Rheumatology Flashcards
What is the definition of osteoarthritis?
Mechanical and biologic events that destabilise the normal process of degradation and synthesis of articular cartilage chondrocytes, extracellular matrix, and subchondral bone and lead to new bone formation
What is the clinical presentation of osteoarthritis?
Joint pain exacerbated by exercise, joint stiffness after rest (gelling), reduced joint functionality, bony deformities (proximal interphalangeal joints (Bouchard nodes) and distal interphalangeal joints (Heberden nodes)), joint malalignment, asymmetrical, crepitus
What are the investigations of osteoarthritis?
o CRP: slightly elevated o Rheumatoid factor and antinuclear antibodies: negative o X-ray: oLoss of joint space oOsteophytes oSubchondral sclerosis oSubchondral cysts
What is the treatment of osteoarthritis?
Exercise, paracetamol, weak opioid, intra-articular corticosteroid injection, arthroplasty, osteotomy, joint fusion
What is the definition of rheumatoid arthritis?
Chronic systemic autoimmune disorder which causes symmetrical inflammation of the synovial joints, leading to joint and periarticular tissue destruction
What is the aetiology of rheumatoid arthritis?
HLA-DR4
What is the pathophysiology of rheumatoid arthritis?
Abnormal, autoimmune response, which targets synovial joints resulting in chronic inflammation and joint damage.
What is the clinical presentation of rheumatoid arthritis?
Symmetrical, polyarthritis of the small joints of the hands and feet, joint pain exacerbated by rest or inactivity, joint stiffness in the early morning which lasts longer than an hour
What are the investigations of rheumatoid arthritis?
o FBC: normocytic anaemia (anaemia of chronic disease)
o CRP and ESR: elevated
o Rheumatoid factor: positive in 70% (non-specific but high values are more specific)
o Anti-cyclic citrullinated peptide antibody: positive in 80% (highly specific)
o X-rays of the hands and feet:
oLoss of joint space
oErosions
oSoftening of bones (osteopenia)
oSoft tissue swelling
What is the treatment of rheumatoid arthritis?
Lifestyle modifications, NSAIDs, DMARDS (methotrexate), TNF-alpha blockers (etanercept), B-cell inhibitors (rituximab), IL-6 blockers (tocilizumab), T cell activation blockers (abatacept), steroids (reduce symptoms and inflammation, and in cases of exacerbation)
What is the definition of gout?
Inflammatory arthritis associated with hyperuricaemia and intra-articular monosodium urate crystals
What is the aetiology of gout?
Hyperuricaemia (overproduction, increase purine intake, decreased uric acid secretion)
What is the pathophysiology of gout?
High urate levels result in supersaturation and crystal formation which deposit in the joints, leading to gout
What is the clinical presentation of gout?
Acute onset of severe joint pain, with swelling, effusion, warmth, erythema, and/or tenderness of the involved joint, Tophi (nodular deposits of uric acid crystals in soft tissues of the body)
What are the investigations of gout?
o Serum uric acid: elevated
o Arthrocentesis with synovial fluid analysis: elevated WCC and strongly negative birefringent needle-shaped monosodium urate crystals under polarised light
What is the treatment of gout?
o Acute attacks: NSAIDS, colchicine, corticosteroids
o Long-term: lifestyle modifications, allopurinol (xanthine oxidate inhibitor)
What is the definition of calcium pyrophosphate deposition disease?
Inflammatory arthritis associated with intra-articular calcium pyrophosphate crystals
What is the pathophysiology of calcium pyrophosphate deposition disease?
Excess pyrophosphate production by chondrocytes causes local CCP supersaturation and crystal formation
What is the clinical presentation of calcium pyrophosphate deposition disease?
o Acute: Acute onset of severe joint pain, with swelling, effusion, warmth, erythema, and/or tenderness of the involved joint, fever, malaise
o Chronic: Severe pain, stiffness, crepitus, and loss of function
What are the investigations of calcium pyrophosphate deposition disease?
o Arthrocentesis with synovial fluid analysis: intracellular or extracellular positively birefringent rhomboid-shaped crystals under polarized light
o X-ray: cartilage calcification
What is the treatment of calcium pyrophosphate deposition disease?
Symptomatic (high dose NSAIDs, colchicine, corticosteroids)
What is the definition of osteoporosis?
Metabolic bone disease characterised by a generalise reduction in bone mass, increased bone fragility and predisposition to a fracture
What is the aetiology of osteoporosis?
Steroid use, hyperthyroidism and hyperparathyroidism, alcohol and tobacco, testosterone decrease, early menopause, renal or liver failure, erosive/inflammatory bone disease, dietary calcium decrease, diabetes mellitus
(SHATTERED)
What is the clinical presentation of osteoporosis?
Asymptomatic until a fracture occurs
What are the investigations of osteoporosis?
o X-ray: fracture
o Bone densitometry DEXA scan: < -2.5
What is the treatment of osteoporosis?
Lifestyle modifications, bisphosphonates (alendronate), hormone replacement therapy, teriparatide
What is the definition of ankylosing spondylitis ?
Seronegative, chronic, multisystem inflammatory disorder involving primarily the sacroiliac joints and axial skeleton
What is the aetiology of ankylosing spondylitis ?
HLA-B27
What is the clinical presentation of ankylosing spondylitis?
Inflammatory back pain (worse at night) and stiffness (morning stiffness relieved by exercise), sacroiliac inflammation, enthesitis (especially Achilles’ tendonitis and plantar fasciitis), iritis/uveitis
What are the investigations of ankylosing spondylitis ?
o FBC: normocytic anaemia
o CRP and ESR: elevated
o X-ray: erosions, syndesmophytes, progressive calcification of syndesmophytes can lead to bamboo spine (fusion of spinous processes), fusion of the sacroiliac joints
o HLA-B27 genetic test: positive
o Shober’s Test: assesses mobility of the spine
What is the treatment of ankylosing spondylitis ?
