Rheumatology Flashcards
What are the four key changes on x-ray for osteoarthritis?
L – Loss of joint space
O – Osteophytes
S – Subchondral sclerosis (increased density of the bone along the joint line)
S – Subchondral cysts (fluid-filled holes in the bone, aka geodes)
What are signs of osteoarthritis in the hands?
Heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in the PIP joints)
Squaring at the base of the thumb at the carpo-metacarpal joint
Weak grip
Reduced range of motion
Management of osteoarthritis:
Start with patient education about the condition and advise on lifestyle changes such as weight loss if overweight to reduce the load on the joint, physiotherapy to improve strength to support the joint and occupational therapy and orthotics to support activities and function.
Pain medication (work down the analgesic ladder).
Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms.
Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.
Summarise rheumatoid arthritis:
- Pathogenesis
- presentation
- Epidemiology
Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa. It is an inflammatory arthritis. Synovial inflammation is called synovitis. Rheumatoid arthritis tends to be symmetrical and affects multiple joints. Therefore it is a symmetrical polyarthritis. Inflammation of the tendons increases the risk of tendon rupture.
It is three times more common in women than men. It most often develops in middle age but can present at any age. Family history is relevant and increases the risk of rheumatoid arthritis.
What antibodies are linked to rheumatoid arthritis?
Cyclic citrullinated peptide antibodies (anti-CCP antibodies) are autoantibodies that are more sensitive and specific to rheumatoid arthritis than rheumatoid factor. Anti-CCP antibodies often pre-date the development of rheumatoid arthritis and give an indication that a patient will go on to develop rheumatoid arthritis at some point.
Rheumatoid factor
Symptoms of rheumatoid:
- Pain
- Swelling
- Stiffness
- Fatigue
- Weight loss
- Flu like illness
- Muscles aches and weakness
Pain from an inflammatory arthritis is worse after rest but improves with activity.
Features of rheumatoid arthritis in the hands:
Very important!!
- Z shaped deformity to the thumb
- Swan neck deformity (hyperextended PIP with flexed DIP)
- Boutonnieres deformity (hyperextended DIP with flexed PIP)
- Ulnar deviation of the fingers at the knuckle (MCP joints)
Investigations for rheumatoid arthritis:
- Check rheumatoid factor
- If RF negative, check anti-CCP antibodies
- Inflammatory markers such as CRP and ESR
- X-ray of hands and feet
- Ultrasound scan of the joints can be used to evaluate and confirm synovitis. It is particularly useful where the findings of the clinical examination are unclear.
What are the features of RA on xray?
- Joint destruction and deformity
- Soft tissue swelling
- Periarticular osteopenia
- Boney erosions
How is RA managed?
A short course of steroids can be used at first presentation and during flare ups to quickly settle the disease. NSAIDs/COX-2 inhibitors are often effective but risk GI bleeding so are often avoided or co-prescribed with proton pump inhibitors (PPIs).
First line is monotherapy with methotrexate, leflunomide or sulfasalazine. Hydroxychloroquine can be considered in mild disease and is considered the “mildest” anti rheumatic drug.
Second line is 2 of these used in combination.
Third line is methotrexate plus a biological therapy, usually a TNF inhibitor.
Fourth line is methotrexate plus rituximab
What biologic therapies are used to managed RA and what complications can occur with these?
The most important biologics to remember are the TNF inhibitors adalimumab, infliximab and etanercept and it is also worth remembering rituximab. The others are very unlikely to come up in your exams but are worth being aware of. Just remember they all lead to immunosuppression so patients are prone to serious infections. They can also lead to reactivation of dormant infections such as TB and hepatitis B.
Side effects
Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia
Side effects
Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia
Methotrexate can cause what side effect?
Pulmonary fibrosis
Read summary of psoriatic arthritis:
Psoriatic arthritis is an inflammatory arthritis associated with psoriasis. This can vary in severity. Patients may have a mild stiffening and soreness in the joint or the joint can be completely destroyed in a condition called arthritis mutilans.
It occurs in 10-20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age.
It is part of the “seronegative spondyloarthropathy” group of conditions.
How does psoriatic arthritis present?
Asymmetrical pauciarthritis affecting mainly the digits (fingers and toes) and feet. Pauciarthritis describes when the arthritis only affects a few joints.
Spondylitic pattern is more common in men. It presents with:
