Rheumatology Flashcards
What are the signs of synovitis?
Boggy swelling, warm and erythema of joint with associate effusions, pain and stiffness Often relieved by activity and NSAIDs
Give examples of an enthesitis
- inflammation of tendon and ligament attachment - plantar faciitis - achilles tenditis - costochondritis
Inflammatory rheumatological pain vs non-inflammatory
- inflammatory pain often relieved by exercise and worse at rest - non inflammatory pain generally exacerbated by activity and relieved at rest
Describe the etg suggested pattern of recognition of articular MSK presentations
- Inflammatory vs non-inflammatory 2. Acute vs chronic 3. Mono/oligo/polyarticular
Define mono/oligo and polyarticular
Mono = 1 Oligo = up to 5 Poly = >5
Give examples of acute INFLAMMATORY articular pain Mono (4) Oligo (5) Poly (5)
Mono: gout, CPPD, reactive arthritis, septic arthritis Oligo: gout, reactive arthritis, enteropathic arthritis, psoriatic arthritis, rhematoid arthritis Poly: viral arthritis, rheumatoid arthritis, gout, drug reaction, reactive arthritis
What is the other name for pseudogout?
Calcium pyrophosphate dihydrate crystal deposition disease
Give examples of chronic INFLAMMATORY articular pain Mono (3) Oligo (4) Poly (6)
Mono: septic arthritis with atypical pathogen, psoriatic arthritis, reactive arthritis Oligo: psoriatic arthritis, reactive arthritis, gout, CPPD Poly: gout, psoriatic arthritis, reactive arthritis, rheumatoid arthritis, SLE, CPPD
What is the classical non-inflammatory arthritis?`
OA, can be mono/oligo/poly
Patern of recoginition of articular MSK presentations. Etg flowchart
Pattern of recognition of peri-articular MKS presentation, ETG flow chart.
How would you classify periarticular MSK presentations?
- Inflammatory vs non-inflammatory
- Acute vs chronic
- Focal vs diffuse
Give examples of ACUTE and CHRONIC inflammatory peri-articular conditions.
Focal: calcific tendinitis of shoulder, de Quervain tenosynovitis, flexor tendosynovitis, preptaella bursitis, plantar fasciitis
Diffuse: PMR (shoulder and hip involvement)
What are the specific investigations for the following…
a) septic arthritis
b) gout/CPPD
c) inflammatory myopathies/giant cell arteritis
a) gram stain and culture of synovial fluid
b) polarised light microscopy of synovial fluid
c) tissue biopsy
What rate of patients with SLE have positive ANA?
90%
But also 5% of the healthy population
What antibodies would you test for in suspected Sjogren’s?
Ro (SS-a) and or La (SS-B) antibodies on enzyme link immunosobrent assay
Anti-ENA antobodies
What are the differences in ESR and CRP?
Both are useful indicators of acute phase response
- ESR is affected by age and hyperviscosity, unlike CRP
- CPR also responds more rapidly than ESR
However a normal ESR/CRP does not exclude inflammatory pathology
What findings on iron studies would suggest anaemia of chronic disease?
- mild normochromic, normocytic anaemia with raised ferritin and low rion
Testing for ANA
DO: young women with intermittent small joint arthralgia, alopecia, paynaud or serositis
DON’T: in patients with non specific long standing history of fatigue and constant pain
Note the higher the ANA titre the higher the likelihood of connective tissue or autoimmune disease (i.e thyroid)
Outline murtagph’s diagnostic model
- What is the probability diagnosis
- What are the serious disorders not to be missed
- WHat are the pitfalls?
- Seven masquerades checklist
- Is the patient trying to tell me something
What are the 7 masquerades?
Depression
Diabetes
Drugs
Anaemia
Thyroid disease
Spinal dysfunction
UTI
When should HLA-B27 be performed?
Inflammatory back pain with strong suspicion of spondyloarthritis
What are potential contraindications to joint aspiration in monoarthritis?
- overlying infection
- overlying psoriasis
- prosthetic joint
Define the findings in synovial fluid analysis for…
A) normal aspirate
B) non-inflammatory
C) non-infective inflammatory
D) septic
Normal: clear, 0-200 WCC, <10% PMN
Non-inflammatory: slightly turbid, 200-2000 WCC, <20% PMN
Non-infective inflamm: slightly turbid, 2000-50,000 WCC, 20-70% PMN
Septic: turbid/purulen, >50,000 WCC, > 70% PMN
Name some non-inflammatory causes of diffuse arthralgia and myalgia.