Physiotherapy, NSAIDs, DMARDs (methotrexate), TNF-alpha blockers (etanercept), local steroid injections
What is the clinical presentation of psoriatic arthritis?
Symmetrical polyarthritis of the DIP joints
What are the investigations of psoriatic arthritis?
X-ray: erosive changes, pencil-in-cup deformity
What is the treatment of psoriatic arthritis?
NSAIDs, DMARDs (methotrexate), TNF-alpha blockers (etanercept)
What is the definition of reactive arthritis?
Sterile inflammation of the synovial membrane, tendons and fascia triggered by an infection at a distant site, usually GI or genital
What is the aetiology of reactive arthritis?
Salmonella, shigella, chlamydia
What is the clinical presentation of reactive arthritis?
Pain and stiffness, enthesitis, keratoderma blennorrhagia (brown, raised plaques on soles and palms)
What are the investigations of reactive arthritis?
o CRP and ESR: elevated
o Infectious serology
o X-ray: enthesitis with periosteal reactions
What is the treatment of reactive arthritis?
NSAIDs, local steroid injections, DMARDs (methotrexate (if symptoms last > 6 months)
What is the definition of septic arthritis?
Infection within a joint (knee > hip > shoulder)
What is the aetiology of septic arthritis?
S.aureus, N.gonorrhoeae, S.epidermis
What is the clinical presentation of septic arthritis?
Hot, red, swollen joint, fever
What are the investigations of septic arthritis?
o Joint aspiration for fluid microscopy: neutrophils
o Joint fluid culture
What is the treatment of septic arthritis?
Joint drainage, broad spectrum antibiotics, specific antibiotics (usually flucloxacillin, vancomycin or ceftriaxone)
What is the definition of osteomyelitis?
Infection of the bone and/or bone marrow
What is the aetiology of osteomyelitis?
S.aureus, pseudomonas, E.coli, S.epidermidis, salmonella (sickle cell disease)
What is the clinical presentation of osteomyelitis?
Pain, swelling, tenderness, warmth, erythema, fever, sinus tracts (chronic osteomyelitis)
What are the investigations of osteomyelitis?
o FBC: elevated WCC
o CRP and ECR: elevated
o Bone biopsy: inflammatory cell, oedema, vascular congestion, necrotic bone (sequetra), new bone formation, neutrophil exudates
What is the treatment of osteomyelitis ?
IV antibiotics (usually flucloxacillin), surgical debridement
What is the definition of Systemic Lupus Erythematosus?
Multisystem autoimmune disease characterised by autoantibody production against nuclear and cytoplasmic autoantigens
What is the aetiology of Systemic Lupus Erythematosus?
Defective phagocytosis
What is the clinical presentation of Systemic Lupus Erythematosus?
Butterfly rash, mouth ulcer, Reynard’s phenomenon, fatigue, depression, weight loss
What are the investigations of Systemic Lupus Erythematosus?
Auto-antibodies (ANA or Anti-dsDNA): positive
What is the treatment of Systemic Lupus Erythematosus?
UV protection, screening for organ involvement, prednisolone (flares), DMARDs (hydroxychloroquine), NSAIDs
What is the definition of osteomalacia?
Inadequate mineralisation of bone
What is the aetiology of osteomalacia?
Calcium deficiency (vitamin D deficiency)
What is the clinical presentation of osteomalacia?
Bone pain and tenderness, fractures, proximal myopathy
What are the investigations of osteomalacia?
o Bone biopsy: incomplete mineralisation o Serum calcium: low o Serum phosphate: low o Serum alkaline phosphatase: raised o X-ray: loss of cortical bone
What is the treatment of osteomalacia?
Vitamin D supplementation
What is the definition of giant cell arteritis?
Vasculitis of head and neck arteries
What is the clinical presentation of giant cell arteritis?
Headache, scalp tenderness, jaw claudication, acute blindness, malaise
What are the investigations of giant cell arteritis?
Temporal artery biopsy: lymphohistiocytic infiltrate
What is the treatment of giant cell arteritis?
Immediate prednisolone, methotrexate, osteoporosis prophylaxis
What is the definition of Wegener’s Granulomatosis?
Systemic ANCA-associated vasculitis
What is the clinical presentation of Wegener’s Granulomatosis?
o Upper respiratory tract: sinusitis, otitis, nasal crusting
o Lungs: pulmonary haemorrhage/nodules, inflammatory infiltrates
o Kidney: glomerulonephritis
o Skin: ulcers, purpura, nodules
o Eyes: uveitis, scleritis, episcleritis
What are the investigations of Wegener’s Granulomatosis?
o c-ANCA: positive
o Urinalysis: haematuria, proteinuria
o Renal biopsy: necrotising glomerulonephritis
o Lung biopsy: necrotising granulomatous inflammation and necrotising vasculitis
What is the treatment of Wegener’s Granulomatosis?
Aggressive immunosuppression
What is the definition of Paget’s Disease?
Metabolic bone disease characterised by excessive chaotic bone turnover in localised parts of the skeleton
What is the pathophysiology of Paget’s Disease?
Exaggerated osteoblast activity which leads to grossly thickened, poorly organised, weak bone, which is prone to deformity and pathological fracture
What is the clinical presentation of Paget’s Disease?
Asymptomatic, bone pain, deafness, fractures, bowing of the femur and tibia
What are the investigations of Paget’s Disease?
o Serum alkaline phosphatase: elevated
o X-ray: localised enlargement of bone
What is the treatment of Paget’s Disease?
Bisphosphonates, analgesia
