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Year 3 Medicine Block > RHEUM: Arthritis > Flashcards

RHEUM: Arthritis Flashcards

1
Q
A
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2
Q

Define rheumatoid arthritis

A

An autoimmune disease associated to Fc portion of IgG (RF) and anti-CCP

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3
Q

Describe the pathogenesis of RA in as much detail as you can

A

1) Citrullination of self antigens. These are recognised by T and B cells. T and B cells produce antibodies aka RF and anti-CCP.
2) Macrophages and fibroblasts get stimulated and release TNFalpha
3) Inflammatory cascade starts - causes proliferation of synoviocytes = these will grow over cartilage and cut off nutrition to it = damages cartilage !
4) Macrophages also stimulate osteoclast = get bone damage

Note: citrullination is just where amino acid arginine is converted to citrulline. This is v important bc citrulline is not one of the 20 amino acids in our DNA code - so leads to modification (here it causes RA!)

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4
Q

What is clinical presentation of RA?

A 
Female gender (3:1). 
30-50yrs
Symptoms are progressive, peripheral and symmetrical polyarthritis 
Affects MCPs,PIPs, MTPs - does NOT affect DIPs
Affects hips, knees, shoulders, c-spine
History over 6 weeks
Morning stiffness for over 30 mins. 
Commonly have fatigue, malaise
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5
Q

What can be found on examination in a pt with RA?

A

Soft tissue swelling and tenderness.
Ulnar deviation, or palmar subluxation of MCPs
Swan neck or/and Boutonniere deformity to digits
Rheumatoid nodules (usually on elbow)
Median N - carpal tunnel association

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6
Q

Name three investigations (or more!) you would consider for a pt with suspected RA

A

RF, anti-CCP, FBC, WCC, inflammatory markers, X ray or can do MRI or USS in early disease.

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7
Q

Why is a WCC done in blood test for suspected RA?

A

Can be elevated due to complication of septic arthritis

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8
Q

Why is FBC carried out as an investigation for RA?

A

May show normocytic anaemia which is a feature of chronic disease

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9
Q

How is RA initially treated?

A

DMARD monotherapy - methotrexate

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10
Q

Describe treatment you would discuss with patient recently diagnosed with RA

A
  • DMARD such as methotrexate. Can discuss use of combination
  • Steriods to be used acutely both orally or intra-articular
  • NSAIDs + PPI to aid with symptom control
  • Non drug options - OT/PT, podiatry, psychological
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11
Q

What are the extra-articular features of severe RA?

A

Remember with mnemonic CAPS: (come in 3s)
C - carpal tunnel, CVD, cord compression
A - anaemia, amyloidosis, arteritis
P - pericarditis, pleural dosease, pulmonary disease
S - Sjögren’s, scleritis, Splenic enlargement

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12
Q

What features are characteristically seen in an XRAY of RA?

A 
LESS 
Loss of joint space 
Erosions (periarticular)
Soft tissue swelling 
Subluxation
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13
Q

Patterns of Joint / Muscle involvement:

If joint involvement was symmetrical it would suggest ____(1)____

Whereas, asymmetrical joint involvement would suggest ___(2)_____ or ____(3)_____

A

(1) RA
(2) Gout
(3) Psoriatic Arthritis

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14
Q

Patterns of Joint / Muscle involvement:

Small joint only would suggest___(1)_____

Large joints only would suggest ___(2)____

Large and small joints would suggest ____(3)______

A

(1) Early stages of RA
(2) OA
(3) Late stages of RA

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15
Q

Give the medical term for describing the number of joints involved for the below:

(1) 1 joint
(2) 2-4 joints
(3) >4 joints

A

(1) monoarticular
(2) Oligoarticular / pauciarticular
(3) Polyarticular

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16
Q

List some causes of acute polyarthritis. Use categories below to give specific conditions