- fibromyalgia
- benign hypermobility syndrome
- OA
- hypothyroidism
- oestomalacia
- multiple myeloma
Name some inflammatory causes of diffuse arthralgia and mylagia
- PMR
- giant cell arteritis
- SLE
- Sjogren syndrome
- Polymyositis
What baseline investigations should be performed for diffuse mylagia and arthralgia?
FBC, ESR, CRP, CK, thyroid function, serum electrolytes, creatinin, ferritin, BSL, liver biochemistry
Assessment of undifferentiated polyarthritis
- DDx: rheumatoid or reactive arthritis
- Most cases of viral arthritis resolve spontaneously within 12 weeks
- Investigations: FBC, ESR/CRP, RF, anti-CCP, ANA, serum uric cadi, liver biochem, creatinine and urinalysis, viral serology
Management of undifferentiated polyarthritis
- smoking cessation
- NSAID + paracetamol
- fish oil 2.7g daily (may take up to 3 months to take effect)
- if severe may need to start prednisolone prior to specialist review however this may delay diagnosis (5-15mg daily)
What is the first line management of “tennis elbow”
- lateral epicondylitis
- first line = referral to physio
- steroid injection may assist analgesia for 4-6 weeks however worse outcomes at seen than in comparison with the “wait and watch”/physio group
- generally a self limiting inflammation which can last up to 12 months
- occurs from chronic micro trauma
DDx of anterior knee pain in active children
- most common = patellofemoral pain syndrome
- usually due to poor foot biomechanics, patella alta or variation in femoral trochlea shapes
- DDx: osgood schlatter, sindig larssen johansen, patella tendon pain, synovial plica pain
XR is always warranted
What is Sindig-Larsen-Johansson syndrome?
Sinding-Larsen-Johansson (SLJ) syndrome is pain at the bottom of the kneecap (patella). It is caused by swelling and irritation of the growth plate there.
What is the other name for tibial tuberosity apophtysitis?
Osgood Schlatter
What is sever’s disease?
Calcanela apophysitis
Inflammation of growth plate in heel
Treatment is avoiding activity!
Name the common growth plate/bony injuries sustained in the following sports:
a) gymnasts
b) throwers
c) rowers
d) volleyball
e) sprinters/runners
A) distal radiaus epiphyseal pain
B) medial epicondyl avulsion or osteochronrosis of elbow capitellum (Panner’s disease)
C) rib stress factures
D) pars interarticularis stress fractures
E) pelvic apophyses irritation, sever’s disease
What is osteochondritis dissecans?
- painful effused knee
- in severe forms cartilage may seperate with or without associated bone and become a losse body in the knee
- commonly associated with medial condyl of femur
“Joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. This bone and cartilage can then break loose, causing pain and possibly hindering joint motion”
Which drugs effect urate levels?
- increase: aspirin, diuretics, especially thiazides
- lower: fenofibrate, losartan, atorvastatin, CCB
If able avoid HCT in patients with gout and hypertension
Assessment of undifferentiated monoarthritis
- common causes: infection, trauma and crystals
- in setting of septic arthritis XR no role as destructive changes only become apparent after 10-14 days
What diagnoses are suggested by oligoarthritis?
Spondyloarthritis!
- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- enteropathic arthritis
- seronegative arthritis
What must not be missed as a diagnosis for migratory polyarthralgia?
ACUTE RHEUMATIC FEVER
Useful investigations for chlidren with suspectec inflammatory rheumatological disease
- FBC, ESR, CRP
- antistreptolysin-O titre (ASOT)
- ferritin, if > 1000 likely systemic arthritis
- e/LFT
- connective tissue: ANA, dsDNA, ENA
- urinalaysis
- plain XR if bony changes suspected: perthes, OM,
- US if suspect synovitis
What are the 4 groups of immunomodulatory drugs used for rheumatological disease?
- systemic corticosteroids
- conventional synthetic DMARDs
- biological DMARDs
- targeted synthetic DMARDs
Give examples of csDMARDs (conventional synthetic)
- azathioprine
- cyclophosphamide
- hycroxychloroquine
- methotrexate
- sulfasalazine
Given examples of bDMARDs (biological)
Abacept, adalimumab, infliximab, rituximab
What genotype test must be performed before starting azathioprine?
csDMARD
- TPMT genotype testing because 1:300 individuals have homozygous genetic mutation which leads to severe myelosuppression if dosing is not reduced
Note: FBC should be done veery 2 weeks during dose changes and then every 4-6 weeks once stable dose achieved
Precautions for NSAID use
- peptic ulcer disease or UGIB
- GRF 30, avoid long term use if GFR 30-60
- liver cirrhosis
- avoid if possible in patients with established CVD
Name the 3 selective COX-2 inhibitors.
