Rheumatology

Question 1

What is the main pathophysiology of rheumatoid arthritis?

Answer 1

B-cells –> RF antibody which is anti-IgG (FC). Inflammatory synovitis
Articular cartilage erosion
Pannus = granulation tissue reducing nutrient supply and increased inflammatory cells.

Question 2

What are the risk factors for rheumatoid arhtritis?

Answer 2

Hereditary - MHC II = HLA-DR1/DR4 
Epigenetic 
Smoking 
Female 
White
Diet

Question 3

What are some local and systemic symptoms/signs of rheumatoid arthritis?

Answer 3

Local

• Joint pain/ache in small symmetrical distal joints. Worse on waking up and hot weather.
• Painless red nodules
• Muscle wasting
• Swan neck or boutonniere deformity

Systemic

• Anaemia (normocytic) - lymphadenopathy
• Splenomegaly - Vasculitis - Sjorgen’s syndrome - lower lobe pulmonary fibrosis.

Question 4

A patient with a history of RA comes in with a acute joint effusion, what is the likely diagnosis and causative agent?

Answer 4

Septic arthritis - staph aureus.

RAPID TREATMENT

Question 5

What are the differential diagnosis for RA and how would you determine?

Answer 5

SLE - reducible nodules (ANA/dsDNA blood test)

Viral arthritis - acute onset.

Question 6

What would be the primary investigations for confirming RA?

Answer 6

Bloods - FBC (anaemia), RF, ANA, Anti-CCP.

X-ray - boney erosions and osteopenia

Question 7

What are the different forms of treatment for RA?

Answer 7

Analgesia = NSAIDs (if over 65 give omeprazole for gastric protection)
Steroid injections, low dose or IM for acute.
DMARDs - methotrexate (1st line) - anti folate. Folic acid reduces gastric upset risk.
Take 6-12 weeks to work. Sulfasalazine, leflunomide, hydrochloroquine.
Biologics - Anti-TNF alpha. Infliximab (1st line). Expensive so only used after 2 DMARDs haven’t worked. Can reactivate latent infection e.g. TB.

Question 8

What becomes inflamed in RA?

Answer 8

Inner synovial membrane

Question 9

What is ankylosing spondylitis?

Answer 9

Inflammation and stiffness of the spine

Question 10

What genetic factor and other conditions increase the risk of ankylosing spondylitis?

Answer 10

HlA-B27, Psoriasis, IBD, chlamydia

Question 11

A 22 yr old male with no PMH comes into the GP suffering from pain particularly in his lower back that is worse in the morning. He states he doesn’t have it when playing football. He has had a fever for the last few weeks and has noticed his shorts getting looser. What are the possible ddx?

Answer 11

1st = ankylosing spondylitis 
2nd = Mechanical 
3rd = Psoriatic arthritis

Question 12

What is the mainstay of treatment for ankylosing spondylitis?

Answer 12

Exercise, physio. NSAIDs if there is a acute flare up.

TNF-a in severe disease

Question 13

What is psoriatic arthritis?

Answer 13

Joint involvement - similar to RA. That can go alongside psoriasis.

Question 14

What joints are affected in psoriatic arthritis?

Answer 14

2-5 asymmetrical weight bearing joints

Question 15

What systemic features may be found in psoriatic arthritis?

Answer 15

Psoriatic lesions - silvery plaques (knees and elbows). Nails - pitted and crumbling. Dactylitis - inflamed digit (sausage finger)
Enthesitis - achilles
Osteolysis - finger bone lysis.
Sacrum involvement.

Question 16

A 60 yr old female comes in with morning pain and stiffness in her shoulders that takes about a hour to recover from. This came on a week ago and she is now finding it hard to get up from a chair. O/E = normal. She has mentioned having a fever and some flu symptoms as well as not feeling her food recently. What are the differential diagnosis and how would you investigate/treat based on the most likely one ?

Answer 16

DDx = polymyalgia rheumatica. Rheumatoid arthritis, osteoarthritis, psoriatic arthritis.

PR - sudden onset and shoulders.
FBC, LFTs, U+E’s, TFT, CK, RD, CCP, ANA, CRP/ESR (main ones)

Low dose steroid for 1-3 years.

Question 17

What type of drugs should be avoided in a patient with polymyalgia rheumatica?

Answer 17

NSAIDs.