Rheumatology Flashcards
What are the key clinical features on examination of RA?
Symmetrical small joint arthropathy Sparing of the DIP Ulnar deviation of the fingers Swan-neck deformities Boutonniere’s deformities Nodules Palmar erythema Disuse atrophy of the small muscles of the hand Vasculitic skin changes Entrapment neuropathies due to synovitis Pleural effusions ILD Pulmonary HTN Splenomegaly Scleritis/episcleritis
How do you approach treatment for RA?
pharmacological:
1) steroids to induce remission, may be continued at low dose to help maintain remission
2) step up approach starting with conventional DMARDS
(Mtx, hydroxychloroquine, sulfasalazine)
3) biological dmards (TNF blockers e.g. etanercept, infliximab, Il-6 blockade tocilizumab, rituximab, JAK blockade e.g. tofacitinib) if active disease despite 2+ dmards for 6 months
General measures;
- PT, OT, vaccinations, bone health, reduce CV RFs
What are the radiographic features seen on X-ray in RA?
Loss of joint space Periarticular erosions Subluxation Soft tissue swelling Just articulate osteoporosis may come before erosions
What are poor prognostic features of RA?
Sustained high levels of inflammation RF and ACPA titres Early erosions on imaging Smoking Extra-articulate features such as ILD, nodules HLA-DRB1*04 homozygosity
What diagnostic criteria are there for RA
ACR criteria:
- more points for more small joint involvement
- points for RF, ACPA
- CRP/ESR
- duration > 6 weeks
How is spondyloarthritis classified?
Axial spondyloarthritis (predom spine, SI joints)
Peripheral spondyloarthritis
Extra-articulate disease
Axial spondyloarthritis subdivided into
- with radiographic sacroilitis = ank spond
- w/o radiographic SI = non-radiographic axial SpA
What are the spondyloarthritides?
Ank spond Psoriatic arthritis Reactive arthritis GI associated arthritis Undifferentiated SpA
What are the principles of management of psoriatic arthropathy?
Analgesia, steroids, NSAIDs, DMARDs (mtx, sulphasalazine), biological DMARDs (TNFablocker or anti-Il 17 e.g. secukinumab
What are the clinical exam findings for Psoriatic arthritis?
Asymmetrical oligoarthritis involving DIP joints or symmetrical poly arthritis
Nail pitting
Onycholysis
Erythematous plaques with silver scaling on the extensor surfaces
What are the clinical features of gout arthropathy?
Asymmetrical deformity and swelling of the small joints of the hand, tophi, may get bursitis too
What is the pathophysiology of gout?
Underexcretion or overproduction of uric acid.
Uric acid comes from the breakdown of purines in the liver by xanthine oxidase
Underexcretion is due to chronic renal disease, drugs e.g. diuretics, ACE-I, aspirin, ciclosporin, idiopathic
Overproduction of purines is due to diets rich in meat and seafood, alcohol, lymphoproliferative and myeloproliferative disorders, idiopathic
How do you distinguish between gout and pseudo gout from joint aspiration?
Gout; negatively birefringent urate crystals
Pseudo gout; positively birefringent pyrophosphate crystals