Celecoxib
Meloxicam
Etoricoxib
Which NSAID has the highest and lower cardiovascular risks
Highest = diclofenac
Lowest = naproxen and potentially low dose celecoxib
What serological tests would you request for suspected SLE if ANA positive?
Anti-dsDNA, anti-phospholipid antibodies, C3 & C4 complement levels
What is first line management for olecranon bursitis?
Naproxen 500mg BD for 7 days
Common diagnosis for the limping child
a) 0-4
b) 5-10
c) >10
A) transient hip synovitis, acute myositis, toddler’s fracture, DDH
B) transient hip synovitis, acute myositis, DDH, Perthe’s
C) Stress fractures and sprains, traction apophysitis (OGS or Sever’s), SUFE
ALL AGES
Infection: OM/septic arthritis, bursitis, discitis, epidural collection
Trauma
NAI
Malignancy: bone, haematological, soft tissue
Immuno/Rheum: reactive arthritis, autoimmune, HSP, vasculitis, GBS
Functional
Intraabdominal pathology
Red flags for a child with a limp
- > 7 days duration
- history of fall, trauma or injury
- severe localised joint pain (septic)
- change to urinary or bowel habits
- inability to walk/weight bare
- nocturnal pain/symptoms
- systemic symptoms: fever, sweats, rash
- constitutional symptoms: fatigue, weight loss, anorexia
- recent viral infection
RCH flow chart for management of child with limp
What are the Kocher criteria for septic arthritis in children?
4 criteria = fever > 38.5, non weight baring, WCC > 12, ESR>4- or CRP >20
0 = low
1 = very low
2= moderate (refer)
3 or 4 = very high (refer)
What is BACM?
Benign acute childhood myositis
- seen in school afted children recovering from URTI
- more commonly seen in boys
- can present in tip toe walking
- rhabdo uncommon but serious complication, should always due urine analysis
Dermatomyositis
- idopthaic inflammatory myopathy characterised by muscle weakness and skin changes
- uncommon but up to 25% of cases are associated with malignancy
- triggers: medications, malignany, viral infections, silica exposure
- clinical features: face rash is common
- “heliotrope rash”: biltera lilac discolouration of eyelids and welling
- “shawl sign” - fixed redness affecting chest/neck and back
- Gottron papules: purple papules and plaques on top of small joints of the hands
- Gottron sign: redness ove rback of hands, elbows and knees
Name 4 rashes associated with dermatomyositis
- heliotrope rash of face
- shawl sign on shoulders/chest
- gottron papules
- gottron sign
How is dermatomyositis diagnosed?
Muscle enzymes:: CK, AST and LH
Antibodies: anti-Jo, anti-OJ, enti EK , anti KS, antzo
DDx - SLE or connective tissue disorder
Management - steroids or immunosuppression
What is meralgia paresthetica?
- symptoms: burning sensation to outter side of thigh
- involving entrapment/compression of lateral femoral cutaneous nerve
- treatment options may include weight loss and wearing loose clothing
Describe the management of a 1st metatarsal shaft #
- short leg walking cast or boot for 6 weeks, with follow up every 2-4 weeks
- healing time up to 6 weeks
Describe management of lesser metatarsal shaft #
- short leg walking cast or moonboot for 6 weeks, follow up every 2-4 weeks
- healing time of 6 weeks
Fracture of the 5th metatarsal tuberosity management
Short leg walking boot for 2 weeks with progressive mobility and ROM as tolerating
- follow up every 2-4 weeks
- healing time 4-8 weeks
What is a Jones # and how is it managed
- proximal fifth metatarsal #
- short leg NON weightbaring for 6-8 weeks
- if evidence of healing at 6-8 weeks start gradual weight baring
- if no evidence of healing continue immobilsation for 4 weeks
- healing time 6-12 weeks
Describe the ottawa foot rules
- bony tenderness at base of 5th
- bony tenderness at naviclar
- inability to weight bare immediately after the injury and at time of examination
Achilles tendinopathy
- often seen in sports with alot of running or jumping
- swelling and pain typically 2-6 cm from tendon insertion into calcaenus
- provocative tests: single heel raise (low load), hopping on affected leg (high load)
Patella tendinopathy
- often in sports with jumping suhc as volleyball, basketball, netball
- patella tendon origin is at lower power of patella and this is where tenderness is felt
- provocative testing: squat on feet on declining surface (low load), high single leg jump or landing from height (high load)
General management principles for tendinopathy
- avoid complete rest but also avoid high loads on tendon i.e. jumping
- substitute isometric exercises and increase load as pain improves
- nil good evidence for PRP at this stage
- can take up to 4 mnoths or longer to improve