologics Local steroids RARELY systemic steroids
When are systemic steroids used in JIA?
In systemic JIA to control pain/fever
In the case of serious disease complications
Bridge between DMARDs
If child undergoing surgery
What are the surgical treatments for JIA?
Synovectomy
Reconstructive/joint replacement
