Rheuma Flashcards
Anti-Ro
Sjogren’s syndrome, SLE, congenital heart block
Anti-La:
Sjogren’s syndrome
- Anti-Jo 1
polymyositis
Anti-SCL-70
diffuse cutaneous systemic
sclerosis
Anti-centromere:
limited cutaneous
systemic sclerosis
Gout
caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricemia (uric acid > 450 μmol/l) mostly due to ↓ renal execretion of UA (90%).
↓ Excretion of uric acid
CKD
Lead
drugs (diueretics)
↑ Production of uric acid
Myeloproliferative/lymphoproliferative disorder * Cytotoxic drugs
* Severe psoriasis
* Chronic kidney disease
* Lead toxicity
Lesch-Nyhan syndrome
Hypoxanthine-guanine phosphoribosyl transferase deficiency
* Inheritance = X-linked recessive
* Features: gout, renal failure, learning difficulties,
head-banging
Tophaceous gout:
Associated with renal impairment and prolonged diuretics use.
* Affected joints are hot swollen and knobby appearance.
* Due to deposition of Na+ urate in skin and joint.
* X-ray: punched out bony cys
gout management
NSAIDs
* Intra-articular steroid injection
* Colchicine has a slower onset of action. (main side-effect is diarrhea and ↑ INR with warfarin)
* If the patient is already taking allopurinol it should be continued
* Rasburicase: is a recombinant version of a urate oxidase enzyme given in acute setting, it allows
allopurinol to be commenced without worsening of symptoms. Only used when other Rx can not be given
Gout: start allopurinol if
≥ 2 attacks in 12 month period
Allopurinol should not be started until 2 weeks after an acute attack has settled.
* Initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of
< 300 μmol/l
* NSAID or colchicine cover should be used when starting allopurinol
Indications for allopurinol* gout
Recurrent attacks - the British Society for Rheumatology recommend ‘In uncomplicated gout uric acid lowering drug therapy should be started if a second attack, or further attacks occur within 1 year’
* Tophi
* Renal disease
* Uric acid renal stones
* Prophylaxis if on cytotoxics or diuretics
Pseudogout features
is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium
Features
* Knee, wrist and shoulders most commonly affected
* X-ray: chondrocalcinosis (linear calcification of the articular cartilage)
* Joint aspiration: weakly-positively birefringent rhomboid shaped crystals
Pseudogout Investigations:
Transferrin saturation (may indicate hemochromatosis, a recognised cause of pseudogout)
Management:
*
*
Aspiration of joint fluid, to exclude septic arthritis and show weakly-positively birefringent brick shaped crystals
NSAIDs or intra-articular, intra-muscular or oral steroids as for gout
Pseudogout risk factors
Risk factors
* Hyperparathyroidism
* Hypothyroidism
* Hemochromatosis
* Acromegaly
* ↓ magnesium, ↓ phosphate
* Wilson’s diseas
Rheumatoid Arthritis:
Epidemiology
Peak onset = 30-50 years, although occurs in all age groups
* ♀:♂ ratio = 3:1
* Prevalence in UK = 1%
* Some ethnic differences e.g. High in native Americans
* Associated with HLA-DR4 (especially felty’s syndrome)
American College of Rheumatology criteria
RA
- Morning stiffness > 1 hr (for at least 6 weeks)
- Soft-tissue swelling of 3 or more joints (for at least 6 weeks)
- Swelling of PIP , MCP or wrist joints (for at least 6 weeks)
- Symmetrical arthritis
- Subcutaneous nodules
- Rheumatoid factor positive
- Radiographic evidence of
erosions or periarticular osteopenia
Rheumatoid arthritis what mediates the path
TNF
NICE recommends that patients with suspected rheumatoid arthritis who are rheumatoid factor negative
should be tested for anti-CCP antibodies.
Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of rheumatoid arthritis.
rheumatoid arthritis Early x-ray findings
Loss of joint space (seen in both RA and osteoarthritis)
* Juxta-articular osteoporosis
* Soft-tissue swelling
rheumatoid arthritis Late x-ray findings
- Periarticular erosions (osteopenia and osteoporosis)
- Subluxation
A number of features have been shown to predict a poor prognosis in patients with rheumatoid arthritis, as listed below
Rheumatoid factor positive
* Poor functional status at presentation
* HLA DR4
* X-ray: early erosions (in < 2 years)
* Extra articular features e.g. Nodules
* ♀sex
* Insidious onset
* Anti-CCP antibodies
Extra-articular complications occur in patients with rheumatoid arthritis (RA):
Respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans,
methotrexate pneumonitis, pleurisy
* Ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration,
keratitis, steroid-induced cataracts, chloroquine retinopathy
* Osteoporosis
* ISCHEMIC heart disease: RA carries a similar risk to T2DM
* Increased risk of infections
* Depression
Felty’s syndrome
(RA + splenomegaly + low white cell count)
Proteus mirabilis is a (G-ve rod), causes UTI →
predisposes susceptible patients to RA
ra Initial therapy
ombination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids)
RA. In Pregnancy
Methotrexate and NSAIDs are absolutely contraindicated
Azathiopurine can be used if sulfasalazine and hydroxychloroquine are not controlling
RA TNF-inhibitors
The current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate
} Safe in pregnancy
In Pregnancy
Methotrexate and NSAIDs are absolutely contraindicated
Azathiopurine can be used if sulfasalazine and hydroxychloroquine are not controlling
* Etanercept: subcutaneous administration, can cause demyelination }
* Infliximab: intravenous administration, risks include reactivation of
tuberculosis
* Adalimumab: subcutaneous administration
Rituximab