  1. Inflammatory arthritis
  2. Autoimmune arthritis
  3. Viral infection
  4. Crystal arthritis
A
  1. Inflammatory arthritis
    - RA
    - PsA
    - Reactive arthritis
  2. Autoimmune arthritis
    - SLE
    - Vasculitis
  3. Viral infection
    - HIV
    - Parovirus
    Chikungunya
  4. Crystal arthritis
    - UNcontrolled Gout
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17
Q

What are the causes of chronic monoarthritis? Use categories below to think of specific conditions

  1. Infections
  2. Inflammatory
  3. Non- inflammatory
  4. Tumours
A
  1. Infections
    - TB
  2. Inflammatory
    - Psoriatic arthritis
    - Reactive arthritis
    - Foreign body
  3. Non- inflammatory
    - OA
    - Trauma (meniscal tear)
    - Osteonecrosis (prednisolone use)
    - Neuropathic ( Charcots arthropathy )
  4. Tumours
    - he says v rare!
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18
Q

What 2 conditions __(1)____ and ____(2)______can cause arthritis of the DIPJs?

In ___(1)___ changes will also be seen on the nail of the digit.

___(2)___ is the most common disease affecting this joint. ____(3)____ nodes can be seen on the DIPJ in this disorder.

A

(1) PsA
(2) OA
(3) Heberden’s Nodes affecting the DIPJ in OA

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19
Q

History taking - PMHS HISTORY of a rheum patient

Seronegative Spondyloarthropathy is associated with which 3 conditions?

A history of STI / diarrhoea could indicate what 2 types of arthiris

A

Seronegative Spondyloarthropathy is associated with:

  • Anterior uveitis
  • Psoriasis
  • IBD

Hx of STI / Diarrhoea could indicate:

  • reactive arthritis
  • gonococcal arthritis
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20
Q

History taking - Social HISTORY of a rheum patient
SMOKING:

Smoking is implicated in causing and making ___(1)____more severe

Patients with ____(2)____ symptoms in the hands should be advised to stop smoking

A

Smoking is implicated in causing and making ___RA____more severe

Patients with ____Raynaud’s ____ symptoms in the hands should be advised to stop smoking

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21
Q

Compare and Contrast the features of Inflammatory vs Mechanical disease.

E.g. Morning stiffness / effect of activity / effect of resting / Fatigue/ systemic involvement

A 
Inflammatory disease:
> 1 hour morning stiffness
Activity - improves 
Resting - worsens
Fatigue - profound 
Systemic symptoms - yes

Mechanical Disease
< 30 mins morning stiffness
Activity - worsens 
Resting - improves 
Fatigue - minimal 
Systemic symptoms - no
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22
Q

History taking - Constitutional symptoms

What are some examples of constitutional symptoms?

What do they indicate? (3)

What are some conditions which may present with constitutional symptoms?

A

Constitutional symptoms

  • Fever
  • Weight loss
  • Night sweats
  • Loss of appetite

What do they indicate?

  1. Inflammation
  2. Infection
  3. Neoplasia

What are some conditions which may present with constitutional symptoms?
Ankylosing spondylitis (all)
GCA
SLE - fever

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23
Q

What are some extra - articular features of RA?

A

Mouth / Eyes

  • scleritis
  • Dry mouth / eyes

Skin
- subcutaneous nodules

Genito-urinary

  • renal failure / hypertension
  • Micro -haematuria / proteinuria

Neuro
- Compressive - e.g. carpal tunnel syndrome

Cardio- Resp
SOB - alveolitis

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24
Q

What are some extra - articular features of RA?

