Rheumatoid arthritis, Septic Arthritis, Psoriatic Arthritis & Ankylosing Spondylitis Flashcards
What is rheumatoid arthritis?
An autoimmune disease that effects that joints, causing them to become painful, swollen and destructed long term.
What is the most common gender and age for someone to be diagnosed with rheumatoid arthritis?
- Females are 3:1 to males
- Peak incidence occurs around 40 years old
What is the pathophysiology of rheumatoid arthritis?
- A person needs to have the specific HLA-DR1/4 gene and then an environmental trigger such as smoking or a pathogen
- This trigger changes a protein compound on cell membranes around the body which the persons immune system now recognises this as an antigen
- Immune cells through the blood enter the joint and recognise these proteins and initiate an immune response that brings more inflammatory mediators to the area
- These inflammatory mediators begin to swell the synovial cells and membrane (pannus)
- From the pannus proteases are released and over time this destroys this joint
What are the clinical features of joint rheumatoid arthritis?
- Insidious onset of pain and stiffness that begins in the smalls joints of the hands/feet
- Pain is usually worst on wakening that can disturb sleep
- Morning stiffness that can last for hours
- Tenderness to palpate or move the joint
- Fever, malaise, weakness and weightloss
What type of deformities can occur in rheumatoid arthritis?
- Butonniere deformity - flexion of the PIP and hyperextension of the DIP
- Swan neck - hyperextension of PIP and flexion of the DIP
- Z deformity
- Ulnar deviation
What are the clinical features of systemic rheumatoid arthritis?
- Blood - anaemia
- Skin - nodules & vasculitis
- Eye - scleritis & dry eyes/mouth
- Lung - pleural effusion and nodules
- Cardiac - pericarditis, myocarditis and atherosclerosis
- Renal - amyloidosis
- Neurological - peripheral neuropathy
How is rheumatoid arthritis diagnosed clinically?
- Presence of stiffness lasting more than 30 minutes
- Symmetrical involvement of MCP/MTP joints
- At least 3 joints that are painful, red and swollen
How is rheumatoid arthritis diagnosed via investigations?
- ESR/CRP
- Rheumatoid factor
- Anti-CCP
- Plain film x-ray
How is rheumatoid arthritis managed?
- Education
- Diagnosing it as early as possible
- Simple analgesics and NSAID’s (Early stage)
- Disease modifying anti-rheumatic drugs (DMARDs)
- Rest in acute flare ups
- Exercise and movement - low weight bearing
- Functional capacity by keeping them moving
- Dietary advice
What is ankylosing spondylitis?
-A seronegative spondyloarthropathy that primarily causes restriction and fusion at the SIJ and Tx spine
What is a seronegative spondyloarthropathy?
-An arthritis affecting the spinal joints which have no known causing factor from a serology test for e.g. a specific auto-antibody linked to the disease
What is the most common gender and age presenting with AS?
- Usually first symptoms occur before age 30 (20% younger than 20)
- Men are more affected about 2:1
What is the genetic link found in AS patients?
- More likely to develop if a 1st degree relative has AS
- Around 5% of people with +HLA-B27 develop AS (upto 90% of AS patients have this gene)
What is the pathophysiology of AS?
- Still largely unclear
- Involves HLA-B27 typically and an immune response leading to an influx of inflammatory cytokines which eventually cause tissue destruction
What are the clinical features of AS?
- LBP that is characteristic with inflammatory nature (more insidious, improves with exercise, persisting stiffness and inflammatory markers present)
- SIJ/Buttock pain
- Movement restriction
- Pain will fluctuate with flare ups
What occurs in chronic AS?
- Bony ankylosing of SIJ
- Marginal syndesmophytes
- Severe movement restriction and deformity
What are some extra-articular/systemic symptoms that can arise from AS?
- Enthesitis (usually at achilles and/or plantar fascia)
- Anterior uveitis
- Peripheral arthritis
- Bowel inflammation
- Osteoporosis
- Pulmonary fibrosis
- Aortic valve incompetance
How is AS diagnosed?
- Plain film x-ray
- MRI
- ESR/CRP
What can be seen on an x-ray in AS?
- Initial stage = joint widening due to acute inflammation
- Reactive sclerosis and erosion
- Syndesmophyte formation
- Bony ridging
How is AS managed?
Symptom management:
- Education
- Support groups
- Keep active to slow movements and stretching
Medications:
- NSAIDs
- TNF inhibitors
- DMARDs
What is Psoriatic Arthritis?
An autoimmune disease characterized by red scaly patches, also classed as a seronegative spondyloarthropathy as all patients with PsA must have psoriasis
What are some common triggers that have caused arthritis in psoriatic patients?
- Stress
- Skin injuries
- Infections
What is the pathophysiology of PA?
- Many people with Psoriasis have an altered version of the gene HLA-B27 present in everyone, however this gene alone isnt enough to cause PA
- This alteration however is more susceptible and when an environmental trigger such as an infection occurs it can cause the immune system to suddenly think the self-antigens the gene presents around the body are actually foreign, causing PA.
How many classifications of PA are there?
Five
What occurs in the distal predominant classification?
- Effects the DIPs and sometimes PIPs
- Dactylitis (sausage fingers)
What occurs in the oglioarticular classification?
- Most common
- Usually involves less than 5 joints
- Asymmetrical
What occurs in the polyarticular classification?
- Similar to RA patterns
- Often affects more than 5 joints
- Symmetrical
What occurs in the spondylitis classification?
- Mimics AS pattern
- Symmetrical through SIJ and Cx spine fusion
What occurs in the arthritis mutilans classification?
- Chronic form of the distal predominant classification
- High levels of bone erosion cause deformity
What are the clinical features of PA?
- Peripheral arthritis (gradual and effects multiple joints that are usually asymmetrical)
- Axial arthritis (mimics AS =- can progress to full ankylosing)
- Dactylitis
- Enthesitis
- Tendonitis/tenosynovitis
How is PA diagnosed?
- If the patient has psoriasis and arthritis then should be suspected (note that psoriasis patients can have OA)
- Blood test (rheumatoid factor & anti-CCP)
- Xray
How is PA managed?
- Control of skin lesions (topical steroids, education about good skin health; cool showers and moisturiser use)
- Decrease stress, smoking and poor diet
- Increase exercise
- Referral to dermatologist - DMARD’s, UV therapy and biologic medications
What is Septic Arthritis?
A bacterial infection within the joint that could be present in any location around the body
What are the risk factors for Septic arthritis?
- Age over 60
- Immunocompromised (HIV, Chemotherapy etc)
- Surgical procedures (artificial joint replacement)
- Joint trauma
- Osteomyelitis
- Rheumatoid arthritis
What is the pathophysiology of Septic Arthritis?
- Somehow bacteria passes from the external environment into the joint this can be via:
1. Hematogenous spread: passing via the blood stream from the lungs from example
2. From a direct puncture wound around the joint which can pierce bacteria in the joint from an object or living on the skin
What are the clinical features of Septic Arthritis?
- Red, hot swollen joint
- Restricted ROM
- Systemic features: Fever, malaise and weakness
What us the most commonly effected joint from septic arthritis?
Knee
What is a complication of septic arthritis?
Joint destruction can occur if it is missed
How is septic arthritis diagnosed?
- Synovial fluid aspirate (looks for exact culture for antibiotics)
- ESR/CRP
- Xray/MRI (evaluate joint destruction)
How is septic arthritis treated?
- Medical intervention required immediately
- Fluid aspiration & surgical drainage
- Antibiotic washout and post surgical IV antibiotics