Anti-CD20 monoclonal antibody, results in B-cell depletion
* Two 1g intravenous infusions are given two weeks apart
* Infusion reactions are common
Abatacept
Fusion protein that modulates a key signal required for activation of T lymphocytes
* Leads to ↓ T-cell proliferation and cytokine production
* Given as an infusion
Respiratory Problems in Rheumatoid Arthritis
A variety of respiratory problems may be seen in patients with rheumatoid arthritis:
* Pulmonary fibrosis
* Pleural effusion
* Pulmonary nodules
* Bronchiolitis obliterans
* Complications of drug therapy e.g. Methotrexate pneumonitis
* Pleurisy
* Caplan’s syndrome - massive fibrotic nodules with occupational coal dust exposure
* Infection (possibly atypical) secondary to immunosuppression
Adult Still’s Disease:
Features:
* Arthralgia
* Fever (noticeable at afternoon and evening)
* Elevated serum ferritin
Rash: salmon-pink, maculopapular, pruritic
* Pyrexia
* Lymphadenopathy
* RF and ANA negative (but ANA 25% positive). ↑ ESR and CRP
* Leukocytosis and thrombocytosis
Stills management
Management:
* NSAIDs
* Steroids
* Methotrexate
Septic Arthritis
Joint aspiration is mandatory in all patients with a hot, swollen joint to rule out septic arthritis. If
this was excluded then intra-articular or system steroid therapy may be considered
Septic Arthritis organisism
Overview
* Most common organism overall is Staphylococcus aureus
* In young adults who are sexually active Neisseria gonorrhea should also be considered
* WBC > 50 x 109/L or > 75% of baseline – neutrophils
septic arthritis Management
- Synovial fluid should be obtained before starting treatment
- Intravenous antibiotics which cover gram-positive cocci are indicated. The BNF currently
recommends flucloxacillin + fusidic acid or clindamycin if penicillin allergic - Antibiotic treatment is normally be given for several weeks (BNF states 6-12 weeks)
- Needle aspiration should be used to decompress the joint
- Surgical drainage may be needed if frequent needle aspiration is required
Osteoarthritis: most common site
The trapeziometacarpal joint (base of thumb) is the most common site of hand osteoarthri
Osteoarthritis analgesia
aracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only
for OA of the knee or hand
* Second-line treatment is oral NSAIDs/cox-2 inhibitors, opioids, capsaicin cream and intra-
articular corticosteroids. A proton pump inhibitor should be co-prescribed with either drug.
These drugs should be avoided if the patient takes aspirin
oa glucosamine?
Normal constituent of glycosaminoglycans in cartilage and synovial fluid
The 2008 NICE guidelines suggest it is NOT RECOMMENDED
* A 2008 drug and therapeutics bulletin review advised that whilst glucosamine provides modest
pain relief in knee osteoarthritis it should not be prescribed on the NHS due to limited evidence of cost-effectiveness
Reactive Arthritis HLA
Reactive Arthritis is one of the HLA-B27 associated seronegative spondyloarthropathies.
Reiter’s syndrome, a term which described a classic triad of urethritis, conjunctivitis and arthritis following a dysenteric illness
reactive art Features
Typically develops within 4 weeks of initial infection - symptoms generally last around 4-6
months
* Arthritis is typically an asymmetrical oligoarthritis of lower limbs
* May present as monoarthritis e.g. Knee
* Symptoms of urethritis
* Eye: conjunctivitis (seen in 50%), anterior uveitis
* Skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma
blenorrhagica (waxy yellow/brown papules on palms and soles)
Ankylosing spondylitis HLA
evelop in upto 50% of HLA B27 +ve patients
reactive arthritis Organisms often responsible for post-dysenteric form
Shigella flexneri
* Salmonella typhimurium
* Salmonella enteritidis
* Yersinia enterocolitica
* Campylobacter
reactive arthritis Organisms often responsible for post-STI form
Chlamydia trachomatis
reactive arthritis Management
Symptomatic: analgesia, NSAIDs, intra-articular steroids
* Sulfasalazine and methotrexate are sometimes used for persistent disease
* Symptoms rarely last more than 12 months
Palindromic Arthritis:
- Rare type of recurrent inflammatory arthritis that causes sudden inflammation in one or several joints (pain, swelling and erythema) followed by complete recovery with no permanent damage.
- Affects articular or periarticular areas, any joint could be affected but mostly large joints
- Lasts < 72 hours before recovering completely
- ♂=♀ - age 20-50 years.
- May progress to RA: incidence of RA may ↑ when RF is present
- Anti-CCP and antikeratin antibodies (AKA) are present in a high proportion of patients
The most common cause of recurrent or relapsing arthritis:
Crystal Arthritis (Gout & Pseudogout)
Recent-Onset Arthritis
parvovirus-induced arthritis
* Exposure to children with recent febrile illness is known risk
* Affects ♀>♂ - mostly women with contact to children (at home or at work)
* Small hands joints, wrists, elbows, hips, knees, and feet are each affected in > 50% of cases.
* Detection of IgM antibody, produced only in early disease, is a marker of recent infection and
therefore strong evidence in favor of parvovirus being the cause of recent-onset arthritis.
Ankylosing Spondylitis HLA
HLA-B27 associated spondyloarthropathies. It typically presents in ♂s (sex ratio 5:1) aged 20-30 years old. It has polygenic inheritance.
Ankylosing Spondylitis a associations
Apical fibrosis (CXR)
* Anterior uveitis
* Aortic regurgitation
* Achilles tendonitis
* A V node block
* Amyloidosis
* And cauda equina