A

Mouth / Eyes

  • scleritis
  • Dry mouth / eyes

Skin
- subcutaneous nodules

Genito-urinary

  • renal failure / hypertension
  • Micro -haematuria / proteinuria

Neuro
- Compresive - e.g. carpal tunnel syndrome

Cardio- Resp
SOB - alveolitis

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25
What gene are the Spondyloarthropathies associated with?
HLA - B27
26
How would a pt with Psoriatic Arthritis present? 1. Typical patient ? 2. Pattern ?
1. 10 % pts with hx of psoriasis - often middle aged. - Male and females equally affected. - Nail - Psoriasis extensor 2. Different patterns! can be symmetrical like RA. Hands/ wrists / ankles /DIP (not MCP like in RA) - OFTEN Asymmetrical olgio / arthritis- swollen feet / fingers. "Dactylitis" = swollen fingers
27
What signs might you see on a pt with Psoriatic Arthritis?
``` Nail pitting Onycholysis - nail coming away from bed Psoritatic plaques Dactylitis (inflammation of full finger) Enthesitis (inflammation where tendon inserts into bone) ``` Associated : EYe - uveitis / conjunctivitis Aortitis - inflammation of aorta Amyloidosis
28
What signs might you see on a pt with Psoriatic Arthritis?
``` Nail pitting Onycholysis - nail coming away from bed Psoritatic plaques Dactylitis (inflammation of full finger) Enthesitis (inflammation where tendon inserts into bone) ``` Associated : EYe - uveitis / conjunctivitis Aortitis - inflammation of aorta Amyloidosis
29
What screening test do patients with Psoriasis complete to see if need to be referred to a rheum?
PEST Psoriasis Epidemiological Screening tool - asks questions about: Joint pain Swelling Hx of Arthitis Nail pitting High score - get you to the rheumatologist.
30
What is arthritis Mutlians? How related to Psoriatic Arthritis?
most severe form of psoriatic arthritis. Osteolysis of bones around the joints in the phalanxes. Causes digit to get shorter and skin to fold over the shortened finger - "telescopic finger"
31
What is arthritis Mutlians? How related to Psoriatic Arthritis?
most severe form of psoriatic arthritis. Osteolysis of bones around the joints in the phalanxes. Causes digit to get shorter and skin to fold over the shortened finger - "telescopic finger"
32
How do you manage Psoriatic Arthritis?
Rheum and Derm together. ``` Drugs: NSAID (pain) DMARDS e.g. methotrexate / sulfasalazine Anti-TNF eg.g. infliximab Last line is a IL12/23 Inhibitor Ustekinumab ```
33
What is reactive arthritis?
Synovitis in joints post an infective trigger
34
How does reactive arthritis typically present?
acute monoarthriits (often lower limb asymmetrical)
35
What are some triggers for reactive arthritis?
Z2F: Most common triggers: gastroenteritis and STI (chlamydia) Distant infection Gastroenteritis: Camplyobacter Shigella Salmonella ``` STI Chlamydia Trachomatis (post urethritis / cervicitis) (Gonorrhoea = gonococcal septic arthritis ) ```
36
Associated symptoms with reactive Arthritis ?
Eye: Bilateral conjunctivitis / uveitis Skin: Circinate Balanitis (dermatitis on head of penis) and urethritis "can't SEE, can't PEE, cant CLIMB A TREE" as arthritis, eye prob, balanitis
37
Investigations for Reactive Arthritis?
Bloods: Inflammatory markerts - CRP Rule out: Septic arthritis- aspirate, gram stain, culture + sensitivities. GIVE AB until excluded Crystal arthritis - aspirate to check for gout / pseudo gout
38
Investigations for Reactive Arthritis?
Bloods: Inflammatory markerts - CRP Rule out: Septic / crystal arthritis - aspirate to check for bacteria / crystals
39
Management for Reactive Arthritis?
Treat infection (may not help arthritis) NSAIDs Steroid injection to joint most resolve within 6 months If reoccurs DMARDS / Anti-TNFA drugs especially likely if HLA-B27 +ve
40
What is Enteropathic arthritis?
10-20% of pts with IBD develop 2/3 get peripheral arthritis 1/3 get axial arthritis
41
With Enteropathic arthritis what are the 2 types of peripheral arthritis and how do they related to IBD flares?
Type 1: correlation with IBD flares - oligoarticular and asymmetric arthritis Type 2 : NO correlation with IBD flares- poly articular symmetrical arthritis
42
