Rheum: General

Question 1

Common conditions that present with monoarthritis?

Answer 1

Crystal arthropathy

Osteoarthritis

Infection

Necrosis

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“COIN”

“Mono, money, coin”

Question 2

Common diseases that present as oligoarthritis

Answer 2

Spondyloarthropathies

haematological disorders

Osteoarthritis

Reactive arthritis (Post-infection)

Erythematosus (Lupus)

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“SHORE”

Question 3

Common conditions that present as polyarthritis

Answer 3

Rheumatoid Arthritis

Viral infections

Erythematosus (SLE)

Sarcoidosis

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“RAVES”

Question 4

Outline SLE

Answer 4

D: Autoimmune condition affecting multiple organ systems by targetting self intracelleular antigens.
E:

I: 40 cases per 100 000 in Europe
G: 90% are female
A: 15-50
R: UV light exposure, genetic factors (Eg HLA
G: Incidence highest in developed countries

P: Fevers, joint pain, rash, in a woman of child bearing age.

I:

Dx: FBC, ESR, CRP, Urinalysis, Us&Es, creatinine, ANA, anti-dsDNA, anti-smith, anti-RNP, anticardiolipin antibodies, CH50, C3 and C4.

M: FBC, anti-dsDNA, CH50

T:

1: hydroxychoroquine

+NSAIDs

+Steroids

w/ lifestyle changes

Joint involvement and serositis:

Methotrexate

Mucocutaneous disease:

Methotrexate

Lupus Nephritis:

Azathioprine (or mycophenylate or others)

Neuropsychiatric lupus:

Cyclophosphamide

P: 80-90% live a normal life span

Question 5

What are the common conditions that present with axial skeletal involvement?

Answer 5

Ankylosing spondylitis

PsA

IBD-associated arthritis

Reactive arthritis

Degenerative arthritis

Question 6

Outline Rheumatoid arthritis

Answer 6

• D: Chronic autoinflammatory condition targeting the joints.
• E:

I: 40 per 100 000. 1-2% of the population

G: F:M, ~2:1

R: Cigarette smoke, Pathogen, Genetics: HLA-DR1, HLA-DR4

• P: Symmetrical Joint pain, swelling, affecting multiple joints. Worse in the mornings.
• With swan neck deformity, Boutonniere’s deformity, ulnar deviation, rheumatoid nodules, vasculitic lesions, pleuritic chest pain, scleritis and/or uveitis
• I:
• Rheumatoid factor (RF): positive
• Anti-cyclic citrullinated peptide (anti-CCP) antibody: positive
• Radiographs: Erosions
• Ultrasound
• ANA: Positive
• Molecular genetics: HLA-DR1, HLA-DR4 positive
• T:
• DMARD: (Eg Methotrexate or hydroxychloroquine or sulfasalazine)

+Prednisolone

+NSAIDs

• Move onto biologics (Eg etanercept or infliximab)
• P: If treatment is prompt, prognosis is good,

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• General/ Extra:
• Arginine is converted to citrulline (Citrullinated peptide)
• T-cells in joint space
• Rheumatoid factor: IgM antibody targeting the Fc domain of altered IgG antibodies

Question 7

Outline osteoarthritis

Answer 7

• D: A degenerative joint disorder where mechanical and biological events that destabilise the articular cartilage chondrocytes, extracellular matrix, and subchondral bone.
• E:

I: 33% in >45 years in UK

G: F>M

R: FHx, Female, obesity, DDH

• P: joint pain and stiffness that is typically worse with activity. Limited range of motion
• I:
• Arthrocentesis: White cells ~1500
• CRP: Normal (RO inflammation)
• ESR: Normal
• Xray:

Loss of joint space

Osteophytes

Subchondral cysts

Subchondral sclerosis

• T:
• Conservative:
• Losing weight
• Physiotherapy
• Medical:
• Paracetamol
• NSAIDs + Capsaicin
• Glucosamine
• Opiods
• Surgical:
• Replacement of affected joint

Question 8

Outline avascular necrosis

Answer 8

D: Bloody supply to the head of femur is impaired. Ball shape of head of femur becomes flattened.

E: Most common in ages 20-50. Risk factors include long term steroid use and chemotherapy agents.

P: Joint pain on bearing weight, most commonly hip.

I: MRI scan (or Contrast CT)

T: Total hip replacement or joint tissue graft.

P: Good.

Question 9

Outline CREST syndrome (Limited cutaneous systemic sclerosis)

Answer 9

D: Limited cutaneous systemic sclerosis. Autoimmune condition caused by excess T-cell stimulation and fibroblast stimulation.

E:

Prevalence is rare: 0.02%

P: “CREST”

Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly, telangiaectasia.

I:

• Fbc
• ANA
• ENA
• ESR
• Anti-centromere antibody

+Pulmonary function tests

T:

• Conservative: Smoking cessation, excercise, physiotherapy
• Medical:
• Immunosuppressants:
• Methotrexate/ Mycophenylate/ Cyclophosphamide/ Azathioprine
• If there is digital ischaemia: Vasodilator
• Raynaud’s: ACE inhibitors
• Dysphagia: oesophageal dilation
• Calcinosis: analgesia
• Diminished joint range: Splints
• Surgical: Excision of calcinosis

P: Prognosis depends on degree of internal organ involvement. Overall its not good.

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Question 10

Outline polymyalgia rheumatica

Answer 10

D: muscle stiffness and raised inflammatory markers

E: > 60 years old

P: usually rapid onset (e.g. < 1 month) aching, morning stiffness in proximal limb muscles

+ mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats

I:

ESR: raised

CRP: raised

FBC: May suggest myeloproliferative disease

US: Bursitis, joint effusions

T: Prednisolone 15mg/od

P: Prognosis is good but relapse can occur. Associated with giant cell arteritis.