How to treat Enteropathic arthritis? What be mindful of?
NSAIDs can cause IBD flare up. use DMARDS TNF inhibitors treat both the bowel disease and arthritis
43
Mnemonic for extra - articular Ankylosing Spondylitis features - 5 As
``` Anterior uveitis Aortic incompetence AV block Apical lung fibrosis Amyloidosis ```
44
What are features on inflammatory back pain? Mnemonic IPAIN
``` Insidious onset Pain at night (getting up helps) Age <40 Improves when exercise No improvement with rest ```
45
What is a DEXA scan?
Measures the amount of radiation absorbed by the bones - indicating bone mineral density - BMD
46
Where should a DEXA scan reading be done to classify and manage OA?
At the hip - neck of femur to confirm OA and monitor treatment .
47
What scores can bone density be represented as? Which score is key for the WHO classification of OA?
Z score ( how much bone mineral density falls below mean of pts age) T score (how much bone mineral density falls below mean of healthy young person) T SCORE - CLINICALLY IMPORTANT
48
How is OA defined?
Degenerative joint disorder where there is progressive loss of articular cartilage accompanied by new bone formation and capsular fibrosis
49
What are the aetiology possibilities for OA?
Failure of normal cartilage subject to abnormal or incongruous loading for long periods Damaged or defective cartilage failing under normal conditions of loading Break up of cartilage due to defective stiffened subchondral hone passing more load to it
50
What are the key features of cartilage in OA
Loss of elasticity with reduced tensile strength | Cellularity and proteoglycan content are reduced
51
What are the RF for OA?
``` Age- over 65 Women are more symptomatic than men Obesity- hand and knee Trauma and joint malalignment Fhx ```
52
What are the most common joints to be affected by OA?
Hip, knee and spine
53
What are the symptoms of OA?
Pain provoked by movement and weight bearing Pain starts off intermittent but as it progresses becomes constant Knee-inactivity gelling and feeling that joint will give way is common
54
What are the xray features of OA?
LOSS loss of joint space osteophytes subchondral scerlosis subchondral cysts
55
What is the aim of treatment? (regarding osteoarthritis)
Pain improvement and reduce disability
56
What non-drug therapy is recommended in patients with OA?
Hip and Knee- strengthening and range of movement exercises Weight loss to reduce joint loading Laterally wedged insoles or walking stick
57
What pharmacological therapy is given for OA?
Paracetamol is first line NSAIDs- short term Topical NSAIDS, topical rubefacients and capsaicin can be used. Intra- articular corticosteroids can be offered.
58
What surgical therapy is offered in OA?
If physio and pharmatherapy is not helpful- joint replacement surgery can be offered
59
What is the triad of reactive arthritis?
Arthritis, urethritis, conjunctivitis
60
Reactive vs Septic arthritis?
Reactive- response to a systemic infection, or post systemic infection e.g. gastroenteritis or chlamydia. No infection in joint Septic- infection is in the joint e.g staphylococcus aureus
61
Never give methotrexate and which AB?
Never give methotrexate and trimethoprim Causes: Bone marrow suppression and severe or fatal pancytopaenia Pt might present with : infection, bleeding anaemia Adverse effect made worse by renal impairment
62
Felty’s syndrome?
triad of RA, low WCC and splenomegaly
63
Xray changes in psoriatic arthiritis?
Dactylitis - soft tissue swelling as whole digit is inflammed 'Pencil in cup' appearance Osteolysis - destruction of bone Periostitis - inflammation of periosteum thick border Ankylosis - bones join together - stiff
64
What is scoring system for RA?
``` DAS28 is disease activity score: 1. Swollen joints 2. Tender joints 3. Raised ESR / CRP Used to monitor progression and response to treatment ``` Diagnostic score is ACR score: 1. Joint involvement (lots of small joints score higher) 2. Presence of AB - RF / Anti-CCP 3. Inflammatory markers - raised ESR / CRP 4. Duration of symptoms >6 weeks Score > or = to 6 = diagnose RA

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